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The musician's hand
Leading Article THE M U S I C I A N ' S H A N D I. WINSPUR and C. B. WYNN PARRY
From the Hand Clinic and Department of Rehabilitation, Devonshire Hospital, London, UK Care of the painful or injured hand or arm in a musician requires time, great patience, sophisticated knowledge and analysis of both the musician and their instrument, and in most cases a non-surgical approach. This is a tall order for the busy hand surgeon. Close collaboration between interested specialized physicians and the hand surgeon facilitates care of these patients. Additional help from music teachers, specialized instrumentalists, psychologists, arts therapists and family may be vital. Nevertheless, nothing short of a comprehensive approach will be successful and a limited approach may be functionally damaging if not disastrous. If an operation is necessary, provided surgery is performed with careful planning and skill, the results need not be as unsatisfactory as previously believed and3ndeed can in certain circumstances salvage a musician's career. Journal of Hand Surgery (British and European Volume, 1997) 22B." 4." 433-440
In recent years, there has been a good deal of publicity concerning problems with musicians suffering for their art. In the British press these have unfortunately been equated to so-called "repetitive strain injury" and it is believed that they are inevitably likely to suffer progressive musculoskeletal problems which threaten their career in music. We believe that this is erroneous - symptoms have a clear cause and they are not inevitable. They are due to incorrect technique, the musician's particular lifestyle as well as the standard incidental orthopaedic/rheumatological complaints that are commonly seen in a hand clinic. Orthopaedic surgeons may well find musicians' problems difficult to assess. Often there are few, if any, physical signs and musicians may present their symptoms in a somewhat unorthodox manner. This article, based on experience running a musicians' clinic for over 25 years (Wynn Parry, 1994) and on operative experience on professional musicians (Winspur, 1995), is designed to help the surgeon assess the likely cause of symptoms in a musician presenting with upper limb pain and suggests a plan of management for such patients and the likely results.
symptoms severe enough to compromise their playing. However, it is important to emphasize that symptoms or injury are not an inevitable accompaniment of a musical career. Most experienced orchestral musicians tell us that provided their technique is good, their lifestyle sensible and their spirit calm they should have no more than the usual run of aches and pains suffered by the normal population. Musicians in general have an innate fear of physicians and of surgeons in particular, and surgery on musicians' hands traditionally has a bad reputation, much of it anecdotal (Brandfonbrener, 1991; Brockman et al, 1990). However, musicians are increasingly turning to physicians for help and it is therefore not surprising that increasingly hand surgeons are having to become involved in the care of musicians. There is increasing concern for musicians' health world-wide and special clinics have been set up for musicians in many countries and a journal devoted exclusively to their problems is published. Recently a group of physicians and surgeons founded the British Performing Arts Medicine Trust (BPAMT). This provides a help line in Central London and special clinics in London, Bristol and Edinburgh in which all clinical specialties involved are represented. Ready access is also available to skilled physiotherapy, Alexander (Rosenthal, 1987) and Feldenkreis (Spire, 1989) teachers, psychologists and music teachers with special interest in technique and ergonomics. Thirty-five GPs have also been trained in the special requirements of musicians and are now attached to the major symphony orchestras and opera companies. In the last 5 years over 500 patients have been personally seen at these clinics and the experience gained analysed. The patients fell into three main groups:
BACKGROUND
That musicians make extraordinary demands on the upper limb needs no emphasis. Just how much demand is shown in a study by Paget of Mlle Janotha playing a presto of Mendelssohn on the piano (Critchley, 1977). In 4 minutes 3 seconds, 5595 notes were played and 72 bimanual finger movements per second were recorded. It requires many years of practice to achieve such dexterity and precision and the majority of musicians will practise many hours a day. In 1987 the International Congress of Symphony Orchestras and Opera Musicians in America carried out the survey of Over 4000 practising musicians (Fishbein and Middlestadt, 1988). The results showed that 84% of string players suffered at least one problem with pain in the shoulders, hands or fingers and that 76% suffered
• • •
433
coincidental rheumatological/orthopaedic disorders or the sequelae of injuries (40%) problems induced directly by playing or of a technical nature (40%) problems induced by psychological and emotional upset (20%).
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THE JOURNAL OF HAND SURGERY VOL. 22B No. 4 AUGUST 1997
Table 1--Specific orthopaediclrheumatologieal diagnoses in 323 patients attending a musicians' clinic True tenosynovitis Rotator cuff/frozen shoulder Old injury Back strain OA Thoracic outlet Tennis elbow Ganglions Carpal tunnel syndrome Rheumatoid arthritis Miscellaneous
31 25 17 16 11 9 6 4 4 3 t1 139 (42% of total)
The 40% who had well recognized orthopaedic or rheumatological disorders are represented in Table 1. Of these a small number were candidates for surgery. Of note is the fact that nine patients were seen and diagnosed as having thoracic outlet syndrome based upon clinical examination and X-rays of their cervical spine. All responded to conservative treatment and none required surgery. Our experience differs in this regard to other reported series (Roos, 1986). In published series from performing arts clinics there is a certain degree of variation in the diagnosis recorded that seems to relate to the particular interest of the physician in charge of the clinic. Thus orthopaedic surgeons report a higher incidence of entrapment neuropathies and tendonitis, neurologists report a higher incidence of dystonia and rheumatologists report a higher incidence of soft tissue injuries and lesions. There is also some confusion in the literature of a semantic nature. Many publications refer to overuse syndromes or tendonitis and yet it is clear that most of these cases do not have the classical swollen painful tendon sheaths that surgeons in the U K would require as mandatory for the diagnosis of such a condition. G E N E R A L I Z E D R H E U M A T O L O G I C A L AND ORTHOPAEDIC DISORDERS These cases represent 40% of patients seen in specialist clinics. However, localized problems in musicians may produce generalized symptoms or indeed generalized symptoms may mask local conditions. Many authors have drawn attention to the importance of noting any past injuries which might not have been adequately rehabilitated for the demands that musicians will make on their limbs. The slight restriction of movement after healed fractures or weakness of muscles following sprains are highly relevant. It is therefore important to take a careful history and to make a complete examination of the patient for residual stiffness or weakness in the neck or shoulder which may significantly affect function in the distal part of the limb and may not be
immediately obvious. The management of generalized rheumatological and orthopaedic problems in the musician is non-controversial. However, it is important to point out that it is always necessary to seek possible technical causes that have either aggravated or, in a few cases, caused the condition. It is also worthy of note that overt tenosynovitis or tendonitis is very rare in our experience and its presence is almost always related to non-musical activities such as DIY or sport. Also there is a high incidence of hypermobility and in our experience some 15% of musicians presenting to the clinic are hypermobile. This is highly relevant, for such patients require more than normal power, strength and stamina in their muscles to cope with the excessive movements that they possess. OVERUSE/MISUSE SYNDROMES
There is no evidence that even intense and protracted playing in itself carries the risk of an overuse syndrome without a pre-existing injury or chronic disease to disrupt normal play. Lippman (1991), one of the most experienced of music physicians, has stated "the term 'overuse' obscures many possible causes and malfunctions that can be connected and that tend to lead the music physician or therapist astray. In practice a second look will reveal that music playing beyond the point of fatigue and disregard for pain and discomfort is misuse, similarly to overdoing any exercise. Overuse is a simplistic descriptive label which ignores various other possible correctable causes of malfunction in the playing of a musical instrument." Thus the term "misuse" is preferable to "overuse" and eliminates any emotive feature that suggests that playing an instrument inevitably leads to problems. TECHNICAL PROBLEMS
These are by far the most important, in our experience. Experience from a musicians' clinic in Holland (Rietveld, 1995) indicates that at leash 50% of patients suffered
