- Email: [email protected]
Controversies surrounding “misuse,” “overuse,” and “repetition” in musicians
Hand Clin 19 (2003) 325–329
Controversies surrounding ‘‘misuse,’’ ‘‘overuse,’’ and ‘‘repetition’’ in musicians Ian Winspur, LLM, FRCS, FACS Hand Clinic, 30 Devonshire Street, London, W1G 6PU, United Kingdom
Arguments of near religious intensity are not unknown to modern hand surgeons: the polarized debate between primary flexor tendon repair and secondary grafting from 1950 to 1970, the divided opinion on single digit replantation from 1975 to 1980, the current advocacy by some surgeons of endoscopic carpal tunnel release. In 1994, referring to an intense courtroom argument between eminent British doctors on the origins of arm pain in a group of turkey processors, some with no physical findings, a senior English judge [1] was moved to state: ‘‘This is an area of medical controversy, the intensity of which as demonstrated by the five days of medical evidence I heard would be worthy of medieval theology.’’
He concluded: ‘‘I am none the wiser!’’
The ongoing arguments regarding the existence of a new syndrome of industrial arm pain and the role of repetition and overuse in producing such a syndrome and other recognized named painful pathologic conditions in the arm pain continue [2–8]. This debate still rages 17 years after the first description in recent times of arm pain without physical findings in workers engaged in light repetitive tasks [8]. Clinical observations and opinions supporting the whole spectrum of claimed etiologies and pathologies have been recorded, but whereas the earlier debates on flexor tendon repair and replantation have been resolved by careful studious clinical observation and scientifically based E-mail address: [email protected]
prospective surveys, such tools have proved virtually impossible to construct in studies concerning repetition, overuse, and arm pain [9]. The debate is additionally confused by external pressures from vested interest, lack of objectivity by doctors, and loose use of lay and medical terms [4,10,11]. Attempts have been made to define and narrow the medical use of certain words and terms, particularly the term ‘‘overuse,’’ but it is still widely and, the author would claim, inappropriately used in the context of hand and arm pain in musicians and the lay public [2,10]. In the case of the instrumental musician, nonspecific arm pain is a common presenting complaint [13–15,22]. This pain has been attributed to simple fatigue and tiredness, ‘‘misuse’’ meaning incorrect technical handling of the instrument, practice, or repertoire, ‘‘overuse’’ meaning too much use, and even to a specific ‘‘overuse syndrome’’ [3,16–18]. Musicians are involved in an activity that is the most repetitive of all activities, however—up to 5595 notes in just over 4 minutes and, in places, 72 finger shifts per second—and many accomplished professionals can complete a full playing career having suffered no complaints at all [15,19]. Additionally, the known described pathologic conditions producing arm pain (eg, De Quervain tendonitis and tennis elbow to name but two) that have been linked to repetition and cumulative trauma are less common in the musician population than in the general public [13–15]. Obviously the present overuse/repetition/cumulative trauma hypothesis is either inaccurate or incomplete and the question arises whether we should be using these terms at all. Given the repetitive nature of instrumental playing we should be able to learn from clinical observation and monitoring of
0749-0712/02/$ - see front matter 2003 Elsevier Inc. All rights reserved. PII: S 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 1 2 4 - 5
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I. Winspur / Hand Clin 19 (2003) 325–329
musicians, most of whom are well motivated, selfemployed, and free from the disturbing external influences that are implicated in industrial arm pain [4]. But again the obstacles of loose and imprecise language, nonscientific observation, and ‘‘junk science’’ interfere. The author aims in this article to identify areas of loose terminology and confusion, clinical controversy, and agreement, and to place nonspecific arm pain and the various named specific organic and pathologic entities seen in musicians on a more logical philologic basis [10]. Overuse In the context of a muscle, tendon, ligament, or bone, this means that the ‘‘stress applied is greater than the tissue can tolerate… and it breaks down’’ [6]. This phenomenon has been recognized in athletes for many years and the simple examples when supramaximal loads are applied are the rupture of Achilles tendons in sprinters or the rupture of the external oblique muscle in soccer players. But it has also become apparent in athletes that repeated application of submaximal, subinjurious loads can in fact cause mechanical damage to tissues, the most well known of such conditions being stress fractures in the metatarsals of runners and epiphyseal injuries in young gymnasts. The forces applied in all these situations, however, are substantial— body weight times the speed of the athlete. Much more contentious is the role of repeated ‘‘microtrauma’’ in producing ‘‘microinjury’’ in patients performing light repetitive tasks. The proponents of these theories received a great boost in 1983 with the publication of an article by Stone in Australia describing a novel condition of disabling arm pain in a group of female light industrial production workers characterized by lack of physical findings and fitting no known organic cause either ‘‘dystrophic, atrophic or neuropathic’’ [8]. The Australian controversy was further fueled by the Australian Occupational Health Authorities’ creation in 1986 of the term occupational overuse syndrome, ‘‘a collective term for a range of conditions characterized by discomfort or persistent pain (in the arms)… caused or aggravated by work.’’ It should be obvious that this syndrome encompasses virtually every painful condition of the hand or arm with the exception of open injuries and acute fractures [20]. Another boost was given with the publication in 1985 in the United States of Silverstein’s research concluding from data obtained by questionnaire, not clinical examination, that certain known named medical conditions such as ten-
