Assessment and Treatment Principles for the Upper Extremities of Instrumental Musicians


  • Performance-related issues are discussed, followed by assessment and treatment techniques for tendinopathies, hypermobility, and focal hand dystonia.

  • Other conditions covered include nerve entrapment syndromes and ganglions.

  • Ideas are presented regarding orthotic intervention, musical ergonomics, warm-up and cool-down exercises, and an example of a graded return-to-play program.

  • Environmental factors and anatomic variations that can affect musicians are mentioned briefly.

  • The four surgical principles that need to be considered when operating on musicians are listed as well as a discussion on using the musical instrument as a rehabilitative tool.

Musicians’ hands are vital to their musical performance. Musicians often have to perform to the limit of their abilities physically, emotionally, and spiritually. They utilize rapid, complex, coordinated movements. Sometimes they are required to play in less than ideal environments and usually they do not have a medical team to support them in the way sports medicine supports athletes. Musicians can be required to play long tours with poor facilities. Noise, drug and alcohol use, and pressures can be high. They frequently injure themselves or acquire injuries that can lead to difficulties or an inability to play their instrument.

Over the last 20 years musicians’ medicine has become increasingly popular, with at least six textbooks relating to this topic published in English. Professional groups and organizations have been established in numerous countries to research preventative measures and effective treatments that are tailored to musicians. Each country has specific circumstances (e.g., health-care system, available financial support, and perceived medical need) that influence the administrative structure of the performing arts organizations. Additionally, alongside national initiatives, there is a growth in international cooperation, assisted by the development of international conferences.

Specialist assessment and rehabilitation techniques are required when dealing with this patient group. An understanding of the instrument and the type of music played is imperative. An area of specialization that has come to the fore in musicians’ medicine is hand therapy.

The focus of performing arts medicine should be prevention. Wynn Parry has made a detailed analysis of the 1046 musicians he has personally seen at British Association of Performing Arts Medicine (BAPAM) clinics ( Fig. 142-1 ). Clear-cut pathologies in which a specific diagnosis can be made were evident in 48% of this group. Of the structural disorders, four broad bands were evident: old injuries (22%), tenosynovitis (12%), hypermobility (9%), and focal hand dystonia (5%). In the remaining 52% few physical signs could be found, and the symptoms were seen as being very vague, general, and due to performance-related issues such as incorrect practice or playing techniques.

Figure 142-1

Percentage breakdown of specific versus nonspecific diagnosis for injured musicians.

(Data from Wynn Parry CB. Managing the physical demands of musical performance. In: Williamon A, ed. Musical Excellence Strategies and Techniques to Enhance Performance. Oxford, U.K.: Oxford University Press, 2004: 41-60).

Performance-Related Issues

Nontrauma-related conditions need careful analysis and consideration, and thus hand surgeons or therapists may be able to assist with providing an anatomic diagnosis for a painful condition in a musician’s hand or arm. Some conditions may result from

  • excessive training

  • change in instrument

  • quality of instrument

Excessive Training

Abrupt increase in practice or performance time is perhaps the most common risk factor. This can occur while attending a summer academy, preparing for a recital or competition, during holiday seasons when performers may be in increased demand, or when an amateur decides to intensify study. Newmark and Lederman carried out research on musicians at a conference. Only two players were professional musicians and 73% (79/109) did not usually practice routinely and had a rapid increase in playing time and so were predisposed to overuse injuries. Of those affected by the significant increase in practice time 61% (48/79) developed new playing-related complaints, whereas 34% (27/79) experienced problems even without a significant increase in playing time. The authors comment that musicians should view themselves as athletes, be more attentive to their physical limitations, condition their bodies accordingly, and work at preventing overuse injuries. They hope that teachers, performers, and physicians learn from the experiences of their respondents and implement a carefully planned increase to playing time.

“Correct” practice technique is imperative. Musicians frequently overpractice, which can have a negative effect on the individual’s whole body—particularly the hands and upper limbs. During long practice sessions, the instrumentalist may begin to use suboptimal body mechanics, which most frequently affect the hands and arms. Training errors often include failure to take at least a 5- or 10-minute break every hour of practice. Practice of physically difficult or awkward passages should be limited to short segments of 2 to 3 minutes each within a practice session.