435
THE MUSICIAN'S H A N D
from technical, postural or stress related problems. Classic orthopaedic and rheumatological conditions were in the minority. Each instrument presents certain particular problems and is liable to cause musculoskeletal symptoms if technique is incorrect. Problems of technique may involve the weight and shape of the instrument in relation to the player's particular physique, the method by which it is held, the posture adopted during playing and the organization of practice sessions. By far the commonest problems are in relationship to keyboard and stringed instruments. Patients tend to present with vague generalized aching and pain related to specific muscle groups or to a particular muscle or tendon insertion. Overt physical signs are not usually present. There is no loss of movement but structural disorders such as rotator cuff ~t'esions or tennis elbow may have developed as a result of abnormal compensatory movements. STRESS
It is well recognized that emotional and psychological stress can manifest itself with generalized or localized musculoskeletal symptoms (Mayou, 1982; Wall, 1994). Musicians labour under constant stress, as is shown in the ICSOM (Fishbein and Middlestadt, 1988) which revealed 21% of musicians concerned with their alcohol intake, 20% taking some sort of drug for tension, and many on beta-blockers for stage fright. Symptoms follow prolonged periods of muscle tension and fatigue, and often appear if the patient is unhappy in the orchestra, with its conductor or with other players, with personal emotional difficulties, with domestic upheavals and worries about career. There are few physical signs other than the tenderness. These difficulties occur not only among classical musicians but also among jazz and rock musicians. However, British orchestral players seem particularly vulnerable as it is estimated that they work twice as hard for one-third of the salary compared with their European colleagues and are seldom able to support themselves exclusively by their orchestral playing. They are therefore constantly dashing between rehearsal, recording session, teaching engagement and concert with time only for rushed, inadequate meals. They sit in uncomfortable, poorly designed chairs, twisting their body to read the score to produce technically difficult sounds while keeping an eye on the conductor. Added to this is a very uncertain career structure with no security, particularly if their musical performance begins to falter. Music students are also vulnerable to stress. It can be induced by the intense competition in colleges and by both over-zealous and ambitious parents and equally by hostile parents and exam pressures. These young people masquerade as organic "repetitive strain injury". The management of stress is outside the scope of this paper. However, in our experience performance arts psychologists - - who are trained musicians - - are of great help with explanations and coping strategies.
THE INSTRUMENT/MUSICIAN INTERFACE Modern musical instruments have been developed along musical rather than ergonomic lines. It is not surprising that many of the musicians' hand and arm problems relate to this poor design but it is not recognized that in certain, admittedly limited, situations design modifications can be made. Each instrument has its own separate interface problems (Markison, 1990) usually identifiable with that instrument, and this along with faulty technique will produce symptoms, the correction of which may require both the adjustment of technique and of the instrument itself. Violin
Violinists are liable to suffer pain in the neck and shoulders if they hold the instrument too far forward. Most violin players of height 1.78 m (5' 10") or more, particularly those with long necks and sloping shoulders, will have neck discomfort which can be alleviated by the provision of an elevated chin rest or modified custom shoulder support or both. The weight of the instrument may vary up to 20% and this may be of importance to players of small physique. The position of the wrist and the ulnar deviation of the fingers necessary in the left hand, particularly of musicians with small hands, may cause pain. Changing to a slightly smaller or narrower necked instrument will be beneficial. The bowing arm is liable to problems if the shoulder lacks full internal rotation and the player bows incorrectly with a restricted arc of arm movement. Excessive power pinch grip on the bow is a potent cause of pain at the base of the thumb. Excessive vibrato liberato causes local pain particularly in the long finger. Piano
The classic problem with pianists is a too kyphotic posture of the neck and upper spine leading to discomfort in the shoulder and neck muscles. Hyperextension of the wrists also causes problems. Weakness of the intrinsic muscles of the hand diminishes overall performance but also overloads ligaments and joints and may cause pain. It is not however realized that piano actions vary considerably in weight and that a change or adjustment in piano may be needed. Cello Cellists are particularly prone to rotator cuff problem and also pain in the bowing thumb. Correct positioning of the instrument and correct bowing technique will alleviate many of these problems. However, for patients with localized mechanical problems at the base of the thumb a change from the French to the German bow, where the weight of the bow is taken in the palm, may be the solution.
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Guitar
Guitarists are frequent attenders at our medical clinics mostly with problems of hand and wrist, although players of the heavier bass guitars have neck problems related to neck straps. Most non-classical guitarists are self-taught and therefore have not received instruction on correct technique, posture and practice (Kember and Wassily, 1995). Additionally, excessive string tension can lead to problems. A number of guitarists have particular problems with left hand and wrist pain and numbness. Many times this is the result of playing with the instrument in too rotated a position and with the left wrist hyperflexed. This unphysiological position produces transient irritation on the median nerve. Adjustment in technique and repositioning of the instrument will allow the wrist to be placed more physiologically and will alleviate the problem. Clarinet/oboe
The weight of these instruments is taken on the distal phalanx of the right thumb and a chronic painful synovitis of the IP joint many times results (Nolan and Eaton, 1989). This can be alleviated by the manufacture of a wider thumb post distributing the load to both the distal and the proximal phalanx. Additionally for specific digital deformity or limitation the keys and key positions can be modified and re-engineered as can the keys on a saxophone. Bassoon
Bassoon players typically complain of neck and shoulder symptoms or of difficulty due to the wide span required, particularly for the base keys in the right hand. The neck and shoulder difficulties are related to carrying the weight of the instrument by a neck strap and this can be alleviated by the provision of a floor spike. Modified bassoons are available for those with small hands. Existing instruments can be slightly modified to facilitate the absence of widespan by re-engineering the base keys.
T H E J O U R N A L OF H A N D SURGERY VOL. 22B No. 4 A U G U S T 1997
should not practise for more than 20 minutes at a stretch, and that practice should always be preceded by proper warm-up, and interspersed with stretching and general mobilizing exercises. Prevention is the secret, but when symptoms have developed they may persist long after the initial insult due to what appears to be central sensitization (Roberts, 1986). Management of symptoms must always be in the context of graded structured playing as rest and non-playing is damaging to the musician. Help from allied professionals will always be required in the areas of technique, interface and psychology, and should be obtained at an early point in the patient's care. These specialists are available via the musicians' clinic network. LOCALIZED CONDITIONS Among symptomatic instrumentalists generalized complaints in the upper extremity are more common than localized. Localized complaints may be due to local pathology, local loading or referred pain to that area. Additionally, local pathology may cause a subtle change in the playing position of the musician which in itself then produces generalized symptoms. Indeed the presence of local pathology may not even be suspected in the patient with generalized complaints. Poor technique, poor generalized physique and posture may produce excessive local loading and symptoms. The surgeon is specifically concerned with localized conditions. The correct treatment of such conditions, however, may not be direct local treatment but correction of the more distant cause. Figure 1 summarizes the above relationships. SURGICAL ASSESSMENT A good history and thorough and complete examination with the patient stripped are the basis of a good initial assessment. The language and terminology used by the musician to describe his plight may be foreign to the
Flute
A highly abnormal posture is required to play this instrument. Wrist and tendon problems develop particularly on the left hand and these can occasionally be remedied by re-engineering of the keys.