nis elbow, carpal tunnel syndrome, and trigger finger were more common in supermarket checkers than in the general population and that therefore repetitive or ‘‘cumulative trauma’’ must be responsible for these conditions [7]. The epidemiology of this study was flawed but the concept of cumulative trauma persists in the United States and certain recognized pathologic entities such as carpal tunnel syndrome and tendonitis are described in the United States under the umbrella of cumulative trauma disorders or overuse conditions. The list of such conditions is long—De Quervain tendonitis, trigger finger, tendonitis, tenosynovitis, peritendonitis, distal nerve compression syndromes, tennis elbow, golfer’s elbow, and the list is perpetuated by the language of the worker’s compensation regulations in most of the United States [9,21]. The pathophysiology of overuse Many and varied are the pathologic processes that have been implicated and incriminated in the ‘‘overuse conditions’’ and, of course, each tissue responds differently to load [4,5]. A potent cause of cramping and crippling pain in the muscles of athletes has been identified as ischemia of muscles within tight septal compartments secondary to raised intracompartmental pressure— the so-called ‘‘compartment syndromes.’’ These have been identified and treated in the legs of runners and sportsmen, and compartment syndromes also have been identified in the arms of athletes, particularly gymnasts, and treated by surgical decompression [22–24]. Histologic changes in the muscles of the hand with some similarities to those occurring in the muscles of athletes suffering from a compartment syndrome also have been identified in a small population of industrial workers with arm pain associated with repetitive work, but similar changes also have been linked to those seen in ‘‘fibromyalgia’’ [25]. One such case has been described in a musician [17,26]. When a muscle is overloaded or the force of a muscle contracture is greater than the tensile strength of the muscle, rupture occurs, and such injuries within the muscle bellies of athletes is seen frequently. Micro rupture (rupture seen only under the electron microscope) also has been identified when a muscle has been subjected to repeated submaximal loading. Tendons also rupture when overloaded and certain research workers have noted micro tears in tendons subjected to repeated submaximal loading, resulting in inflammation in
I. Winspur / Hand Clin 19 (2003) 325–329
the surrounding tenosynovium (peritendonitis) [6]. This is the pathologic explanation given for the relationship of De Quervain tendonitis, trigger fingers, and flexor tenosynovitis to repetitive loading [27]. Many other workers, however, have demonstrated the changes associated with degeneration (chronic not acute inflammation) in tissue biopsy observed at the time of surgery from known sufferers of De Quervain tendonitis and tennis elbow [28]. Similarly in carpal tunnel syndrome, the commonest of the nerve compression syndromes in all populations, workers have identified the changes of synovial hypertrophy (acute inflammation) but others have found the changes usually associated with chronic inflammation and degeneration [27,29]. Good prospective studies have so far proved impossible to construct and therefore scientific answers beyond hypothesis still are not available. The jury is therefore still out on the clear pathologic basis of these conditions. Therefore, nonspecific arm pain should be referred to properly as such and the named conditions only by their medical descriptions without mention of presumed etiology, pathology, or ‘‘overuse’’ [10]. Fatigue Muscle fatigue is defined as the process in which muscle function diminishes with use to a point that it can no longer perform its expected function with the same level or intensity as when rested (exhaustion). The process is chemical and physical, and the discomfort is mediated through free nerve endings in the muscle. Fatigue and exhaustion are protective phenomena preventing injury and are reversible with varying short periods of rest. When the discomfort of fatigue is prolonged 12–24 hours after cessation of the activity, it is considered to be delayed soreness, and when lasting 1–3 days after the cessation of activity it is clinically suggestive of muscle damage. Biopsies of such cases from marathon runners have indicated the changes of injury, as has one biopsy from a musician [25]. Training and conditioning can dramatically increase muscle tolerance before fatigue sets in and such conditioning also produces beneficial changes in tendon, ligaments, and bones, enhancing their strength and resistance to overloading. Such must be the case in the well trained, pain-free professional musician [30]. But pain can take on a life of its own. In muscles repeatedly subjected to fatigue the free nerve endings have been shown to become sensitized and to develop a reduced threshold for firing, thereby
327
producing the pain of fatigue at lower exertional levels. The brain also cannot differentiate the various pain sources, be they from peripheral free nerve endings (nociceptors) or from peripheral sensory fibers (neuroreceptors), and, if the gates are overloaded centrally, mediated pain can develop and linger long after the peripheral sources have settled or at a lower threshold of peripheral stimulation [6]. Nevertheless, ‘‘fatigue’’ would seem to be an appropriate term to use for most quickly recovering nonspecific arm pain in musicians, not ‘‘overuse.’’