A physical warm-up and cool-down before and after playing is desirable and seen as being essential. The neck, shoulders, and arms should be the focus areas. This might include slow rolling of the head and neck, shoulder shrugs, side bends, and torso twists. If the musician plays an instrument, such as the violin, viola, or flute, that requires constrained postures, these sessions are of particular importance. Much time is spent with patients discussing “graded-return-to-play” programs and practice techniques, which are discussed later in the chapter.

Change in Instrument

Changing from violin to viola (increasing the size of the instrument), electric bass to string bass (increasing the length of the fingerboard and required finger span), synthesizer to acoustic piano (increasing the force requirements for sound production), flute to piccolo (decreasing hand span and finger spacing), bassoon to contrabassoon (increasing the weight of the instrument and the hand span), or from a standard drum set to an “extended” set (increasing upper extremity reach requirements) represents the range of possible changes and how those changes can affect the upper extremities. These changes may predispose the musician to injury, especially if combined with an abrupt increase in playing time. The solution is to decrease the intensity of practice when such a change is made, and then to gradually build to the desired level of play. A change in teacher or style of music performed may result in a change in technique, which then requires a similar modification to the intensity of practice.

Quality of Instrument

Leaking keys or valves on a poorly maintained wind instrument can result in increased fingertip pressure required to produce a clean sound. Bridges on string instruments that are too high can increase the force needed to depress the strings. A piano in poor condition may require more force to achieve the desired dynamics and subtleties in sound, color, dynamic, and shade. Animal studies have shown that highly repetitive motor movements can contribute to degradation in the somatosensory cortex. However, Byl and associates comment that when the speed and force of the repetitive motor task is varied and interspersed with other regular activities, the degradation of hand cortical representation and loss of motor control can be minimized. Thus, it is important to maintain instruments in top playing condition, with the hope of decreasing excessive energy outlay for the desired level of performance. Musicians need to intersperse practice and playing with other activities in order to decrease the chances of developing medical conditions.

Nonmusical Activities and Factors

A musician may have excellent technique and practice habits, but may sustain upper extremity trauma from a variety of nonmusical activities. Musicians can suffer trauma while engaged in sporting or home hobby activities. These injuries need to be managed within the context of their instrument and the demands placed on their hands. Sports such as volleyball and martial arts are correlated with a particularly high incidence of hand injuries. Other hand-intensive activities that may cause problems include knitting, needlepoint, woodworking, fly tying and fishing, writing, and computer use.

Environmental Factors

Cold temperatures produce a number of adverse effects on musicians’ limbs. Cutaneous sensitivity decreases in the cold, which may lead to the use of excessive fingertip pressure, an increase in joint fluid viscosity, slowing of nerve conduction velocity, and diminished blood flow because of vasoconstriction. These effects may occur in spite of increased muscular demands. Players must guard against these effects by whatever means available, including wearing thermal underwear under their performance clothes, layering clothes, using fingerless gloves, or placing a heater in the practice studio.

Anatomic Variations

Anatomic variations range from the obvious to the subtle. Obvious ones, such as small stature or hand size, can be a problem when playing large or awkward instruments or certain pieces of music composed by persons with unusually large or flexible hands, such as Paganini or Rachmaninoff. An example of this can be seen in Figure 142-2 .

Figure 142-2

A, Cornetto player displaying wrist and elbow positioning. This patient presented with ulnar nerve symptoms and intrinsic muscle strain in both hands, probably due to long-term positioning of both upper extremities in awkward positions because of the constraints of the instrument. B, Small hand size with limited finger span resulting in intrinsic muscle strain.

A troublesome subtle variation is positive ulnar variance, which can cause an impingement syndrome when playing instruments requiring ulnar deviation—for example, certain fingers in the piano, harp, matched grip with the drums, the left hand in the trumpet, and at the end of the up-bow passage in stringed instruments. For musicians playing these instruments, accessory tendons in the first dorsal extensor compartment can predispose to de Quervain’s disease.