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1
COMPLA,NTS
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lOOM ..... S
SYSTEsMEIC S S S
GENERAL MANAGEMENT Playing a musical instrument is a physical activity which requires a general level of fitness. Non-contact sports should be encouraged, and body control and stretching techniques such as yoga and Alexander technique can be very beneficial. Most "damage" is done in practice. John Williams, the world-renowned guitarist, stresses that one
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SOI'~ATIZATI0 N
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INVESTIGATIONAND TREATMENT
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TECHNIQUE !
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Fig 1 Handand arm pain in musicians.
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THEMUSICIAN'SHAND
437
surgeon and the actual instrument, its mechanisms and the interface are often completely unknown to the surgeon. Therefore it is important that the musician also be examined with his instrument and while playing (Amadio and Russotti, 1990). This requires understanding and time, conditions seldom available to the surgeon in the middle of a busy clinic. Statistically, even when presenting with a localized complaint the patient's problems will lie within the areas of technique, posture or generalized musculoskeletal disorder. Specialist hand surgeons therefore in most circumstances are poorly placed to perform preliminary assessment and this is ideally performed by an experienced non-surgical physician working with a music teacher. In less than ideal circumstances if one, as a hand surgeon, is required to perform initial assessment tfiere are no short cuts and unless complete analysis is performed mistakes will be made. Among local conditions one would expect a broad spectrum of common pathological entities (Table 2) without any great diagnostic problems. The management however may lie in areas of adjustment technique or interface rather than by a direct surgical approach. Surgical indications
Standard surgical indications are of little help when dealing with musicians. In certain circumstances indications should be much stricter, in others modified and in others relaxed. Wisdom and prudence are better guides.
Reduced indications Open trauma from domestic accidents with kitchen knives etc. does occur with unfortunate frequency to musicians. In these circumstances considerable additional effort (despite the accepted risks) should be committed to restoring anatomical integrity when normally one would accept what is perhaps a minor defect. Examples of this are the repair of the isolated flexor profundus laceration in zone 1 which should be repaired through an intact sublimis (Leddy, 1993) or the repair of
non-critical digital nerves or the more distal nerve injury when in a non-musician the minor defect would be accepted.
Modified indications Instrumentalists requiring wide span (i.e. pianists and bassoon players) with Dupuytren's contracture have considerable mechanical difficulty often in the early stages of the disease when very little digital contracture exists but a troublesome band runs across the base of the little and ring finger web, with loss of abduction of the little finger. This is a clear indication in these patients for surgical release. Conversely, digital flexion contractures, even when moderately advanced, can cause no functional problems to many string players and in these cases, even when clear indications exist for release, no operation should be done. Small localized lesions (e.g. flexor sheath ganglions on percussionists) cause modification in the player's technique, which in itself can cause substantial generalized symptomatology out of proportion to the basic localized lesion. In such circumstances surgical excision should be performed when perhaps not otherwise indicated.
Stricter indications If in doubt, the conservative course is the route of choice when dealing with the musician's hand. Nowhere is this more clearly seen than when dealing with musicians referred with the diagnosis of "carpal tunnel syndrome", i.e. median nerve related paraesthesia and hypoaesthesia (Trouli and Reissis, 1994). However the clinical picture is much more complicated and, having excluded those with a more proximal pathology for their symptoms, w~ recognize clinically three subgroups in musicians with carpal tunnel like symptoms.
Subgroup 1 - - classic idiopathic carpal tunnel syndrome These musicians are older and are usually in their fifth or sixth decade. They present with classic symptoms of
Table 2--Instruments and medical conditions in 22 professional musicians undergoing operations Instruments
Piano String Woodwind Guitar Percussion
8 6 4 3 1
Dupuytren's contracture Tumours Trauma Carpal tunnel syndrome Arthrodesis Ulnar neuropathy(elbow)
7 5 4 3 2 1
Medical condition
438
carpal tunnel syndrome unrelated to levels of playing and unrelieved by periods of rest and with very constant symptoms of night time numbness, paraesthesia and upper arm aching. Examination will reveal classical findings related to the median nerve at the wrist. Nerve conduction testing will be abnormal, i.e. they have classic idiopathic carpal tunnel syndrome. They can be expected to have the same dramatic benefit from surgical release as the general population and will resume their full playing quickly. Median nerve paraesthesia in guitarists is well recognized. On careful questioning, it usually occurs in the left or fingering hand, occurs while playing or shortly after, does not occur when resting and does not occur at night. Nerve conduction tests will be nori~al. On careful analysis one usually finds a technical fault in the playing and when this playing position is readjusted their symptoms disappear. These patients respond very poorly to surgery!
T H E J O U R N A L OF H A N D SURGERY VOL. 22B No. 4 A U G U S T 1997
• •
provision must be made for very early return to limited playing and practice anticipated anatomical compromise must be adjusted to fit the instrument.
These three factors should be obvious but unless one carefully examines, and occasionally measures the patient in the playing position on his instrument, mistakes will be made.
Subgroup 2 - - acute positional
Subgroup 3 - - transient tenosynovial swelling These patients are commonly younger pianists or violinists who give a clear history of median nerve paraesthesia or numbness associated with extended or vigorous playing. Their symptoms are present while or immediately after playing and are not present during periods of rest or holiday. They occasionally experience a few episodes of night numbness but these disappear immediately following a brief period of rest. On examination the clinical findings usually are of some slight visible boggy swelling on the flexor aspect of the wrist and many times some palpable tender nodules and swelling over the flexor tendons and tendon sheaths in the distal palm usually involving the long finger. Nerve conduction tests are normal. They respond well to slightly reduced playing and steroid injections into the carpal tunnel. Additionally, longer term conditioning, modification of warm-up practice and playing schedules may be required and also attention paid to technique and to the piano action. However, they will generally fare well following this type of care. They fare very badly following surgical release. Simply stated, when dealing with musicians, the absence of abnormal delay in median nerve conduction across the wrist when measured by standard technique is an absolute contraindication to surgical release (by any method) of the carpal tunnel.
SURGICAL TECHNIQUES Generally local anaesthesia is used as musicians tend to be more accepting of this than general anaesthesia with its perceived added risks and "loss of control". Musicians fare well under local anaesthesia and with rapid recovery "rehabilitation" in the broad sense starts within a few hours of the operation. Standard surgical techniques are used but these must be modified in three critical areas: * incisions must be placed away from critical tactile points
Location of incisions The precise contact point to be avoided may not be obvious without prior analysis by the surgeon. Woodwind players support the instrument along the ulnar border of the right thumb and a mid lateral incision in this area is unacceptably tender (a palmar approach is more appropriate). The chanter on a bagpipe is fingered by the palmar aspect of the middle segment of the digit and the palmar zig-zag approach violates critical sensitive areas. The correct approach in this circumstance should be a non-standard ulnar midlateral approach elevating the digital nerve and its more proximal palmar branches with the flap.
Early return to playing Depriving the musician of his or her means of selfexpression is devastating and easily leads to depression. Absence from playing is also physically damaging to musicians. There is no evidence that prolonged rest has any place in management of any condition in the musician and in the post operative situation every effort should be made to facilitate a very early return to limited playing. The siting and direction of the incisions and also the type of closure may all need to be modified. In this regard the closed rather than open techniques of Dupuytren's release are to be preferred (Gonzalez, 1974; Hueston, 1961). When a joint requires arthrodesis (an exceptional but not necessarily career-ending event) tension band technique even in the distal joints (Allende and Engleman, 1980) along with very careful pin placement can allow early return to limited playing. The average time off the instrument in the authors, current experience has been 2 to 4 weeks but a target of 5 to 6 days is ideal (Table 3).
