Upper Limb Disorders in Musicians

Raoul TUBIANA
Institut de la Main - Centre Orthopédique Jouvenet - F-75016 Paris


INTRODUCTION

Orthopaedists are seeing this type of problem more and more frequently in their clinics. The problems themselves are not a new phenomenon, but for a long time they were played down both by doctors, who had no treatment to offer for a set of poorly-defined symptoms which were often regarded as psychosomatic, for want of a more accurate diagnosis; and by professional musicians themselves, who were very concerned for their career and their future.

An extraordinarily large number of people play a musical instrument these days, many of them self-taught; and this has led to a considerable increase in the number of cases of these disorders. As a result, epidemiological studies have been carried out, which have confirmed that there is a serious problem. Thus, in 1986, Fishbein et al. performed a study among 4,000 orchestral musicians in the United States, which showed that 66% of string players and 48% of wind players were suffering from musculoskeletal disorders. These findings have been confirmed more recently, in 1997, by Ian James, who studied 56 international orchestras. Although it is mainly orchestral musicians who are affected, any musicians (professionals, amateurs, or conservatoire-level students) who play for long periods of time may suffer from performance-related disorders. Twenty-nine per cent. of the 22,000 members of the Music Teachers National Association in the United States reported that they were affected (Brandfonbrener 1990).

I have been interested in these disorders for a long time, and since 1975, Philippe Chamagne and I have conducted a musicians' clinic. Chamagne has gradually become involved on a full-time basis in the rehabilitation of musicians and is now internationally renowned in this field. We have seen more than 2,000 musicians in our clinics, most of them suffering from upper limb disorders.

Before looking more closely at these disorders and how they can be treated, it should be emphasised that a musician's career is different from any other kind of career. One of the main differences is that a musical education begins at a very early age, often at about four or five years, well before the end of the growth period; another factor is that a musician's career may last for many years, exposing him or her to the risk of degeneration caused by tissue wear and tear. However, there is another, even more important, factor: A career as a professional musician demands complete self-sacrifice, and success will only be fully achieved by those who are completely committed to music as a way of life, since constant practice is needed to maintain the level of neuromuscular activity already achieved, involving speed, precision and endurance, all at the same time. Musicians sometimes play 25-30 notes a second!

As an example, Critchley (1977) reported that, when playing a Mendelssohn presto for piano lasting for four minutes three seconds, the pianist sounded 5,595 notes, executing 72 bimanual finger movements per second. It is hard to grasp the complexity, and vulnerability, of the functions involved.

Finally, it should never be forgotten that musicians are artists first and foremost. In other words, a musician is a particularly sensitive and emotional person whose work and career are the main focus of his or her life; everything else in a musician's life, even relationships, must take second place. The quest for perfection will keep a musician in a state of tension which can be hard to live with, especially if - as often happens - there are also physiological, material or emotional problems.


THE DISORDERS

There are several different types of disorder, although none is really specific. Some of them are very similar to other occupational disorders which involve the upper limb, but it can be very difficult to diagnose them if the physician has no experience of musicians as patients.

In this article, I will not be dealing with the neurological, rheumatic, vascular and infectious disorders which can affect the upper limb in musicians, and which can be very difficult to diagnose and treat; nor will I be discussing acute trauma, which always has repercussions on a musician's playing, and which should be treated conservatively or surgically under the best possible conditions, so that movement is restored as early as possible.

The scope of this article is restricted to occupational disorders affecting the upper limb, including musculotendinous disorders, joint disorders, peripheral nerve lesions, and, finally, functional dystonia.


Musculotendinous disorders

These are by far the most common disorders affecting musicians; the proportion varies according to the instrument played and the sex of the musician. In general, women suffer from them more often than men, but there are variations. Wynn Parry (1997) found that violinists of both sexes suffered equally, while among cellists, more women than men were affected. Obviously this might be related to differences in finger length and limb length, differences in muscle strength, and differences in joint stability.

There are two main groups of musculotendinous conditions: non-inflammatory disorders and inflammatory disorders.

The dominant factor in both groups is pain; however, the pain pattern will be found to vary with the disorder.