Tendinous interconnections between the flexor digitorum superficialis of the fourth and fifth fingers can lead to severe problems if they occur in the left hand of violinists or violists ( Fig. 142-3 ). Cervical ribs may cause problems on the left side in string bass players or musicians who are required to flex or rotate their neck while playing instruments such as the viola, violin, or flute.

Figure 142-3

A, The wrist flexion and forearm hypersupination required to reach the higher positions on the viola. B, The size of the instrument relative to the individual can influence the ease of playing and the possibility of the musician being predisposed to developing medical symptoms.

Clear-Cut Pathologies Affecting Musicians


Tendinopathies are a common degenerative rather than inflammatory condition. Histopathologic surgical specimens show a lack of inflammation. The term tendinopathy should be used rather than tendinitis, tendinosis, paratendinitis, or tenosynovitis, as this term refers to the primary symptomatic tendon disorder and has no implication of pathology. The cause of tendinopathy is unclear but three broad ideas cover possible methods of development:

  • Mechanical —Perhaps the tendon has been overloaded, causing damage to the extracellular matrix, which in turn has caused a failed healing response in the tenocytes.

  • Vascular —Tissue hypoxia may decrease the viability of tendon cells, and as the tendon reperfuses, oxygen free radicals are released, possibly leading to a pathologic tendon. Free radicals are associated with ageing, neurodegenerative diseases, chondral and meniscal lesions, and tendon degeneration in rats. If this hypothesis is valid then the possibility of treating tendinopathies with antioxidants is raised.

  • Neural —There may be a neurogenic origin to diseased tissues as mast cell degranulation and release of substance P has been implicated and found in degenerative tendons.

Butler and Sandford outline the intrinsic and extrinsic factors that can lead to tendinopathies developing.

  • Intrinsic factors include:

    • Age —mostly affects people older than 30 years of age

    • Nutrition —predominately affects people with poorer nutrition levels

    • Anatomic variations —affects people with extra long tendons or individuals who have two tendons in one tendon sheath

    • Joint laxity —hypermobile patients are more frequently affected

    • Gender —women are more often affected than men

    • Systemic disease —diabetic patients are more commonly affected

  • Extrinsic factors include:

    • Occupation —if you work in confined spaces or perform repetitive movements

    • Sport/hobby —if forceful repetitive movements or sustained postures are required

    • Physical load —if heavy loads are required to be repeatedly moved

    • Equipment —if the equipment is not well maintained, of poor quality, or inappropriate to the individual

    • Rapid increase in work load —if the work load is intense, fast-paced, and pressurized

    • Environment —if the environment is too cold, too hot, cramped, or pressured

De Quervain’s Disease

De Quervain’s disease is a stenosing tenovaginitis of the abductor pollicis longus and extensor pollicis brevis. These two muscles commonly share a tendon sheath and, although the tendons are entirely normal and no inflammation is present, a cross section of the fibro-osseous channel shows diminishment of the channel and fibrotic thickening of the extensor retinaculum. Clinical examination shows swelling, thickening, and pain of the first dorsal compartment. There is pain on resisted thumb extension and abduction, and weak pinch grip. A Finkelstein test is positive. There are no reliability studies for this test, but it is commonly utilized in the clinical setting. Differential diagnosis for de Quervain’s disease includes first carpometacarpal joint osteoarthritis, scaphoid fracture, intersection syndrome, superficial radial nerve irritation (Wartenberg’s syndrome), and central referral.

Other tendinopathies include lateral and medial elbow pain, trigger finger, and carpal tunnel syndrome.

Treatment Principles for Tendinopathies

Patient education, ergonomic advice, activity modification, biomechanical considerations, electrotherapy, acupuncture, ice, strengthening, stretching, myofascial release, trigger point therapy, orthotic positioning, administration of nonsteroidal anti-inflammatory drugs (NSAIDs), local steroid injections, and surgery are all possible treatments for the symptomatic patient.

Patient Education

The patient with a tendinopathy or muscular strain who rests just enough to keep playing, but manifests lingering symptoms, can develop a chronic condition that flares up repeatedly until adequate rehabilitation is received. Requirements for adequate rehabilitation include full range of motion (ROM), minimum pain on palpation of the muscle bellies or tendon origins and insertions, reasonable normative maximum grip strength, good endurance rates, and high levels of coordination. The musician must be aware that the length of the healing process is in months rather than weeks, and that the key to getting better and staying better is to modify the way the task is being performed as this may be predisposing to the condition.