The playing position The "functional" position for a musician may come as a surprise to the surgeon. Hence when planning arthrodesis or tenodesis, the patient and the surgeon must analyse carefully the playing position and measure the required optimum position for the joint in question and reproduce this exactly at the time of operation using a sterile goniometer.
THE MUSICIAN'S HAND
439
Table 3--Results in 23 professional musicians treated by operation (one lost to follow-up. Twentytwo returned to full-time playing). Follow-up 3 months to 10 years Time o f f instrument (weeks)
Time to full playing (weeks) 5.2
Dupuytren's
2.1
Tumours
1
3.8
Trauma
6
10.5
Carpal tunnel syndrome
1.8
Arthrodesis
3
13
U l n a r nerve release (elbow)
6
12
Average
3.3
Results of surgery
There are many reports of poor results from surgery in musicians (Brockman et al, 1990). However, two recent papers on specific extensor tendon binding or triggering give grounds for guarded optimism (Benetar, 1994; McGregor and Glarer, 1988). Additionally, on thorough searching, others report successful surgical intervention in a number of local conditions in musicians (Lederman, 1994). The authors' experience over 10 years of operating on professional musicians and utilizing the analysis and techniques discussed would confirm that musicians are not necessarily the surgical nightmare one assumes (Table 3). DYSTONIA
Dystonia accounts for 10% of referrals to music clinics world wide (Graffman, 1986). It is one of the most dreaded problems to afflict musicians. It usually affects players in mid-career and seldom before the musician has played seriously for less than 10 years. It starts with the inability to move a particular finger at the speed and later with the accuracy required to play. The condition is painless and the phenomenon never affects any other activity (e.g. a violinist so afflicted can play the piano without trouble). This is the key to diagnosis. Very occasionally a structural lesion such as a meningioma may be the cause and therefore a thorough and complete neurological investigation should be performed initially. However in most cases no focal neurological lesion can be demonstrated and the condition can be best regarded as a fatigue or disorganization possibly at the basal ganglion level in the brain stem. Dystonia will however present to surgeons since, of course, it does present as a localized phenomenon. Successful treatment involves a combination of modalities, particularly a very specific modification of activity and limited resting, utilization of the Feldenkreis and Alexander techniques and physiotherapy by a specialist conversant with disorders of coordination (Chamagne, 1983). Drugs are of no help in our
6
8.4
experience. There is no doubt that the earlier the patient is seen the more likely he is to recover (Tubiana and Chamagne, 1993). The most valuable help the surgeon can give, having recognized the condition and given the diagnosis, is to state clearly that there is no damage and that with careful re-education a full playing career may again be achieved. Address
British Performing Arts Medicine Trust (BPAMT), 18 Ogle Street, London W1P 7LG. Tel: 0171 636 6860 References Amadio PC, Russotti GN (1990). Evaluation and treatment of hand and wrist disorders in musicians. Hand Clinics, 6: 405-416. Allende B, Engelman J (1980). Tension band arthrodesis in finger joints. Journal of Hand Surgery, 5:269 271. Benatar N (1994). Radial subluxation of the connexus intertendineus. Journal of~ Hand Surgery, 18B: 81-87. Brockman R, Chamagne P, Tubiana R. The upper extremity in musicians. In: Tubiana R (Ed.): The hand, Philadelphia, W B Saunders, 1990, Vol 4: 873485. Brandfonbrener A (1991 ). Special treatment for musicians? Some specific hazards of elective surgery. Medical Problems of Performing Artists, 6: 37-38. Chamagne P (1983). Approche kin6sith6rapique des crampes fonctionnelles dites professionnelles. Semestrial de l'H6pital de Paris, 59: 3080-3086. Critchley N. Occupational palsies in musical performers. In: Critchley N, Henson R (Eds): Music and the brain. London, Heinemann, 1977: 365. Fishbein N, Middlestadt SE (1988). Medical problems among the ICSOM musicians - overview of a national survey. Medical Problems of Performing Artists, 3: 1-8. Gonzalez RI. Open fasciotomy and full thickness skin graft in the correction of digital flexion deformity. In: Huston J T, Tubiana R (Eds): Dupuytren's disease. Edinburgh, Churchill Livingstone, 1974:123 127. Graffman G (1986). Doctor, can you lend an ear? Medical Problems of Performing Artists, 1: 3-4. Hueston JT (1961). Limited fasciectomy for Dupuytren's contracture. Plastic and Reconstructive Surgery, 27:569 585. Kember J, Wassily S A (1995). You and your guitar. Classical Guitar, 14:3 8. Leddy J. Flexor tendons--acute injury. In: Green, (Ed.): Operative hand surgery, 3rd edn. New York, Churchill Livingstone, 1993, Vol 2: 1823-1845. Lederman R (1994). Neuromuscular problems in the performing arts. Muscle and Nerve, 17: 569-577. Lippman HI (1991). A fresh look at the overuse syndrome in musical performers. Medical Problems of Performing Artists, 6: 57-60. Markison RE (1990). Treatment of musical hands: redesign of the interface. Hand Clinics, 6:525 544. Mayou RA. Somatic symptoms without physical cause. In: Weatherall D J, Ledingham JGG, Warrell DA (Eds): Oxford textbook of medicine. Oxford, Oxford University Press, 1982:25.55 56. McGregor I, Glover L (1988). The E-flat hand. Journal of Hand Surgery, 13A: 692-693.
440 Nolan WK Eaton RG (1989). Thumb problems of professional musicians. Medical Problems of Performing Artists, 4: 20-22. Rietveld B (1995). Performing arts clinics--a Dutch approach. Performing Arts Medical News, 3: 12-18. Roberts WJ (I986). A hypothesis on a physiological basis for causalgia and related pains. Pain, 24:297 312. Roos DB (1986). Thoracic outlet syndromes: symptoms, diagnosis, anatomy and surgical treatment. Medical Problems of Performing Artists, h 90-92. Rosenthal E (1987). The Alexander Technique, what it is and how it works. Medical Problems of Performing Artists, 2:53 57. Spire M (I989). The Feldenkreis Method. An interview with Anat Baniel. Medical Problems of Performing Artists, 4:i59 162. Trouli H, Reissis N (1994). Carpal tunnel symptoms in patients: anxiety for both patient and surgeon. Journal of Hand Surgery, 19B (Supplement): 11. Tubiana R, Chamagne P (1993). Les affections professionnelles du membre
THE JOURNAL OF HAND SURGERY VOL. 22B No. 4 AUGUST 1997 sup6rieur chez les musiciens. Bulletin Acad6mie Nationale de M6decine, 177: 203516. Wall PD. Pain without peripheral pathology. In: Wall PD, Melzack R (Eds): Textbook of pain, 2nd edn. Edinburgh, Churchill Livingstone, 1994: 4 28. Winspur 1 (1995). The professional musician and the hand surgeon. In: Vastamaki M e t al (Eds): Proceedings of the 6th Congress of IFFSH Helsinki. Bologna, Monduzi Editori, 1995:1207-1211. Wynn Parry C B (1994). Musicians suffer a variety of problems. Journal of Hand Surgery, 19B (Supplement): 11 12. Mr I. Winspur,The Hand Clinic, DevonshireHospital, 29 DevonshireStreet, London W1N IRF, UK. © i997 The British Societyfor Surgery of the Hand
From the Hand Clinic and Department of Rehabilitation, Devonshire Hospital, London, UK Care of the painful or injured hand or arm in a musician requires time, great patience, sophisticated knowledge and analysis of both the musician and their instrument, and in most cases a non-surgical approach. This is a tall order for the busy hand surgeon. Close collaboration between interested specialized physicians and the hand surgeon facilitates care of these patients. Additional help from music teachers, specialized instrumentalists, psychologists, arts therapists and family may be vital. Nevertheless, nothing short of a comprehensive approach will be successful and a limited approach may be functionally damaging if not disastrous. If an operation is necessary, provided surgery is performed with careful planning and skill, the results need not be as unsatisfactory as previously believed and3ndeed can in certain circumstances salvage a musician's career. Journal of Hand Surgery (British and European Volume, 1997) 22B." 4." 433-440
In recent years, there has been a good deal of publicity concerning problems with musicians suffering for their art. In the British press these have unfortunately been equated to so-called "repetitive strain injury" and it is believed that they are inevitably likely to suffer progressive musculoskeletal problems which threaten their career in music. We believe that this is erroneous - symptoms have a clear cause and they are not inevitable. They are due to incorrect technique, the musician's particular lifestyle as well as the standard incidental orthopaedic/rheumatological complaints that are commonly seen in a hand clinic. Orthopaedic surgeons may well find musicians' problems difficult to assess. Often there are few, if any, physical signs and musicians may present their symptoms in a somewhat unorthodox manner. This article, based on experience running a musicians' clinic for over 25 years (Wynn Parry, 1994) and on operative experience on professional musicians (Winspur, 1995), is designed to help the surgeon assess the likely cause of symptoms in a musician presenting with upper limb pain and suggests a plan of management for such patients and the likely results.