Non-inflammatory disorders

The non-inflammatory disorders are caused by repeated physical effort which exceeds the normal physiological capacity of the tissues, which is why they have been called "overuse syndromes". Overuse syndrome is a specific disorder which was identified only a few years ago, and which since then has aroused a great deal of interest, since in many countries the functional disorders it is reputed to cause have major social and medicolegal implications. The syndromes are seen in manual workers, particularly computer keyboard operators, in athletes, and in musicians. The principal manifestation is pain, which varies in location depending on the instrument, and which is often related to decreased strength, decreased dexterity and sometimes even to difficulty in co-ordinating finger movements when tired. The pathophysiology of the syndrome has still not been fully elucidated, as the degree to which a tissue will tolerate fatigue depends on a number of factors. A clinical examination does not reveal any sensory disturbances or abnormal reflexes; however, there are often postural problems or excessive laxity in the joints, which might have a role in triggering the pain. For this reason, Lippmann (1991) proposed the term "misuse" rather than overuse. Repeated muscle contraction is well tolerated, even over a long period of time, if the posture is good; however, if the posture is poor, it will rapidly lead to pain (Figs. 1a and 1b, Fig. 2), if there is a history of locomotor disorders, or joint instability.

fig1a fig1b fig2
Figure 1:
1a) Correct posture in a pianist; the pelvis and shoulders remain in parallel planes although the spine is in lateral inclination. The balance and stability of the shoulder girdle are of prime importance in musicians; it is the muscles of the shoulder girdle which support the weight of the upper limbs, and often the weight of the instrument. Good stability of the proximal part of the limb allows freedom for the hands in playing.
1b) Non-physiological position in a guitarist. Raising one foot too high causes tilting of the pelvis, listing, and asymmetry of the shoulder girdle.
Figure 2:
Flautist leaning too far forward, which tilts the pelvis, accentuates thoracic kyphosis and causes hyperlordosis of the cervical spine to keep the head upright.

Whatever the cause, the musician will change position or move in a different way in order to reduce the pain, and effort is transferred to different muscle groups, which may become painful in their turn after the muscle groups originally involved have recovered.


Inflammatory lesions

These include tendinitis and tenosynovitis. The location will vary depending on the instrument. The disorders will not be described in detail here as orthopaedists are very familiar with them already. They must be distinguished from overuse syndromes, as the two conditions are treated differently (Table 1).

Tendinitis
vs. overuse syndromes
  Tendinitis
Tenosynovitis
Overuse syndromes
Cause After trauma +
sometimes repeated trauma
Repeated effort ++
Poor posture ++
Location Hand, wrist and forearm + Neck and shoulders
Pain Very localised Diffuse
Swelling Tendon sheaths Muscles
Traetment NSAIDs +
Corticosteroid injections

Occasionally, surgery
Rest +++
Anti-inflammatories not very effective
No surgery


Joint disorders

We often find that the musicians who come to see us are suffering from joint instability. We always look for this condition, as it can cause other problems.

Instability of the finger joints may be congenital or acquired; it is classed as acquired when a single joint which takes the weight of the instrument or is in constant use, such as the metacarpophalangeal joint of the right thumb in a guitarist, exhibits an abnormal degree of passive mobility. A clinical distinction must be made between joint instability in finger hyperextension, and lateral movement, which is much more difficult to control. Some musicians feel that a hypermobile joint is an advantage, but in fact the opposite is true, as additional muscle force has to be used in order to stabilise such joints.

The musicians who have attended our clinic have often been found to be suffering from osteoarthritis of the fingers, but it is difficult to attribute this solely to the playing of an instrument. However, joint instability could lead to this kind of degeneration.


Peripheral nerve lesions

There are many causes of nerve entrapment in musicians. Pianists may suffer from carpal tunnel tenosynovitis; flautists and violinists may compress a nerve by resting their instrument on the base of the left index finger; excessive flexion of the left wrist in guitarists, or prolonged flexion of the left elbow in violinists, may cause entrapment of the ulnar nerve. Long-limbed subjects with sloping shoulders and insufficient scapulo-thoracic muscle development may suffer from compression of the lower roots of the brachial plexus.

In string players, mechanical irritation may also cause painful neuritis of the digital nerves.


Functional dystonia

This is the condition most feared by musicians as it leads to difficulties in controlling movements, which can interrupt or terminate the musician's career. It is characterised by the onset of involuntary muscle contractions and movements; its distinguishing feature is that it only occurs during a specific and well-defined action. For example, one or more fingers, frequently the 4th or the 5th finger, will remain flexed or will straighten involuntarily when the musician is playing, often during a difficult passage which requires great speed or a change of rhythm. In wind players, the muscles around the mouth may remain contracted. It is a localised neurological disorder (focal dystonia) related to an occupation which demands rapid repetition of identical movements. This type of functional dystonia is also seen in telegraphists, writers, and other professions. It is incorrectly referred to as "cramp". However, cramp refers to painful and paroxysmal muscle contractions, while " musician's cramp", or indeed writer's cramp, is in principle neither painful nor very severe (Rondot 1991). The disorder is, rather, a form of localised idiopathic functional dystonia.