Activity Modification and Ergonomic and Biomechanical Considerations

Some awkward postures are probably unavoidable, but some are related to poor instrumental ergonomics and technical difficulties. Marked wrist deviation and excessive fingertip loading can lead to increased tissue stresses and elevated pressures in the carpal tunnel. The use of excessive force, whether it be gripping drumsticks, pressing down on strings or keys, or clenching the violin between neck and shoulder, increases the risk of soft tissue injury. Carrying heavier instruments can strain the hands. Using wheels or backpack-style straps on cases can effectively reduce the carrying load placed on the limbs.

Many adaptive devices and cases have been specifically designed to decrease joint strain, distribute the load of the instrument, or protect the instrument and yet be lighter and more ergonomically sound. Some examples of such supports are shown in Figure 142-4 .

Figure 142-4

A, Ton Kooiman “Etude” clarinet thumb rest. B, A support for the left index finger of a flautist that assists in maintaining the metacarpophalangeal joint in a more neutral position. C, Fully adjustable A -frame guitar leg support that has been padded with Velfoam to decrease pressure on the upper thigh. D, Fully adjustable Ergoplay guitar support attaches to the classical guitar and elevates it so that the musician can play with both feet firmly on the floor and avoid using a foot stool.

Computer Use

Computer use is ubiquitous, often ergonomically unsound, and frequently intense, especially among students. The musician must be counseled to minimize computer use, especially during periods of intensified musical activity. Optimal ergonomic positioning while at the computer should be enforced for all patients, and keyboard short cuts should be used wherever possible in order to decrease the total number of keystrokes made during a session at the computer ( Fig. 142-5 ).

Figure 142-5

A, Incorrect wrist and finger position resting on computer keyboard gel wrist support. B, Correct arm, wrist, and finger position at the keyboard. C, Correct ergonomic set-up for working at the computer.

Here are some general concepts that are readily accepted when using a computer keyboard and mouse:

  • Keep wrists neutral.

  • Don’t rest wrists while typing.

  • Move the whole arm while keying.

  • Avoid stretching the fingers to reach keys that are far away.

  • Keep fingers curved and relax the thumb.

  • Use a light touch.

  • Keep fingernails short.

  • Avoid double clicking as much as possible when using a mouse.

Myofascial Pain and Stretching

Myofascial pain may be due to overactivity of motor end plates in muscles, which results in distinct referral patterns of pain. For example, a tender point or trigger point in the brachioradialis can refer to the elbow, thumb, and dorsum of the hand. Treatment can include trigger pointing, soft tissue massage, stretching, icing, acupuncture, home acupressure, and activity modification (e.g., how to carry items, and sleeping positions that assist in decreasing symptoms). See Figure 142-6 for examples of possible forearm flexor and extensor muscles stretches.

Figure 142-6

A, Forearm flexor stretch. With the elbow straight, and palm facing upward, gently move your wrist backward, using your own muscle strength until you feel a stretch. Then, with the other hand, gently pull the wrist further backward by placing light pressure in the palm. Hold this stretch for 10 seconds. B, Forearm extensor stretch. With the elbow straight and palm facing downward, gently bring the wrist and fingers in toward you using your own muscle strength until you feel a stretch. Then with the other hand, lightly push on the back of your wrist, bringing it further toward you. Hold this stretch for 10 seconds.

It must be noted that although these stretches can be useful for most musicians, hypermobile individuals must not go into their hypermobile range, but rather keep the elbow slightly flexed while performing the exercises.


Musicians seem to have a higher incidence of hypermobility than the population at large. Increased range can be very advantageous to musicians such as string players and pianists. Indeed some very virtuosic players such as Paganini and Liszt were hypermobile. Larson and colleagues studied 660 musicians and concluded that hypermobility in the fingers, thumb, and wrist may be an asset when playing repetitive motions on instruments such as the flute, violin, or piano. This author went on to say, however, that hypermobility may be a limitation when the joints are required to be stabilizers—for example knee joints for timpanists who stand to play. Larson and coworkers showed that musculoskeletal symptoms associated with practice and performance may be due to the lack of hypermobility of some joints involved in intensive repetitive movement. Subjects who played instruments requiring repetitive motion reported fewer symptoms in their joints if they were hypermobile.