symptoms severe enough to compromise their playing. However, it is important to emphasize that symptoms or injury are not an inevitable accompaniment of a musical career. Most experienced orchestral musicians tell us that provided their technique is good, their lifestyle sensible and their spirit calm they should have no more than the usual run of aches and pains suffered by the normal population. Musicians in general have an innate fear of physicians and of surgeons in particular, and surgery on musicians' hands traditionally has a bad reputation, much of it anecdotal (Brandfonbrener, 1991; Brockman et al, 1990). However, musicians are increasingly turning to physicians for help and it is therefore not surprising that increasingly hand surgeons are having to become involved in the care of musicians. There is increasing concern for musicians' health world-wide and special clinics have been set up for musicians in many countries and a journal devoted exclusively to their problems is published. Recently a group of physicians and surgeons founded the British Performing Arts Medicine Trust (BPAMT). This provides a help line in Central London and special clinics in London, Bristol and Edinburgh in which all clinical specialties involved are represented. Ready access is also available to skilled physiotherapy, Alexander (Rosenthal, 1987) and Feldenkreis (Spire, 1989) teachers, psychologists and music teachers with special interest in technique and ergonomics. Thirty-five GPs have also been trained in the special requirements of musicians and are now attached to the major symphony orchestras and opera companies. In the last 5 years over 500 patients have been personally seen at these clinics and the experience gained analysed. The patients fell into three main groups:
BACKGROUND
That musicians make extraordinary demands on the upper limb needs no emphasis. Just how much demand is shown in a study by Paget of Mlle Janotha playing a presto of Mendelssohn on the piano (Critchley, 1977). In 4 minutes 3 seconds, 5595 notes were played and 72 bimanual finger movements per second were recorded. It requires many years of practice to achieve such dexterity and precision and the majority of musicians will practise many hours a day. In 1987 the International Congress of Symphony Orchestras and Opera Musicians in America carried out the survey of Over 4000 practising musicians (Fishbein and Middlestadt, 1988). The results showed that 84% of string players suffered at least one problem with pain in the shoulders, hands or fingers and that 76% suffered
• • •
433
coincidental rheumatological/orthopaedic disorders or the sequelae of injuries (40%) problems induced directly by playing or of a technical nature (40%) problems induced by psychological and emotional upset (20%).
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THE JOURNAL OF HAND SURGERY VOL. 22B No. 4 AUGUST 1997
Table 1--Specific orthopaediclrheumatologieal diagnoses in 323 patients attending a musicians' clinic True tenosynovitis Rotator cuff/frozen shoulder Old injury Back strain OA Thoracic outlet Tennis elbow Ganglions Carpal tunnel syndrome Rheumatoid arthritis Miscellaneous
31 25 17 16 11 9 6 4 4 3 t1 139 (42% of total)
The 40% who had well recognized orthopaedic or rheumatological disorders are represented in Table 1. Of these a small number were candidates for surgery. Of note is the fact that nine patients were seen and diagnosed as having thoracic outlet syndrome based upon clinical examination and X-rays of their cervical spine. All responded to conservative treatment and none required surgery. Our experience differs in this regard to other reported series (Roos, 1986). In published series from performing arts clinics there is a certain degree of variation in the diagnosis recorded that seems to relate to the particular interest of the physician in charge of the clinic. Thus orthopaedic surgeons report a higher incidence of entrapment neuropathies and tendonitis, neurologists report a higher incidence of dystonia and rheumatologists report a higher incidence of soft tissue injuries and lesions. There is also some confusion in the literature of a semantic nature. Many publications refer to overuse syndromes or tendonitis and yet it is clear that most of these cases do not have the classical swollen painful tendon sheaths that surgeons in the U K would require as mandatory for the diagnosis of such a condition. G E N E R A L I Z E D R H E U M A T O L O G I C A L AND ORTHOPAEDIC DISORDERS These cases represent 40% of patients seen in specialist clinics. However, localized problems in musicians may produce generalized symptoms or indeed generalized symptoms may mask local conditions. Many authors have drawn attention to the importance of noting any past injuries which might not have been adequately rehabilitated for the demands that musicians will make on their limbs. The slight restriction of movement after healed fractures or weakness of muscles following sprains are highly relevant. It is therefore important to take a careful history and to make a complete examination of the patient for residual stiffness or weakness in the neck or shoulder which may significantly affect function in the distal part of the limb and may not be
immediately obvious. The management of generalized rheumatological and orthopaedic problems in the musician is non-controversial. However, it is important to point out that it is always necessary to seek possible technical causes that have either aggravated or, in a few cases, caused the condition. It is also worthy of note that overt tenosynovitis or tendonitis is very rare in our experience and its presence is almost always related to non-musical activities such as DIY or sport. Also there is a high incidence of hypermobility and in our experience some 15% of musicians presenting to the clinic are hypermobile. This is highly relevant, for such patients require more than normal power, strength and stamina in their muscles to cope with the excessive movements that they possess. OVERUSE/MISUSE SYNDROMES
There is no evidence that even intense and protracted playing in itself carries the risk of an overuse syndrome without a pre-existing injury or chronic disease to disrupt normal play. Lippman (1991), one of the most experienced of music physicians, has stated "the term 'overuse' obscures many possible causes and malfunctions that can be connected and that tend to lead the music physician or therapist astray. In practice a second look will reveal that music playing beyond the point of fatigue and disregard for pain and discomfort is misuse, similarly to overdoing any exercise. Overuse is a simplistic descriptive label which ignores various other possible correctable causes of malfunction in the playing of a musical instrument." Thus the term "misuse" is preferable to "overuse" and eliminates any emotive feature that suggests that playing an instrument inevitably leads to problems. TECHNICAL PROBLEMS
These are by far the most important, in our experience. Experience from a musicians' clinic in Holland (Rietveld, 1995) indicates that at leash 50% of patients suffered
435
THE MUSICIAN'S H A N D
from technical, postural or stress related problems. Classic orthopaedic and rheumatological conditions were in the minority. Each instrument presents certain particular problems and is liable to cause musculoskeletal symptoms if technique is incorrect. Problems of technique may involve the weight and shape of the instrument in relation to the player's particular physique, the method by which it is held, the posture adopted during playing and the organization of practice sessions. By far the commonest problems are in relationship to keyboard and stringed instruments. Patients tend to present with vague generalized aching and pain related to specific muscle groups or to a particular muscle or tendon insertion. Overt physical signs are not usually present. There is no loss of movement but structural disorders such as rotator cuff ~t'esions or tennis elbow may have developed as a result of abnormal compensatory movements. STRESS