The ‘‘overuse syndrome’’ At the height of the repetitive strain epidemic in Australia, the term ‘‘occupational overuse syndrome’’ was invoked. At that time many Australian orchestral players were complaining of assorted arm pain out of proportion to musicians in other orchestras surveyed around the world [13,14]. Fry nevertheless coined the term ‘‘overuse syndrome,’’ applying it to musicians [3,17]. He used this term to describe an ascending pattern of complaints and physical problems in musicians from nonspecific arm pain, by far the commonest condition, through the named conditions affecting tendons, ligaments, and nerves to focal dystonia and reflex sympathetic dystrophy—a syndrome covering virtually every painful eventuality in musicians apart from fractures and open wounds [20]. The overuse hypothesis was based on muscle biopsy work on a few industrial workers with arm pain, the biopsy findings in one musician, and the author’s personal clinical observations on several Australian musicians who were at that time, as were most of their countrymen, complaining of a far higher incidence of arm complaints than any other industrial group or world orchestra then or subsequently [17,26]. Fry’s work was based honestly on his personal experience and his understandings derived from sports medicine and the pathophysiologic explanation of sports injuries, and from his own work with musicians in Australia and America. He also postulated that some nonspecific arm pain in musicians was caused by higher intracompartmental pressures without documenting any increased pressure readings. A pilot MRI study in musicians to confirm this hypothesis concluded the following [31]. 1. No evidence indicates that overuse syndrome is caused by increased intracompartmental pressure.
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2. No evidence indicates that intramuscular edema is present in overuse syndrome. 3. No MRI signs show inflammation of the connective tissue that would indicate tendonitis, tenosynovitis, or epicondylitis in overuse syndrome. 4. There is still no objective test for the diagnosis of overuse syndrome. In fact there is a world of difference between the loading and stresses in a marathon runner’s legs, a soccer player’s groin, or a gymnast’s arms than in the arms and hands of musicians, and extrapolations from one to the other do not stand up to logical or scientific scrutiny. Repetitive trauma and overuse has been incriminated in the claimed increased frequency of carpal tunnel syndrome in musicians but in fact the general occurrence of these conditions is less, as demonstrated in the larger series of musicians than in the general population [11,13,32]. This is probably explained by the phenomenon of conditioning as described previously. The hypothesis that focal dystonia follows overuse is fascinating but is not accepted by experienced workers in the field; much more likely are the explanations given in chapter 19. Therefore, the most we can state is that many musicians at some point in their lives suffer nonspecific arm pain, others at some point, but with lesser frequency than the general population, suffer one or another of the named painful conditions of the upper limb, and a few (but a higher number than seen in the general population) suffer the painless condition (most commonly without any painful precedence or preexisting condition) called focal dystonia. Misuse Misuse means incorrect use but also can mean mistreatment. And indeed the use of the word in the context of arm pain in musicians covers both these eventualities [18]. Musicians may well be mistreating themselves by excessive practice, excessive working hours driven by teachers, ambition, or financial need, or by neglect of the fundamentals of sleep, simple exercise, good diet, and a calm lifestyle. As far as misusing the instrument or the body, the musical literature is full of manuals on correct technique, position, and posture, and there is little doubt that poor technique and poor posture or an alteration in established technique can rapidly lead to physical complaints in the musician. What is not widely appreciated is that some
musicians are just not physically suited for their chosen instrument—the harpist with short arms, the violinist with a long neck, and the child with small hands [33]. Steinway has produced a piano with a slightly smaller keyboard and narrower keys for small hands for more than 100 years but it has never proved popular, and Stradivarius experimented with ergonomically shaped violas 300 years ago, only to have them rejected [34]. Hence misuse, although implying criticism of the musician, may be in fact a useful all-embracing term that can accurately be used in the analysis of several physical problems seen in musicians without implying any conscious or direct contribution or fault by the musician.