Jull states that for many musicians hypermobility is an impediment. The weakness in muscle power and increased vulnerability of the associated joint can lead to an increased propensity for these musicians to develop injuries or chronic “overuse” syndromes. There is evidence to suggest that hypermobile joints have a decreased sensitivity to proprioception, so musicians may exert more force than necessary on keys or strings, thus increasing the possibility of chronic strain.

Hypermobility and the Role of Hand Therapy

Patients are routinely assessed for hypermobility in the initial examination, using the nine-point Beighton score and involving the following features:

  • Dorsal flexion of the fifth metacarpophalangeal (MCP) joint at 90 degrees. One point for each hand equals two possible points.

  • Ability to appose the thumb to the radial aspect of the forearm. One point for each thumb, equals two possible points.

  • Hyperextension of the elbow beyond 10 degrees. One point for each elbow, equals two possible points.

  • Hyperextension of the knee by 10 degrees. One point for each knee, equals two possible points.

  • The ability to put the hands flat on the floor with the knees extended when bending forward. One possible point.

Assessment on the instrument is imperative, as hyperlaxity may be more evident while the musician is playing. Brandfonbrener consistently found a correlation between musicians with hand and arm pain and the presence of joint laxity. Whether or not the hypermobility is the primary cause of symptoms, joint protection advice is always provided. Specific exercises can be helpful, and many adaptive ways of performing tasks can be incorporated into the patient’s lifestyle.

Advice and adaptive task performance can prevent injuries from developing and ensure that the performer is more able to have a generally more fulfilling and less painful time especially when playing their instrument. Patients can benefit greatly from a rehabilitation program to improve muscle power. The stability-strengthening exercises encourage co-contraction of the muscles surrounding a joint. Isometric strengthening and proprioception exercises both on and away from the instrument can assist in achieving this goal ( Fig. 142-7 ).

Figure 142-7

Patient handout showing stability exercises for the wrist and forearm.

Therapeutic putty exercises can be very useful in increasing intrinsic muscle strength and proprioceptive awareness. Orthotic positioning options are discussed later in the chapter.

When exercising away from the instrument, initial stability exercises include isometric muscle contraction in a pain-free range while wearing a support. Later in the rehabilitation phase, exercises can be progressed to include concentric and eccentric strengthening. Isometric strengthening exercises on the instrument can be a useful tool—for example exercises in the neutral joint position while holding the bow, string instrument, or clarinet. Proprioception exercises and retraining such as tapping exercises and weight-bearing exercises in a neutral position should be performed first with the eyes open and then with the eyes closed. After months of performing strengthening exercises, symptoms can improve, and it is not uncommon to detect an improvement in ligament tautness with joint translation testing. It is encouraging for the musician to be told that biomechanical dysfunction can be improved.

The intrinsic and extrinsic muscles of the hand are frequently stressed in an attempt to compensate for joint instability. Strengthening exercises using therapeutic putty can be useful when treating hypermobile patients. Treatment must focus on stability-strengthening exercises, temporary supports, sensorimotor retraining to improve proprioception, and patient education regarding good practice habits and healthy joint use. Temporary supports to maintain the joint in a neutral position are useful for playing, and the patient should be gradually weaned as strength increases and symptoms decrease. Supports can include light thermoplastic orthoses, neoprene wraps, wrist braces, Lycra finger sleeves, or a Coban wrap. It may take many months for stability strength to improve enough for a modified playing schedule to be instigated. Temporary orthoses or wraps may need to be worn for some time. Exercises must be continued until enough muscle strength has been gained or orthotic use continued until a neutral joint position can be maintained.

Focal Hand Dystonia

Dystonia is a syndrome characterized by involuntary prolonged muscle contractions that can lead to sustained twisting postures. Three criteria are used in classifying this syndrome: age of onset, cause, and distribution of symptoms. Onset before 28 years of age is classified as early, and after this age is classified as late-onset dystonia. Cause can be divided into primary/idiopathic (no obvious affects on the brain) or secondary/symptomatic (often the basal ganglia are affected, resulting in more generalized symptoms). Distribution of symptom manifestation can be

  • General —symptoms manifest in all extremities including the trunk.