It is well recognized that emotional and psychological stress can manifest itself with generalized or localized musculoskeletal symptoms (Mayou, 1982; Wall, 1994). Musicians labour under constant stress, as is shown in the ICSOM (Fishbein and Middlestadt, 1988) which revealed 21% of musicians concerned with their alcohol intake, 20% taking some sort of drug for tension, and many on beta-blockers for stage fright. Symptoms follow prolonged periods of muscle tension and fatigue, and often appear if the patient is unhappy in the orchestra, with its conductor or with other players, with personal emotional difficulties, with domestic upheavals and worries about career. There are few physical signs other than the tenderness. These difficulties occur not only among classical musicians but also among jazz and rock musicians. However, British orchestral players seem particularly vulnerable as it is estimated that they work twice as hard for one-third of the salary compared with their European colleagues and are seldom able to support themselves exclusively by their orchestral playing. They are therefore constantly dashing between rehearsal, recording session, teaching engagement and concert with time only for rushed, inadequate meals. They sit in uncomfortable, poorly designed chairs, twisting their body to read the score to produce technically difficult sounds while keeping an eye on the conductor. Added to this is a very uncertain career structure with no security, particularly if their musical performance begins to falter. Music students are also vulnerable to stress. It can be induced by the intense competition in colleges and by both over-zealous and ambitious parents and equally by hostile parents and exam pressures. These young people masquerade as organic "repetitive strain injury". The management of stress is outside the scope of this paper. However, in our experience performance arts psychologists - - who are trained musicians - - are of great help with explanations and coping strategies.
THE INSTRUMENT/MUSICIAN INTERFACE Modern musical instruments have been developed along musical rather than ergonomic lines. It is not surprising that many of the musicians' hand and arm problems relate to this poor design but it is not recognized that in certain, admittedly limited, situations design modifications can be made. Each instrument has its own separate interface problems (Markison, 1990) usually identifiable with that instrument, and this along with faulty technique will produce symptoms, the correction of which may require both the adjustment of technique and of the instrument itself. Violin
Violinists are liable to suffer pain in the neck and shoulders if they hold the instrument too far forward. Most violin players of height 1.78 m (5' 10") or more, particularly those with long necks and sloping shoulders, will have neck discomfort which can be alleviated by the provision of an elevated chin rest or modified custom shoulder support or both. The weight of the instrument may vary up to 20% and this may be of importance to players of small physique. The position of the wrist and the ulnar deviation of the fingers necessary in the left hand, particularly of musicians with small hands, may cause pain. Changing to a slightly smaller or narrower necked instrument will be beneficial. The bowing arm is liable to problems if the shoulder lacks full internal rotation and the player bows incorrectly with a restricted arc of arm movement. Excessive power pinch grip on the bow is a potent cause of pain at the base of the thumb. Excessive vibrato liberato causes local pain particularly in the long finger. Piano
The classic problem with pianists is a too kyphotic posture of the neck and upper spine leading to discomfort in the shoulder and neck muscles. Hyperextension of the wrists also causes problems. Weakness of the intrinsic muscles of the hand diminishes overall performance but also overloads ligaments and joints and may cause pain. It is not however realized that piano actions vary considerably in weight and that a change or adjustment in piano may be needed. Cello Cellists are particularly prone to rotator cuff problem and also pain in the bowing thumb. Correct positioning of the instrument and correct bowing technique will alleviate many of these problems. However, for patients with localized mechanical problems at the base of the thumb a change from the French to the German bow, where the weight of the bow is taken in the palm, may be the solution.
436
Guitar
Guitarists are frequent attenders at our medical clinics mostly with problems of hand and wrist, although players of the heavier bass guitars have neck problems related to neck straps. Most non-classical guitarists are self-taught and therefore have not received instruction on correct technique, posture and practice (Kember and Wassily, 1995). Additionally, excessive string tension can lead to problems. A number of guitarists have particular problems with left hand and wrist pain and numbness. Many times this is the result of playing with the instrument in too rotated a position and with the left wrist hyperflexed. This unphysiological position produces transient irritation on the median nerve. Adjustment in technique and repositioning of the instrument will allow the wrist to be placed more physiologically and will alleviate the problem. Clarinet/oboe
The weight of these instruments is taken on the distal phalanx of the right thumb and a chronic painful synovitis of the IP joint many times results (Nolan and Eaton, 1989). This can be alleviated by the manufacture of a wider thumb post distributing the load to both the distal and the proximal phalanx. Additionally for specific digital deformity or limitation the keys and key positions can be modified and re-engineered as can the keys on a saxophone. Bassoon
Bassoon players typically complain of neck and shoulder symptoms or of difficulty due to the wide span required, particularly for the base keys in the right hand. The neck and shoulder difficulties are related to carrying the weight of the instrument by a neck strap and this can be alleviated by the provision of a floor spike. Modified bassoons are available for those with small hands. Existing instruments can be slightly modified to facilitate the absence of widespan by re-engineering the base keys.
T H E J O U R N A L OF H A N D SURGERY VOL. 22B No. 4 A U G U S T 1997
should not practise for more than 20 minutes at a stretch, and that practice should always be preceded by proper warm-up, and interspersed with stretching and general mobilizing exercises. Prevention is the secret, but when symptoms have developed they may persist long after the initial insult due to what appears to be central sensitization (Roberts, 1986). Management of symptoms must always be in the context of graded structured playing as rest and non-playing is damaging to the musician. Help from allied professionals will always be required in the areas of technique, interface and psychology, and should be obtained at an early point in the patient's care. These specialists are available via the musicians' clinic network. LOCALIZED CONDITIONS Among symptomatic instrumentalists generalized complaints in the upper extremity are more common than localized. Localized complaints may be due to local pathology, local loading or referred pain to that area. Additionally, local pathology may cause a subtle change in the playing position of the musician which in itself then produces generalized symptoms. Indeed the presence of local pathology may not even be suspected in the patient with generalized complaints. Poor technique, poor generalized physique and posture may produce excessive local loading and symptoms. The surgeon is specifically concerned with localized conditions. The correct treatment of such conditions, however, may not be direct local treatment but correction of the more distant cause. Figure 1 summarizes the above relationships. SURGICAL ASSESSMENT A good history and thorough and complete examination with the patient stripped are the basis of a good initial assessment. The language and terminology used by the musician to describe his plight may be foreign to the
Flute
A highly abnormal posture is required to play this instrument. Wrist and tendon problems develop particularly on the left hand and these can occasionally be remedied by re-engineering of the keys.