From what do musicians suffer? Musicians suffer nonspecific arm pain, the usual named painful conditions and syndromes of the hand and arm seen in the general population, and the unusual and fortunately uncommon condition of focal dystonia [11–16]. The origins of their arm pain may be simple fatigue, pushed in a few to the point of delayed soreness implying some degree of tissue injury secondary to misuse. They suffer carpal tunnel syndrome, trigger fingers, and De Quervain tendonitis less frequently than the general public and there is still no clear evidence that the cause of these conditions in musicians or any population lies in tissue injury caused by overuse or cumulative trauma. There is no clear evidence at all that musicians develop true overuse injuries with tissue damage as seen in athletes, and experimental evidence used to prove the existence of so called ‘‘overuse syndrome’’ in musicians is either flimsy or statistically flawed. There is no clear scientific evidence at all to date that overuse per se is an etiology factor in the development of focal dystonia. In 1991 Lippman stated: ‘‘Overuse is a simplistic descriptive label which ignores various other possible correctable causes of misfunction or malfunction in the playing of a musical instrument. The music physician is challenged to assess the physical; technical and behavioural basis of malfunction, the combination of which defines the individual musician’s playing troubles and leads to a diagnosis that can be a guide for remedial action. Since overuse implies a need for therapeutic rest, it may cause unwarranted disuse, which remains second best to appropriate use in otherwise healthy musicians who have developed malfunction from misuse. In
I. Winspur / Hand Clin 19 (2003) 325–329 this context, ‘‘overuse’’ is indeed overused in present practice.’’ [17]
Twelve years later the same conclusions stand. [18]
References [1] Mountenay and others v Matthews. Med Legal Rev 1994;5:293–8. [2] Dawson W, et al. What’s in a name? Med Prob Perf Art 1998;13:45–50. [3] Fry HJH. Overuse syndrome. In: Tubiana R, Amadio P, editors. Medical problems of the instrumentalist musician. London: Martin Dunitz; 2000. [4] Ireland DCR. RSI: the Australian experience—1992 update. J Hand Surg 1995;20A:553–56. [5] Luciere Y. Neurosis in the workplace. Med J Aust 1988;145:323–6. [6] Pitner M. Pathophysiology of overuse injuries in the hand and wrist. Hand Clin 1990;6:355–64. [7] Silverstein B. The prevalence of upper extremity cumulative trauma disorders in industry [dissertation]. Ann Arbor (MI): University of Michigan; 1985. [8] Stone WE. Repetitive strain injuries. Med J Aust 1983;2:616–8. [9] Hadler N. Coping with arm pain in the workplace in musculoskeletal disorders. New York: Raven Press; 1993. [10] Davis TCR. Diagnostic criteria for upper limb disorders in epidemiological studies. J Hand Surg 1998;23B:567–9. [11] Dawson W. Upper extremity overuse in instrumentalists. Med Prob Perf Art 2001;16:66–71. [12] Amadio P, Russoti GM. Evaluation and treatment of hand disorders in musicians. Hand Clin 1990; 6:405–61. [13] Fishbein M, et al. Medical problems among ICSOM musicians. Med Prob Perf Art 1988;3:1–8. [14] James I. Survey of orchestras. In: Tubiana R, Amadio P, editors. Medical problems of the instrumentalist musician. London: Martin Dunitz; 2000. [15] Lippman HA. A fresh look at the overuse syndrome in musical performance. Med Prob Perf Art 1991; 6:57–60. [16] Brandfonbrener A. Epidemiology and risk factors. In: Tubiana R, Amadio P, editors. Medical prob-