  • Hemi —symptoms are focused on one side of the body.

  • Segmental— a segment of the body is affected.

  • Focal —a single body part is affected.

Any part of the body can be affected by focal dystonia, including the neck, eyelids, vocal cords, or hand.

This following section focuses on focal hand dystonia, a late-onset, primary dystonia that is often task-specific and includes musician’s and writer’s cramp ( Fig. 142-8 ).

Figure 142-8

Task-specific action-induced focal hand dystonia has different forms, including musician’s dystonia that can affect the hand and embouchure (A) and writer’s cramp (B) .

Focal Hand Dystonia in Musicians

FHD in musicians is a painless primary dystonia that tends to be task-specific, focal, and of late onset. Symptoms can include lack of coordination, cramping, and tremor and tend to be specific to each individual and related to the instrument played rather than hand dominance ( Fig. 142-9 ).

Figure 142-9

Focal hand dystonia in musicians showing lack of motor coordination or loss of voluntary control in a cellist’s (A) and pianist’s (B) right small and ring fingers.

Patients can respond to sensory tricks and, if they do, this is usually a good indicator of how successful hand therapy will be. Sensory tricks can be used to “fool” the brain and give a “nonsense” feedback loop that breaks the fixed link in the sensory motor loop for a short period. Often the novelty is only effective for a short time until the brain recalibrates to an automatic pattern, which is the dystonic one. Coban, Blu-Tack, latex gloves, and orthoses can all be used as sensory tricks ( Fig. 142-10 ).

Figure 142-10

A, B, Cellist utilizing latex glove as a sensory trick. C, Dorsal blocking orthoses to limit hyperextension of the compensatory finger, and in turn act as a sensory trick in patients with focal hand dystonia.

The estimated prevalence of FHD among professional musicians is about 2% to 10%, which is higher than that of writer’s cramp (0.1%) in the general population. FHD is overwhelmingly more common in classical rather than pop, rock, or jazz musicians. The high percentage of FHD in this population reflects the specific demands of continuous repetition made by classical music.


At present there is no cure for dystonia, and many of the treatments available have significant limitations. Current treatments include oral medication such as trihexyphenidyl, botulinum toxin injections, surgery, rehabilitative therapies, and supportive approaches. Butler and Rosenkranz published two papers that clearly outline many of the treatments that have been researched and undergone clinical trials.

The rehabilitative approaches include

  • Sensory reeducation —focuses on sensory discrimination.

  • Sensory–motor retuning (SMR) —combines both the sensory and motor aspects of FHD.

  • Multidisciplinary approach —includes hand therapy and combines the sensory and motor aspects of FHD.

  • Limb immobilization —interrupts motor performance and decreases afferents from the limb.

  • Supportive approaches —can include assistive devices, instrument modification, Alexander technique, and psychotherapy. There is a strong clinical impression within a very experienced group of treating practitioners that some personality abnormalities and a strong psychological trait is correlated with patients who develop FHD.

The mechanisms by which FHD develops in musicians need to be identified. Treatment must assist in reestablishing sensory–motor control. A comprehensive therapy program with an aggressive sensory reeducation element can improve sensory processing and motor control of the hand. SMR is of value for treating FHD in pianists and guitarists. Scientific research investigating preventative measures and appropriate treatments for FHD is essential. Collaboration and a multidisciplinary team approach to prevention, treatment, and research are imperative and will be of benefit to all.

A fuller overview of current treatment principles can be found in Butler and Rosenkranz.

Work-Related Upper Limb Disorders, “Overuse,” or Nonspecific Arm Pain

The term overuse injury has been defined as a condition that occurs when any biologic tissue is stressed beyond its physical or physiologic limits. The common presenting complaints are pain and stiffness but may include swelling and diminished coordination and function. Some histologic studies have revealed pathologic but nonspecific changes. There is no clear evidence that musicians suffer true overuse with tissue damage, as seen in athletes, and the experimental evidence used to argue this point in musicians is not strong.