-"
i~
1
COMPLA,NTS
!"
lOOM ..... S
SYSTEsMEIC S S S
GENERAL MANAGEMENT Playing a musical instrument is a physical activity which requires a general level of fitness. Non-contact sports should be encouraged, and body control and stretching techniques such as yoga and Alexander technique can be very beneficial. Most "damage" is done in practice. John Williams, the world-renowned guitarist, stresses that one
! OENE~UZEO
LOCALIZED
SOI'~ATIZATI0 N
60%
fi /
INVESTIGATIONAND TREATMENT
,o,o
cO~.EOT,O./I
TECHNIQUE !
"°'°
Fig 1 Handand arm pain in musicians.
j
i
'°'°
/
THEMUSICIAN'SHAND
437
surgeon and the actual instrument, its mechanisms and the interface are often completely unknown to the surgeon. Therefore it is important that the musician also be examined with his instrument and while playing (Amadio and Russotti, 1990). This requires understanding and time, conditions seldom available to the surgeon in the middle of a busy clinic. Statistically, even when presenting with a localized complaint the patient's problems will lie within the areas of technique, posture or generalized musculoskeletal disorder. Specialist hand surgeons therefore in most circumstances are poorly placed to perform preliminary assessment and this is ideally performed by an experienced non-surgical physician working with a music teacher. In less than ideal circumstances if one, as a hand surgeon, is required to perform initial assessment tfiere are no short cuts and unless complete analysis is performed mistakes will be made. Among local conditions one would expect a broad spectrum of common pathological entities (Table 2) without any great diagnostic problems. The management however may lie in areas of adjustment technique or interface rather than by a direct surgical approach. Surgical indications
Standard surgical indications are of little help when dealing with musicians. In certain circumstances indications should be much stricter, in others modified and in others relaxed. Wisdom and prudence are better guides.
Reduced indications Open trauma from domestic accidents with kitchen knives etc. does occur with unfortunate frequency to musicians. In these circumstances considerable additional effort (despite the accepted risks) should be committed to restoring anatomical integrity when normally one would accept what is perhaps a minor defect. Examples of this are the repair of the isolated flexor profundus laceration in zone 1 which should be repaired through an intact sublimis (Leddy, 1993) or the repair of
non-critical digital nerves or the more distal nerve injury when in a non-musician the minor defect would be accepted.
Modified indications Instrumentalists requiring wide span (i.e. pianists and bassoon players) with Dupuytren's contracture have considerable mechanical difficulty often in the early stages of the disease when very little digital contracture exists but a troublesome band runs across the base of the little and ring finger web, with loss of abduction of the little finger. This is a clear indication in these patients for surgical release. Conversely, digital flexion contractures, even when moderately advanced, can cause no functional problems to many string players and in these cases, even when clear indications exist for release, no operation should be done. Small localized lesions (e.g. flexor sheath ganglions on percussionists) cause modification in the player's technique, which in itself can cause substantial generalized symptomatology out of proportion to the basic localized lesion. In such circumstances surgical excision should be performed when perhaps not otherwise indicated.
Stricter indications If in doubt, the conservative course is the route of choice when dealing with the musician's hand. Nowhere is this more clearly seen than when dealing with musicians referred with the diagnosis of "carpal tunnel syndrome", i.e. median nerve related paraesthesia and hypoaesthesia (Trouli and Reissis, 1994). However the clinical picture is much more complicated and, having excluded those with a more proximal pathology for their symptoms, w~ recognize clinically three subgroups in musicians with carpal tunnel like symptoms.
Subgroup 1 - - classic idiopathic carpal tunnel syndrome These musicians are older and are usually in their fifth or sixth decade. They present with classic symptoms of
Table 2--Instruments and medical conditions in 22 professional musicians undergoing operations Instruments
Piano String Woodwind Guitar Percussion
8 6 4 3 1
Dupuytren's contracture Tumours Trauma Carpal tunnel syndrome Arthrodesis Ulnar neuropathy(elbow)
7 5 4 3 2 1
Medical condition
438
carpal tunnel syndrome unrelated to levels of playing and unrelieved by periods of rest and with very constant symptoms of night time numbness, paraesthesia and upper arm aching. Examination will reveal classical findings related to the median nerve at the wrist. Nerve conduction testing will be abnormal, i.e. they have classic idiopathic carpal tunnel syndrome. They can be expected to have the same dramatic benefit from surgical release as the general population and will resume their full playing quickly. Median nerve paraesthesia in guitarists is well recognized. On careful questioning, it usually occurs in the left or fingering hand, occurs while playing or shortly after, does not occur when resting and does not occur at night. Nerve conduction tests will be nori~al. On careful analysis one usually finds a technical fault in the playing and when this playing position is readjusted their symptoms disappear. These patients respond very poorly to surgery!
T H E J O U R N A L OF H A N D SURGERY VOL. 22B No. 4 A U G U S T 1997
• •
provision must be made for very early return to limited playing and practice anticipated anatomical compromise must be adjusted to fit the instrument.
These three factors should be obvious but unless one carefully examines, and occasionally measures the patient in the playing position on his instrument, mistakes will be made.
Subgroup 2 - - acute positional
Subgroup 3 - - transient tenosynovial swelling These patients are commonly younger pianists or violinists who give a clear history of median nerve paraesthesia or numbness associated with extended or vigorous playing. Their symptoms are present while or immediately after playing and are not present during periods of rest or holiday. They occasionally experience a few episodes of night numbness but these disappear immediately following a brief period of rest. On examination the clinical findings usually are of some slight visible boggy swelling on the flexor aspect of the wrist and many times some palpable tender nodules and swelling over the flexor tendons and tendon sheaths in the distal palm usually involving the long finger. Nerve conduction tests are normal. They respond well to slightly reduced playing and steroid injections into the carpal tunnel. Additionally, longer term conditioning, modification of warm-up practice and playing schedules may be required and also attention paid to technique and to the piano action. However, they will generally fare well following this type of care. They fare very badly following surgical release. Simply stated, when dealing with musicians, the absence of abnormal delay in median nerve conduction across the wrist when measured by standard technique is an absolute contraindication to surgical release (by any method) of the carpal tunnel.
SURGICAL TECHNIQUES Generally local anaesthesia is used as musicians tend to be more accepting of this than general anaesthesia with its perceived added risks and "loss of control". Musicians fare well under local anaesthesia and with rapid recovery "rehabilitation" in the broad sense starts within a few hours of the operation. Standard surgical techniques are used but these must be modified in three critical areas: * incisions must be placed away from critical tactile points
Location of incisions The precise contact point to be avoided may not be obvious without prior analysis by the surgeon. Woodwind players support the instrument along the ulnar border of the right thumb and a mid lateral incision in this area is unacceptably tender (a palmar approach is more appropriate). The chanter on a bagpipe is fingered by the palmar aspect of the middle segment of the digit and the palmar zig-zag approach violates critical sensitive areas. The correct approach in this circumstance should be a non-standard ulnar midlateral approach elevating the digital nerve and its more proximal palmar branches with the flap.
Early return to playing Depriving the musician of his or her means of selfexpression is devastating and easily leads to depression. Absence from playing is also physically damaging to musicians. There is no evidence that prolonged rest has any place in management of any condition in the musician and in the post operative situation every effort should be made to facilitate a very early return to limited playing. The siting and direction of the incisions and also the type of closure may all need to be modified. In this regard the closed rather than open techniques of Dupuytren's release are to be preferred (Gonzalez, 1974; Hueston, 1961). When a joint requires arthrodesis (an exceptional but not necessarily career-ending event) tension band technique even in the distal joints (Allende and Engleman, 1980) along with very careful pin placement can allow early return to limited playing. The average time off the instrument in the authors, current experience has been 2 to 4 weeks but a target of 5 to 6 days is ideal (Table 3).