The condition develops gradually, usually in an active musician. In some cases, the predominant feature is spasm, while in others it is the development of involuntary movements, which are sometimes accompanied by tremor. It is significant that the motor disorders are triggered by the same sequence in a piece, and that they usually disappear when the musician is not playing the instrument. The conscious efforts that the musician makes to control his or her fingers will only make matters worse, so orchestral musicians prefer to "cheat" by avoiding risky passages. This solution is obviously much more difficult for soloists.

Some of our patients complain of pain, although in theory dystonia is painless; however, they report that this pain was not an initial manifestation of the disorder, and came on only after repeated episodes of muscle spasm. In any case, dystonia differs from muscle and tendon disorders in that pain is not the dominant phenomenon.

In some severe forms, the disorder tends to spread and may be triggered by activities other than playing the instrument, such as writing or typing. It is very rare to find other forms of dystonia occurring in other parts of the body. Familial cases have also been reported; we have sometimes seen cases of torticollis or writer's cramp in family members of our musicians, which obviously suggests a genetic origin.

Predisposing factors have also been suggested; these include a history of trauma (Fletcher 1991, Schott 1985), a change in technique, a change of instrument, or a sudden increase in musical activity. Apart from the action which causes the dystonia, neurological examination will not reveal any idiopathic dystonia or elicit any signs. There is no paralysis, there are no sensory disturbances of the skin, and the reflexes are normal. In contrast, a more thorough examination may detect proprioceptive disorders. In the great majority of cases, the EMG is normal.

There has been much argument about whether these very specific dystonias are organic or neurotic in origin. The disorders are so specific, and the anxiety of the musicians is sometimes so pronounced, that the patient's psychological state may be held responsible; however, it must be borne in mind that it is profoundly disturbing for a musician to find that the finger control which took so much time and effort to acquire has suddenly let him down. It is now generally agreed that the depressive disorders which are occasionally seen are mainly reactive, and can be explained by the motor disorders which are threatening the musician's career.

Many neurologists feel that dystonia is a disorder of central origin, related to a lesion of the basal ganglia; this theory seems to be supported by some MRI images obtained in cases of dystonia in non-musicians. Perhaps there are several forms of functional dystonia. The forms which affect musicians have certain special features, and they seem to occur more frequently than other types of localised dystonia, because of the extreme precision of movements required and the emotional reactions of the artist, which are always intense.

Since 1975, Philippe Chamagne and I have examined about 400 cases of dystonia in musicians; this is an abnormally high proportion compared with the other disorders seen in musicians. Our papers on the subject (1983, 1993) may have been responsible for this. The normal proportion of cases of functional dystonia in relation to all occupational disorders in musicians is only 8% according to Lederman (1991) and 14% according to Hochberg (1990). We agree with these two authors that dystonia is markedly more common in men, and that the mean age is about 38 years. It is interesting to compare these data with those for overuse syndromes, which affect predominantly women and for which the mean age is much lower (25 years in our series).

A break-down of our cases by instrument shows that pianists and string players were easily the most affected (Figs. 3, 4, 5, 6, 7); there were 142 pianists, 105 guitarists, 86 violinists, 8 viola players, 8 cellists and double bass players, 4 accordionists, and 2 harpists. However, there were only 24 wind players, two of whom were suffering from lip problems; this small number is probably due to our specialisation in hand surgery, which is not very relevant to this category of instrumentalists. We have also treated 10 percussionists, and even 3 conductors!

All the musicians who were suffering from dystonia had major postural disorders involving not only the upper limbs, but also the shoulder girdle and, in many cases, the spine. In most cases the ulnar metacarpal heads have collapsed (Fig. 8), indicating weakening of the corresponding intrinsic muscles, while the forearm muscles are well developed. Finger spread is often reduced. The shoulders are often asymmetrical, with the arm on the affected side in internal rotation, indicating a weakening of the exteral rotators. The shoulder blades often stick out. When the patient is asked to play his or her instrument, the non-physiological positioning is seen at once, with the wrist flexed and the hand abducted, and one shoulder lifted. The head is no longer in line with the spine, the pelvis is tilted, and there is often a lack of balance between agonist and antagonist muscle groups.