The clinician needs to be careful to assess the patient thoroughly with respect to diagnosis and then to review for nonspecific arm pains. The diagnosis of nonspecific arm pain should not be seen as a blanket term for patients for whom no specific diagnosis can be made.

Classification and Grading

Work-related upper limb disorders (WRULDs), overuse, or nonspecific arm pain injuries can be classified as acute or chronic. An acute injury follows a specific incident, such as overpracticing a difficult passage. The musician may experience pain or stiffness during practice or the following day. A chronic injury usually has a more insidious onset. The limb becomes progressively more painful and dysfunctional over time.

Fry has developed a five-category grading system:

  • Grade 1. Pain at one site only while playing

  • Grade 2. Pain at multiple sites

  • Grade 3. Pain that persists well beyond the time that the musician stops playing

  • Grade 4. All of the above plus activities of daily living (ADL) begin to cause pain

  • Grade 5. All of the above plus all daily activities that engage the affected body part cause pain

Most injuries fall into categories 1 to 3. The earlier the symptoms are recognized and treated, the sooner the recovery is likely to occur and the more complete it is likely to be. Unfortunately, the prevalence of injury can be quite high, especially among professional orchestra members. A survey of more than 2000 orchestra members revealed 76% of those surveyed had significant physical problems. Subtle loss of motor control or technique may be one of the earliest signs of overuse.

Treatments for Nonspecific Arm Pain

The cornerstone of treatment is pain avoidance, also known as relative rest. Other treatment modalities will usually be inadequate unless relative rest is strictly observed. It is important to emphasize to the musician that they must not avoid playing altogether, but equally that they must not play for long periods of time. The patient must become highly aware of pain-producing activities, be they musical, nonvocational, or ADL. The patient must learn to avoid, or at least modify, those activities to minimize the number of daily painful “twinges.”

Hand therapists can assist in giving advice about joint protection and energy conservation techniques. These principles are similar to those used for patients with rheumatoid arthritis ( Box 142-1 ).

Box 142-1

Patient Handout on Joint Protection and Energy Conservation Techniques

Main Methods of Joint Protection

  • 1

    Use joints in a good position.

  • 2

    Avoid activities that do not allow for a change in position.

  • 3

    Respect pain.

  • 4

    Avoid tight grips or gripping for long periods, especially small and narrow objects.

  • 5

    Avoid actions that may lead to joint deformity.

  • 6

    Use one large joint or many joints.

Use Joints in a Good Position

Joints work best in certain positions. When they are used in the wrong position, such as twisting, extra force is placed through the joint and the muscles are unable to work as well, eventually causing pain and deformity.

Avoid Activities That Don’t Let You Change the Position of Your Hand

When you are in a position for a long time your muscles get stiff and pull the joint into a bad position. The muscles also get tired quickly and so the force is taken up by the joint and not the muscles, thereby leading to pain and damage.

Respect Pain

The nature of arthritis means that you may always have pain. If pain continues for hours after an activity has stopped, this means that the activity was too much and should have been changed or stopped sooner. Your therapist will talk to you about the many ways of dealing with pain, such as the use of orthoses, saving energy, learning relaxation methods, planning the day ahead or using equipment or gadgets to help you with certain activities.

Avoid Tight Grips or Gripping for Long Periods

Gripping tightly increases your pain and may damage your joints further. It is better to avoid it if possible. If you grip something that is small or narrow it can require greater power to hold and manipulate it. More power usually means an increase in pain and an increase of forces through the joints. Some examples of how to decrease strain on joints include:

  • Using thicker or padded pens for writing

  • Resting books on a table or book rest

  • Using a chopping board with spikes to secure vegetables

  • Using nonslip mats under bowls to hold them

  • Allowing hand washing to drip-dry rather than wringing it out

  • Relaxing your hands regularly during activities such as knitting or writing

  • Building up objects using foam tubing or using special grip aids

  • Increasing the grip ability on a slippery object such as a shiny pen or toothbrush by using Elastoplast or Coban tape

  • Many items have been ergonomically designed and can be purchased from many supermarkets and department stores.