The playing position The "functional" position for a musician may come as a surprise to the surgeon. Hence when planning arthrodesis or tenodesis, the patient and the surgeon must analyse carefully the playing position and measure the required optimum position for the joint in question and reproduce this exactly at the time of operation using a sterile goniometer.
THE MUSICIAN'S HAND
439
Table 3--Results in 23 professional musicians treated by operation (one lost to follow-up. Twentytwo returned to full-time playing). Follow-up 3 months to 10 years Time o f f instrument (weeks)
Time to full playing (weeks) 5.2
Dupuytren's
2.1
Tumours
1
3.8
Trauma
6
10.5
Carpal tunnel syndrome
1.8
Arthrodesis
3
13
U l n a r nerve release (elbow)
6
12
Average
3.3
Results of surgery
There are many reports of poor results from surgery in musicians (Brockman et al, 1990). However, two recent papers on specific extensor tendon binding or triggering give grounds for guarded optimism (Benetar, 1994; McGregor and Glarer, 1988). Additionally, on thorough searching, others report successful surgical intervention in a number of local conditions in musicians (Lederman, 1994). The authors' experience over 10 years of operating on professional musicians and utilizing the analysis and techniques discussed would confirm that musicians are not necessarily the surgical nightmare one assumes (Table 3). DYSTONIA
Dystonia accounts for 10% of referrals to music clinics world wide (Graffman, 1986). It is one of the most dreaded problems to afflict musicians. It usually affects players in mid-career and seldom before the musician has played seriously for less than 10 years. It starts with the inability to move a particular finger at the speed and later with the accuracy required to play. The condition is painless and the phenomenon never affects any other activity (e.g. a violinist so afflicted can play the piano without trouble). This is the key to diagnosis. Very occasionally a structural lesion such as a meningioma may be the cause and therefore a thorough and complete neurological investigation should be performed initially. However in most cases no focal neurological lesion can be demonstrated and the condition can be best regarded as a fatigue or disorganization possibly at the basal ganglion level in the brain stem. Dystonia will however present to surgeons since, of course, it does present as a localized phenomenon. Successful treatment involves a combination of modalities, particularly a very specific modification of activity and limited resting, utilization of the Feldenkreis and Alexander techniques and physiotherapy by a specialist conversant with disorders of coordination (Chamagne, 1983). Drugs are of no help in our
6
8.4
experience. There is no doubt that the earlier the patient is seen the more likely he is to recover (Tubiana and Chamagne, 1993). The most valuable help the surgeon can give, having recognized the condition and given the diagnosis, is to state clearly that there is no damage and that with careful re-education a full playing career may again be achieved. Address
British Performing Arts Medicine Trust (BPAMT), 18 Ogle Street, London W1P 7LG. Tel: 0171 636 6860 References Amadio PC, Russotti GN (1990). Evaluation and treatment of hand and wrist disorders in musicians. Hand Clinics, 6: 405-416. Allende B, Engelman J (1980). Tension band arthrodesis in finger joints. Journal of Hand Surgery, 5:269 271. Benatar N (1994). Radial subluxation of the connexus intertendineus. Journal of~ Hand Surgery, 18B: 81-87. Brockman R, Chamagne P, Tubiana R. The upper extremity in musicians. In: Tubiana R (Ed.): The hand, Philadelphia, W B Saunders, 1990, Vol 4: 873485. Brandfonbrener A (1991 ). Special treatment for musicians? Some specific hazards of elective surgery. Medical Problems of Performing Artists, 6: 37-38. Chamagne P (1983). Approche kin6sith6rapique des crampes fonctionnelles dites professionnelles. Semestrial de l'H6pital de Paris, 59: 3080-3086. Critchley N. Occupational palsies in musical performers. In: Critchley N, Henson R (Eds): Music and the brain. London, Heinemann, 1977: 365. Fishbein N, Middlestadt SE (1988). Medical problems among the ICSOM musicians - overview of a national survey. Medical Problems of Performing Artists, 3: 1-8. Gonzalez RI. Open fasciotomy and full thickness skin graft in the correction of digital flexion deformity. In: Huston J T, Tubiana R (Eds): Dupuytren's disease. Edinburgh, Churchill Livingstone, 1974:123 127. Graffman G (1986). Doctor, can you lend an ear? Medical Problems of Performing Artists, 1: 3-4. Hueston JT (1961). Limited fasciectomy for Dupuytren's contracture. Plastic and Reconstructive Surgery, 27:569 585. Kember J, Wassily S A (1995). You and your guitar. Classical Guitar, 14:3 8. Leddy J. Flexor tendons--acute injury. In: Green, (Ed.): Operative hand surgery, 3rd edn. New York, Churchill Livingstone, 1993, Vol 2: 1823-1845. Lederman R (1994). Neuromuscular problems in the performing arts. Muscle and Nerve, 17: 569-577. Lippman HI (1991). A fresh look at the overuse syndrome in musical performers. Medical Problems of Performing Artists, 6: 57-60. Markison RE (1990). Treatment of musical hands: redesign of the interface. Hand Clinics, 6:525 544. Mayou RA. Somatic symptoms without physical cause. In: Weatherall D J, Ledingham JGG, Warrell DA (Eds): Oxford textbook of medicine. Oxford, Oxford University Press, 1982:25.55 56. McGregor I, Glover L (1988). The E-flat hand. Journal of Hand Surgery, 13A: 692-693.
440 Nolan WK Eaton RG (1989). Thumb problems of professional musicians. Medical Problems of Performing Artists, 4: 20-22. Rietveld B (1995). Performing arts clinics--a Dutch approach. Performing Arts Medical News, 3: 12-18. Roberts WJ (I986). A hypothesis on a physiological basis for causalgia and related pains. Pain, 24:297 312. Roos DB (1986). Thoracic outlet syndromes: symptoms, diagnosis, anatomy and surgical treatment. Medical Problems of Performing Artists, h 90-92. Rosenthal E (1987). The Alexander Technique, what it is and how it works. Medical Problems of Performing Artists, 2:53 57. Spire M (I989). The Feldenkreis Method. An interview with Anat Baniel. Medical Problems of Performing Artists, 4:i59 162. Trouli H, Reissis N (1994). Carpal tunnel symptoms in patients: anxiety for both patient and surgeon. Journal of Hand Surgery, 19B (Supplement): 11. Tubiana R, Chamagne P (1993). Les affections professionnelles du membre
THE JOURNAL OF HAND SURGERY VOL. 22B No. 4 AUGUST 1997 sup6rieur chez les musiciens. Bulletin Acad6mie Nationale de M6decine, 177: 203516. Wall PD. Pain without peripheral pathology. In: Wall PD, Melzack R (Eds): Textbook of pain, 2nd edn. Edinburgh, Churchill Livingstone, 1994: 4 28. Winspur 1 (1995). The professional musician and the hand surgeon. In: Vastamaki M e t al (Eds): Proceedings of the 6th Congress of IFFSH Helsinki. Bologna, Monduzi Editori, 1995:1207-1211. Wynn Parry C B (1994). Musicians suffer a variety of problems. Journal of Hand Surgery, 19B (Supplement): 11 12. Mr I. Winspur,The Hand Clinic, DevonshireHospital, 29 DevonshireStreet, London W1N IRF, UK. © i997 The British Societyfor Surgery of the Hand