Almost all these patients with postural disorders will also adopt non-physiological positions in handling their instruments (Figs. 9, 10), with the hand in hyperpronation, the wrist excessively flexed and the arm in internal rotation, and so on. As orthopods, our natural inclination has been to correct these disorders empirically.

fig3
Figure 3: Functional dystonia of the left hand in a guitarist. Loss of control of the 4th and 5th fingers in flexion.
fig4
Figure 4: Functional dystonia of the right hand in a guitarist. The thumb is clenched inside the hand.
fig5
Figure 5: Functional dystonia of the right hand in a guitarist. Here, the thumb remains extended.
fig6
Figure 6: Dystonia of the left hand in an accordionist; the thumb is in extension.
fig7
Figure 7: This oboist's little finger remains extended
fig8
Figure 8: Collapse of the metacarpal heads of the right hand in a pianist with dystonia of the right hand.
fig9
Figure 9: Abnormal position with the wrist in flexion in order to facilitate finger extension.
fig10
Figure 10: Non-physiological position in a guitarist, with right wrist flexed and hand abducted.


TREATMENT

Orthopaedic specialists, and more particularly, hand surgeons, are likely to see musicians in their clinics. A specialist must be equipped to deal with this type of disorder before embarking on treatment; physiotherapists must be aware of the problems, as they will be the ones who treat the majority of these patients.

This type of disorder should be treated by a therapist who specialises in the field, and who should ideally have had some musical education, be very patient, have sufficient time to give, and be sufficiently open-minded to be able to understand the particular psychology of artists. The Medécine des Arts association organises training sessions leading to a diploma for physiotherapists. Specialist physiotherapy is the basis of management of most occupational disorders in musicians. Until this specialist physiotherapy becomes available, these patients should be sent to specialist centres; a list is available from Medécine des Arts (Association Européenne Médecine des Arts, 715 Chemin du Quart, F-82000 Montauban).

Treatment of upper limb disorders in musicians should obviously be guided by the clinical presentation.

Basic treatment of painful disorders of the musculotendinous system consists in resting the worst affected part of the body, often using splints. The differences between the treatment for overuse syndromes and that for inflammatory disorders have already been described. Inflammatory disorders will benefit from anti-inflammatory drugs, which are not very efficacious in overuse syndromes, where the most important element of treatment is resting the muscle involved. However, prolonged immobilisation is not recommended as it weakens the muscles and is disheartening for the musician. Instead, treatment should take the form of "active rest", in which the wearing of removable postural braces is alternated with gentle physiotherapy.

In all cases, once the pain has stopped, the return to playing should be very gradual and should be monitored by a physiotherapist specialising in this field. It is important to watch the patient playing his or her instrument so that poor posture can be corrected.

Joint instability is difficult to treat. Major instability in the metacarpophalangeal joint of the thumb can be corrected by arthrodesis, but there is no satisfactory solution for the other fingers. Exercises can be used to reinforce the extrinsic and intrinsic muscle groups, and great care should be taken to prevent the development of non-physiological positioning. Small finger splints have often been found to be very useful.

Peripheral nerve entrapment is initially treated with rest, splints and anti-inflammatory medication. If the problem persists, the nerve will have to be released surgically.

Surgery for proximal compression syndromes has sometimes been overdone; it should only be undertaken after an attempt has been made to re-educate the muscles over several months, which often achieves good results.

Functional dystonia poses the most difficult problems of therapy, with much more uncertain results. Most of our patients had already tried several types of treatment, with no lasting benefit; these have included general sedatives, various relaxation techniques, or intra-muscular injections of botulinum toxin. R. Cole (1991) concluded his study of the toxin with the words, "focal dystonia in a musician ... is characterised by both spasms and a disorder of co-ordination. Improvement in the spasms can be accomplished with botulinum toxin injections, but the motor co-ordination component is not addressed with this treatment".

Our observation of non-physiological positioning and poor posture was the basis for our system of rational re-education. Since 1975, we have been gradually refining the treatment we provide; the treatment goal is not just rehabilitation, but re-education in the fullest sense of the term. We try to help the musician to become aware of his or her bad posture and to "unprogram" the movements which are causing problems; to correct postural faults; and then to relearn movements which do not misuse the body. This re-education cannot be limited just to the hand, but addresses the whole arm and the spine.

It should be emphasised that treatment at the psychological level cannot be separated from physical re-education. The exercises underpin the mental adjustment to the new situation. The first encounter between the patient, the physician and the therapist is extremely important. The therapist plays a crucial role in this process, since he or she will be closely involved with the patient for many months: It is the therapist who will have to help the musician to be patient, and who will provide essential psychological support. Treatment should be given in a pleasant room, preferably on a one-to-one basis; and the therapist and patient should talk to each other while going through the physical exercises. It is very important to gain the patient's trust. One way of doing this is to explain the treatment that is being given, so the conversation should include discussion of the physical aspects of the motor problems and their causes.