Avoid Activities that Could Lead to Deforming Positions

Some directions of force can be more detrimental than others to the hand. Damage to your joints could lead to deformities in your hand, such as your fingers appearing to drift in the direction of your little finger (ulnar deviation) or your individual fingers bending or straightening in unusual positions (swan-neck deformity). Activities can be changed to avoid these.

  • When turning taps or opening and closing jars, use the palm of your hand and use one hand to open and the other to close. Remind others not to close them too tightly.

  • Use a flat hand when possible such as when dusting or wiping.

  • Try to use lightweight mugs with large handles rather than small teacups so pressure is not put on just one or two fingers.

Use One Large joint or Many Joints

Stronger muscles protect large joints, so it is better to use large joints when possible or try to spread the force over many joints.

  • Use the palms of your hands and not your fingers when you carry plates or dishes.

  • When standing up from a chair, try to rock gently forward and use your leg muscles to stand up rather than pushing from your knuckles or wrists.

  • Carry light bags from a strap on your shoulder rather than your hands.

  • Use your bottom or hips to close drawers or move light chairs.

  • Use your forearms to take the weight of objects when carrying, not your hands.

Main Methods of Energy Conservation

  • 1

    Balance rest and activity.

  • 2

    Organize and arrange space.

  • 3

    Stop activities or parts of them.

  • 4

    Reduce the amount of weight you take through your joints.

  • 5

    Use equipment that saves energy.

Balance Rest and Activity

It is important to balance your rest and activity to allow your joints to rest and repair. Stop before you feel tired or are in pain and avoid activities that you can’t stop when you need to.

  • Try to plan ahead. Write a weekly or daily diary with activities in red and rest times in blue. Think about what you need to do and space the harder activities out over time.

  • Activities such as vacuuming, ironing, and cleaning windows mean that you are dong the same movements lots of times and keeping the hand in the same position for long periods of time. Try to do them for very short periods, or when possible get someone else to do them for you.

Organize and Arrange Space

Prepare your work areas so you have everything you need for that activity. Store items you use often in places that are easy to reach, and keep things in small refillable containers, rather than large, heavy jars.

Stop Activities or Parts of Them

  • Use clothes that are easy to care for.

  • Make the bed on one side and then the other.

  • Soak dishes before washing them and let them drip-dry.

  • When possible use tinned, frozen, or prepared foods.

  • Hang items within easy reach.

  • When possible get someone else to help with activities.

Reduce the Amount of Weight You take Through Your Joints

  • Consider using wheeled trolleys rather than carrying things.

  • Slide pans when possible, and use a wire basket or slotted spoon to drain vegetables.

  • When you buy new equipment, make sure it is lightweight.

  • Use a teapot or kettle tipper, and fill the kettle with a lightweight jug.

Use Equipment that Saves Energy

Your therapist will discuss with you some of the things that are available to buy.

Automatic washing machines, frost-free freezers, and food processors are all energy-saving devices; and simple things such as sharp knives use less pressure and, therefore, less energy.

Should I Exercise My Hands?

It is important to maintain the amount of movement you have in your joints so that you are able to use your hands as much as possible. You may find that without regular exercise your hands feel weak and activities become more difficult. Exercise can help to relieve pain, keep bones and muscles strong, and keep your joints moving. Strong muscles around your joints can help keep them in a good position, but do not overdo your exercises or use weights or resistance as this may harm your joints.

Do I Need to Wear an Orthosis?

Your therapist will talk to you about wearing an orthosis. They can be used to rest a joint and allow the muscles around it to relax. This can help reduce swelling and pain. Orthoses can also be used to prevent deformities around the joint or stop existing deformities from worsening. It is often advisable to wear one during activity to support a joint and restrict movement.

There are various types of orthosis and your therapist may provide you with more than one.

A thermoplastic resting orthosis can be made, which due to its strength can also be used during activity to restrict movement around the joint. Softer orthoses made from neoprene are also available that allow more movement.

Other therapy tools that people have found useful are Lycra gloves worn at night and hot or cold gel packs. Your therapist will talk about your symptoms and your daily activities ( Fig. 142-11 ).

Apr 21, 2019 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Assessment and Treatment Principles for the Upper Extremities of Instrumental Musicians

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