[19]
[20]
[21] [22]
[23]
[24]
[25] [26]
[27]
[28] [29]
[30]
[31] [32] [33] [34]
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lems of the instrumentalist musician. London: Martin Dunitz; 2000. Fry HJH. Overuse syndrome in musicians. Lancet 1986;2:728–31. Wynn Parry C. Misuse and overuse. In: Winspur I, Wynn Parry C, editors. The musician’s hand. London: Martin Dunitz; 1998. Critchley M, Henson RA. Music and the brain: studies in the neurology of music. Springfield (IL): Charles C Thomas; 1977. White J. A search for the pathophysiology of nonspecific ‘‘occupational overuse syndrome.’’ Hand Clin 2003;19:331–41. Winspur I. Arm pain without physical findings— medicine v the law. J Hand Surg 2001;26B:409–13. Imbriglia JE, Boland DM. An exercise-induced compartment syndrome of the distal forearm. J Hand Surg 1984;9A:142–3. Kutz JE, Singer R, Lindsay M. Chronic exertional compartment syndrome of the forearm. J Hand Surg 1985;10A:302–4. Phillips JH, Mackinnon SE, Murray JF, et al. Exercise induced chronic compartment syndrome of the first dorsal interosseus muscle of the hand. J Hand Surg 1986;11A:124–7. Dennett X, Fry HJH. Overuse syndrome: a muscle biopsy study. Lancet 1988;1:905–8. Dennett X, Fry HJH. Focal necrotising myopathy in a musician with overuse syndrome. Medecine Des Arts 2000;30:17–20. Fuchs PC, Nathan PA, Myers LD. Synovial histology in carpal tunnel syndrome. J Hand Surg 1991;16A:753–8. Kay NRM. De Quervains disease. J Hand Surg 2000;25B:65–9. Schuind F, Ventura M, Pasteels JL. Idiopathic carpal tunnel syndrome: histologic study of flexor tendon synovium. J Hand Surg 1990;15A:497–9. Wynn Parry C. The musician’s hand. In: Salter M, Cheshire L, editors. Hand therapy principles and practice. Oxford: Butterworth Heinman; 2000. Bengtson K, et al. Musicians overuse syndrome: a pilot study of MRI. Med Prob Perf Art 1993;8:77–9. Winspur I, Wynn Parry C. Musicians’ hands. Med Prob Perf Art 2000;15:31–4. Markison RE. Treatment of musical hands: redesign of the interface. Hand Clin 1990;6:525–44. Donison C. Hand size vs the standard piano keyboard. Med Prob Perf Art 2000;15:111–4.
Controversies surrounding ‘‘misuse,’’ ‘‘overuse,’’ and ‘‘repetition’’ in musicians Ian Winspur, LLM, FRCS, FACS Hand Clinic, 30 Devonshire Street, London, W1G 6PU, United Kingdom
Arguments of near religious intensity are not unknown to modern hand surgeons: the polarized debate between primary flexor tendon repair and secondary grafting from 1950 to 1970, the divided opinion on single digit replantation from 1975 to 1980, the current advocacy by some surgeons of endoscopic carpal tunnel release. In 1994, referring to an intense courtroom argument between eminent British doctors on the origins of arm pain in a group of turkey processors, some with no physical findings, a senior English judge [1] was moved to state: ‘‘This is an area of medical controversy, the intensity of which as demonstrated by the five days of medical evidence I heard would be worthy of medieval theology.’’
He concluded: ‘‘I am none the wiser!’’