Chamagne has established a four-stage re-education system that embodies our principles. In the first stage, the patient is placed in front of a mirror, to become aware of his or her body and to begin to correct poor body movements. The goal of the next stage is to relax the antagonist muscle groups, whose excessive sensitivity and tone appear to play a very important role. During the third stage, muscles are built up again; and during the fourth and final stage the musician learns a new playing position.

In order to evaluate the original incapacity objectively, we use a 6-point scale which goes from 0 (unable to play) to 5 (normal playing). This grading is now employed for overuse syndromes as well as for dystonia. It is also used to assess the results. Musicians suffering from overuse syndromes have almost all returned to playing within a period which varies according to how long the disorder had been present (average time of return to playing: between three and four months). Some very long-standing cases have taken more than a year to recover, and occasionally recovery has been incomplete with some residual pain, increased fatigability, and the possibility of recurrence.

Functional dystonia generally requires more prolonged treatment, for at least a year. The most serious cases (Grades 0 or 1) have only a small chance of improvement, but the majority of our patients with dystonia have benefited from the treatment we gave them. The likelihood of improvement and recovery increases with the original grade, i.e. the higher the grade, the better the chance of improvement. The quality and regularity of treatment is also important, as is the patient's motivation: It is essential that the patient should take an active part in the re-education process; this, in turn, requires considerable physical and mental effort on his or her part. If the patient co-operates fully, the outcome is likely to be good. In contrast, we feel that duration of the disorder is a less important factor: Some of our musicians who had had signs of dystonia for several years have responded favourably to treatment. However, it is better to start treatment as soon as possible.

Detailed results have been published by stage of disorder and by instrument (1993-1995). The satisfactory results obtained using this method for correcting non-physiological positioning and the re-education of posture for disorders affecting precision of movement, emphasise the importance of peripheral factors in the onset of functional dystonia in musicians. This does not make any assumptions about the pathogenesis of the disorder, which is still not known. We feel that relaxation techniques and intra-muscular injections of botulinum toxin may have an adjuvant role, but they should always be combined with a full programme of re-education, which is the basic treatment for dystonia.


Surgery

Surgery has only a limited place in the treatment of upper limb disorders in musicians. Apart from nerve entrapment syndromes, there are few indications for surgery; and in hand conditions, more than anywhere else, stringent patient selection is a must. However, stabilization of a very unstable metacarpophalangeal thumb joint may be useful. We have also performed arthrodesis on painful and unstable OA DIP joints, with good results. The indications for OA of the trapeziometacarpal joint are more difficult, and should be determined for each patient individually. We have also operated in cases of trigger finger recurring after a trial of injections, and in intractable De Quervain's disease.

There may be an indication for section of anomalous slips between the flexor pollicis longus and the flexor digitorum profundus (Linburg, 1979). Correction of a slip which is limiting interdigital web spread is possible, but making a normal web deeper has no effect on the playing of instruments, and section of the intertendinous connections of the extensors in order to increase finger spread can be dangerous. Correction of painful dislocations of the extensor tensors can be useful, as occasionally is tenosynovectomy in intractable cases, or decompression of a chronic compartment syndrome, which is a rare condition (Styf, 1987).

The indications for surgery for non-occupational disorders are the same for musicians as for other patients. We have operated on many musicians suffering from Dupuytren's contracture, from rheumatoid arthritis, ganglions and various tumours; and, obviously, we have treated cases of trauma. In these cases, surgery should not be regarded as a last resort, especially if early intervention will result in better restoration of function. This is particularly true in the case of fractures, when prolonged immobilisation may cause stiffness. Internal fixation may allow movement to be resumed after a very short time.

It goes without saying that, in musicians, any surgery on the hand or arm should be undertaken with the utmost care, and the approach should be carefully considered, since a tender scar may compromise resumption of normal practice. It is essential to begin rehabilitation early on, if possible with a specialist physiotherapist, to prevent bad posture being adopted in order to avoid painful movements or to compensate for muscular deficiencies.


Preventive measures (1)

We cannot conclude this article on hand disorders in musicians without touching on prevention. It is possible to prevent these disorders to some extent by analysing the principal factors responsible; these include poor position, intensive practice, change in technique, inappropriate lifestyle, and anxiety. The last of these is probably the most difficult to treat.

(1) See Traité de Chirurgie de la Main, Volume 6, the section Prévention de la pathologie des musiciens, which deals with the prevention of musicians' disorders.