The ongoing arguments regarding the existence of a new syndrome of industrial arm pain and the role of repetition and overuse in producing such a syndrome and other recognized named painful pathologic conditions in the arm pain continue [2–8]. This debate still rages 17 years after the first description in recent times of arm pain without physical findings in workers engaged in light repetitive tasks [8]. Clinical observations and opinions supporting the whole spectrum of claimed etiologies and pathologies have been recorded, but whereas the earlier debates on flexor tendon repair and replantation have been resolved by careful studious clinical observation and scientifically based E-mail address: [email protected]
prospective surveys, such tools have proved virtually impossible to construct in studies concerning repetition, overuse, and arm pain [9]. The debate is additionally confused by external pressures from vested interest, lack of objectivity by doctors, and loose use of lay and medical terms [4,10,11]. Attempts have been made to define and narrow the medical use of certain words and terms, particularly the term ‘‘overuse,’’ but it is still widely and, the author would claim, inappropriately used in the context of hand and arm pain in musicians and the lay public [2,10]. In the case of the instrumental musician, nonspecific arm pain is a common presenting complaint [13–15,22]. This pain has been attributed to simple fatigue and tiredness, ‘‘misuse’’ meaning incorrect technical handling of the instrument, practice, or repertoire, ‘‘overuse’’ meaning too much use, and even to a specific ‘‘overuse syndrome’’ [3,16–18]. Musicians are involved in an activity that is the most repetitive of all activities, however—up to 5595 notes in just over 4 minutes and, in places, 72 finger shifts per second—and many accomplished professionals can complete a full playing career having suffered no complaints at all [15,19]. Additionally, the known described pathologic conditions producing arm pain (eg, De Quervain tendonitis and tennis elbow to name but two) that have been linked to repetition and cumulative trauma are less common in the musician population than in the general public [13–15]. Obviously the present overuse/repetition/cumulative trauma hypothesis is either inaccurate or incomplete and the question arises whether we should be using these terms at all. Given the repetitive nature of instrumental playing we should be able to learn from clinical observation and monitoring of
0749-0712/02/$ - see front matter 2003 Elsevier Inc. All rights reserved. PII: S 0 7 4 9 - 0 7 1 2 ( 0 2 ) 0 0 1 2 4 - 5
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I. Winspur / Hand Clin 19 (2003) 325–329
musicians, most of whom are well motivated, selfemployed, and free from the disturbing external influences that are implicated in industrial arm pain [4]. But again the obstacles of loose and imprecise language, nonscientific observation, and ‘‘junk science’’ interfere. The author aims in this article to identify areas of loose terminology and confusion, clinical controversy, and agreement, and to place nonspecific arm pain and the various named specific organic and pathologic entities seen in musicians on a more logical philologic basis [10]. Overuse In the context of a muscle, tendon, ligament, or bone, this means that the ‘‘stress applied is greater than the tissue can tolerate… and it breaks down’’ [6]. This phenomenon has been recognized in athletes for many years and the simple examples when supramaximal loads are applied are the rupture of Achilles tendons in sprinters or the rupture of the external oblique muscle in soccer players. But it has also become apparent in athletes that repeated application of submaximal, subinjurious loads can in fact cause mechanical damage to tissues, the most well known of such conditions being stress fractures in the metatarsals of runners and epiphyseal injuries in young gymnasts. The forces applied in all these situations, however, are substantial— body weight times the speed of the athlete. Much more contentious is the role of repeated ‘‘microtrauma’’ in producing ‘‘microinjury’’ in patients performing light repetitive tasks. The proponents of these theories received a great boost in 1983 with the publication of an article by Stone in Australia describing a novel condition of disabling arm pain in a group of female light industrial production workers characterized by lack of physical findings and fitting no known organic cause either ‘‘dystrophic, atrophic or neuropathic’’ [8]. The Australian controversy was further fueled by the Australian Occupational Health Authorities’ creation in 1986 of the term occupational overuse syndrome, ‘‘a collective term for a range of conditions characterized by discomfort or persistent pain (in the arms)… caused or aggravated by work.’’ It should be obvious that this syndrome encompasses virtually every painful condition of the hand or arm with the exception of open injuries and acute fractures [20]. Another boost was given with the publication in 1985 in the United States of Silverstein’s research concluding from data obtained by questionnaire, not clinical examination, that certain known named medical conditions such as ten-
nis elbow, carpal tunnel syndrome, and trigger finger were more common in supermarket checkers than in the general population and that therefore repetitive or ‘‘cumulative trauma’’ must be responsible for these conditions [7]. The epidemiology of this study was flawed but the concept of cumulative trauma persists in the United States and certain recognized pathologic entities such as carpal tunnel syndrome and tendonitis are described in the United States under the umbrella of cumulative trauma disorders or overuse conditions. The list of such conditions is long—De Quervain tendonitis, trigger finger, tendonitis, tenosynovitis, peritendonitis, distal nerve compression syndromes, tennis elbow, golfer’s elbow, and the list is perpetuated by the language of the worker’s compensation regulations in most of the United States [9,21]. The pathophysiology of overuse Many and varied are the pathologic processes that have been implicated and incriminated in the ‘‘overuse conditions’’ and, of course, each tissue responds differently to load [4,5]. A potent cause of cramping and crippling pain in the muscles of athletes has been identified as ischemia of muscles within tight septal compartments secondary to raised intracompartmental pressure— the so-called ‘‘compartment syndromes.’’ These have been identified and treated in the legs of runners and sportsmen, and compartment syndromes also have been identified in the arms of athletes, particularly gymnasts, and treated by surgical decompression [22–24]. Histologic changes in the muscles of the hand with some similarities to those occurring in the muscles of athletes suffering from a compartment syndrome also have been identified in a small population of industrial workers with arm pain associated with repetitive work, but similar changes also have been linked to those seen in ‘‘fibromyalgia’’ [25]. One such case has been described in a musician [17,26]. When a muscle is overloaded or the force of a muscle contracture is greater than the tensile strength of the muscle, rupture occurs, and such injuries within the muscle bellies of athletes is seen frequently. Micro rupture (rupture seen only under the electron microscope) also has been identified when a muscle has been subjected to repeated submaximal loading. Tendons also rupture when overloaded and certain research workers have noted micro tears in tendons subjected to repeated submaximal loading, resulting in inflammation in
I. Winspur / Hand Clin 19 (2003) 325–329
the surrounding tenosynovium (peritendonitis) [6]. This is the pathologic explanation given for the relationship of De Quervain tendonitis, trigger fingers, and flexor tenosynovitis to repetitive loading [27]. Many other workers, however, have demonstrated the changes associated with degeneration (chronic not acute inflammation) in tissue biopsy observed at the time of surgery from known sufferers of De Quervain tendonitis and tennis elbow [28]. Similarly in carpal tunnel syndrome, the commonest of the nerve compression syndromes in all populations, workers have identified the changes of synovial hypertrophy (acute inflammation) but others have found the changes usually associated with chronic inflammation and degeneration [27,29]. Good prospective studies have so far proved impossible to construct and therefore scientific answers beyond hypothesis still are not available. The jury is therefore still out on the clear pathologic basis of these conditions. Therefore, nonspecific arm pain should be referred to properly as such and the named conditions only by their medical descriptions without mention of presumed etiology, pathology, or ‘‘overuse’’ [10]. Fatigue Muscle fatigue is defined as the process in which muscle function diminishes with use to a point that it can no longer perform its expected function with the same level or intensity as when rested (exhaustion). The process is chemical and physical, and the discomfort is mediated through free nerve endings in the muscle. Fatigue and exhaustion are protective phenomena preventing injury and are reversible with varying short periods of rest. When the discomfort of fatigue is prolonged 12–24 hours after cessation of the activity, it is considered to be delayed soreness, and when lasting 1–3 days after the cessation of activity it is clinically suggestive of muscle damage. Biopsies of such cases from marathon runners have indicated the changes of injury, as has one biopsy from a musician [25]. Training and conditioning can dramatically increase muscle tolerance before fatigue sets in and such conditioning also produces beneficial changes in tendon, ligaments, and bones, enhancing their strength and resistance to overloading. Such must be the case in the well trained, pain-free professional musician [30]. But pain can take on a life of its own. In muscles repeatedly subjected to fatigue the free nerve endings have been shown to become sensitized and to develop a reduced threshold for firing, thereby
327
producing the pain of fatigue at lower exertional levels. The brain also cannot differentiate the various pain sources, be they from peripheral free nerve endings (nociceptors) or from peripheral sensory fibers (neuroreceptors), and, if the gates are overloaded centrally, mediated pain can develop and linger long after the peripheral sources have settled or at a lower threshold of peripheral stimulation [6]. Nevertheless, ‘‘fatigue’’ would seem to be an appropriate term to use for most quickly recovering nonspecific arm pain in musicians, not ‘‘overuse.’’
The ‘‘overuse syndrome’’ At the height of the repetitive strain epidemic in Australia, the term ‘‘occupational overuse syndrome’’ was invoked. At that time many Australian orchestral players were complaining of assorted arm pain out of proportion to musicians in other orchestras surveyed around the world [13,14]. Fry nevertheless coined the term ‘‘overuse syndrome,’’ applying it to musicians [3,17]. He used this term to describe an ascending pattern of complaints and physical problems in musicians from nonspecific arm pain, by far the commonest condition, through the named conditions affecting tendons, ligaments, and nerves to focal dystonia and reflex sympathetic dystrophy—a syndrome covering virtually every painful eventuality in musicians apart from fractures and open wounds [20]. The overuse hypothesis was based on muscle biopsy work on a few industrial workers with arm pain, the biopsy findings in one musician, and the author’s personal clinical observations on several Australian musicians who were at that time, as were most of their countrymen, complaining of a far higher incidence of arm complaints than any other industrial group or world orchestra then or subsequently [17,26]. Fry’s work was based honestly on his personal experience and his understandings derived from sports medicine and the pathophysiologic explanation of sports injuries, and from his own work with musicians in Australia and America. He also postulated that some nonspecific arm pain in musicians was caused by higher intracompartmental pressures without documenting any increased pressure readings. A pilot MRI study in musicians to confirm this hypothesis concluded the following [31]. 1. No evidence indicates that overuse syndrome is caused by increased intracompartmental pressure.
328
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2. No evidence indicates that intramuscular edema is present in overuse syndrome. 3. No MRI signs show inflammation of the connective tissue that would indicate tendonitis, tenosynovitis, or epicondylitis in overuse syndrome. 4. There is still no objective test for the diagnosis of overuse syndrome. In fact there is a world of difference between the loading and stresses in a marathon runner’s legs, a soccer player’s groin, or a gymnast’s arms than in the arms and hands of musicians, and extrapolations from one to the other do not stand up to logical or scientific scrutiny. Repetitive trauma and overuse has been incriminated in the claimed increased frequency of carpal tunnel syndrome in musicians but in fact the general occurrence of these conditions is less, as demonstrated in the larger series of musicians than in the general population [11,13,32]. This is probably explained by the phenomenon of conditioning as described previously. The hypothesis that focal dystonia follows overuse is fascinating but is not accepted by experienced workers in the field; much more likely are the explanations given in chapter 19. Therefore, the most we can state is that many musicians at some point in their lives suffer nonspecific arm pain, others at some point, but with lesser frequency than the general population, suffer one or another of the named painful conditions of the upper limb, and a few (but a higher number than seen in the general population) suffer the painless condition (most commonly without any painful precedence or preexisting condition) called focal dystonia. Misuse Misuse means incorrect use but also can mean mistreatment. And indeed the use of the word in the context of arm pain in musicians covers both these eventualities [18]. Musicians may well be mistreating themselves by excessive practice, excessive working hours driven by teachers, ambition, or financial need, or by neglect of the fundamentals of sleep, simple exercise, good diet, and a calm lifestyle. As far as misusing the instrument or the body, the musical literature is full of manuals on correct technique, position, and posture, and there is little doubt that poor technique and poor posture or an alteration in established technique can rapidly lead to physical complaints in the musician. What is not widely appreciated is that some
musicians are just not physically suited for their chosen instrument—the harpist with short arms, the violinist with a long neck, and the child with small hands [33]. Steinway has produced a piano with a slightly smaller keyboard and narrower keys for small hands for more than 100 years but it has never proved popular, and Stradivarius experimented with ergonomically shaped violas 300 years ago, only to have them rejected [34]. Hence misuse, although implying criticism of the musician, may be in fact a useful all-embracing term that can accurately be used in the analysis of several physical problems seen in musicians without implying any conscious or direct contribution or fault by the musician.
From what do musicians suffer? Musicians suffer nonspecific arm pain, the usual named painful conditions and syndromes of the hand and arm seen in the general population, and the unusual and fortunately uncommon condition of focal dystonia [11–16]. The origins of their arm pain may be simple fatigue, pushed in a few to the point of delayed soreness implying some degree of tissue injury secondary to misuse. They suffer carpal tunnel syndrome, trigger fingers, and De Quervain tendonitis less frequently than the general public and there is still no clear evidence that the cause of these conditions in musicians or any population lies in tissue injury caused by overuse or cumulative trauma. There is no clear evidence at all that musicians develop true overuse injuries with tissue damage as seen in athletes, and experimental evidence used to prove the existence of so called ‘‘overuse syndrome’’ in musicians is either flimsy or statistically flawed. There is no clear scientific evidence at all to date that overuse per se is an etiology factor in the development of focal dystonia. In 1991 Lippman stated: ‘‘Overuse is a simplistic descriptive label which ignores various other possible correctable causes of misfunction or malfunction in the playing of a musical instrument. The music physician is challenged to assess the physical; technical and behavioural basis of malfunction, the combination of which defines the individual musician’s playing troubles and leads to a diagnosis that can be a guide for remedial action. Since overuse implies a need for therapeutic rest, it may cause unwarranted disuse, which remains second best to appropriate use in otherwise healthy musicians who have developed malfunction from misuse. In
I. Winspur / Hand Clin 19 (2003) 325–329 this context, ‘‘overuse’’ is indeed overused in present practice.’’ [17]
Twelve years later the same conclusions stand. [18]
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