repetitive injuries in musicians

“Playing a musical instrument at an elite level is a highly complex motor skill. The regular daily training loads resulting from practice, rehearsals and performances place great demands on the neuromusculoskeletal systems of the body. As a consequence, performance-related musculoskeletal disorders (PRMDs) are globally recognized as common phenomena amongst professional orchestral musicians. These disorders create a significant financial burden to individuals and orchestras as well as lead to serious consequences to the musicians‘ performance and ultimately their career.”  From the July, 2014 issue of of the scientific journal, Frontiers in Psychology

As a music lover myself (HERE and HERE), I’m always amazed by how many professional or aspiring-to-be-professional musicians I see in my clinic.  There are keyboardists (pianists), drummers, banjo pickers, and guitar players — not to mention those amazing individuals who can do it all.  After looking at the immense amount of peer-reviewed literature on the biomechanical stresses they butt heads with on a daily basis, I shouldn’t be surprised.  Allow me to show some excerpts of an email I received from “Joe” just a few days ago.

Dear Dr. Schierling,

I’m a college student who has been playing guitar for 15 years.   I have been dealing with tendonitis / carpal-tunnel syndrome for the last several years. I’ve been treating myself by doing ice water dips (12, fifteen-second reps, 5 min break between each rep…I try to do this 5 times a week or as needed) for the past year. I also do intense deep tissue massage on myself and have been trying to build up my hand/forearm muscles.  This will completely alleviate my symptoms, albeit for only two weeks tops. After that period, the soreness or “hot spots” along the tendons that I had worked so hard on reversing with deep tissue massage come back and the tingling along with it. 

I feel now that I am just managing my symptoms, not curing them. I don’t have a quarter of the stamina I used to back in high-school. When I think back to the middle of my guitar career, pain and stiffness were NEVER an issue. Ironically, back then I never did stretches, supplements, or exercises and never took breaks while practicing like I do today.

I would rate the pain on a scale of 1-10 as a 5. Tightness as a 7. Since I am very conscious about my condition, I know not to abuse my arms, and stop as soon as I feel tightness and any minor pain. It is very discouraging though that I have gone from being able to play as much as I like with no pain whatsoever, to now having to take month-long breaks to allow my condition to subside.

I’m an aspiring professional guitarist, but I honestly feel that this condition will eventually end my career, given that I need to practice up to 6 to 8 hours a day to stay competitive with other guitarists.  You are the only person who I feel truly understands this topic and are my last hope. I truly appreciate all the free information you have on your site. It seems like the majority of the internet is just repeating what my big-pharma brain-washed physician has told me in the past.

Thanks for the kind words Joe, but I must admit to you — the more I learn, the more I realize just how little I really know.  One thing I do know from the numerous emails I receive on the subject is that seemingly endless, intense practice sessions are the norm for these individuals.  Just last week I treated a classical pianist who, when his forearms, wrists, and hands will let him, practices eight hours a day.  Not sure yet how he has responded to treatment. 

Just like ATHLETIC INJURIES, there are hundreds upon hundreds (probably thousands) of studies and articles concerning being a musician, and the injuries / health problems they are so frequently plagued with.  Below are a few of the newer ones, cherry picked from the study’s abstracts.  There is so much information on this topic, I could easily have written a book on the subject.

• After combing through numerous data bases of thousands upon thousands of studies, authors published a meta-analysis in the March, 2015 issue of Medical Problems of Performing Artists (Pain Prevalence in Instrumental Musicians: A Systematic Review), which revealed that as a group, musicians tend to deal with significantly greater amounts of CHRONIC PAIN than the general public.  “The prevalence of pain in general, across all groups of musicians and periods of interest over which pain was assessed, varied between 29.0 and 90.0%, whereas the prevalence of pain affecting playing capacity varied between 25.8 and 84.4%. There was a tendency for guitar players to have the highest pain prevalence. The most affected body regions were the low back (9.8 to 66.7%) and neck (9.8 to 48.5%).“

• In a study published in last June’s issue of the same journal (Musculoskeletal Pain Among Polish Music School Students) “225 instrumentalists aged 10-18 years, including 107 string-players, 64 keyboardists, and 54 wind-players,” were assessed for Chronic Pain related to their playing / practicing.  “Musculoskeletal pain in various body parts had already commenced at a young age in our sample of music students. The young instrumentalists most often complained of pain located in the neck (60.4%), wrists (44.4%), and upper (41.7%) and lower back (38.2%) areas. Girls complained of musculoskeletal pain significantly more often than the boys.  The probability of pain symptoms increased with each consecutive year of practice.“

• Last month’s issue of the Journal of Integrative Medicine (Immediate Effects of Tuina Techniques on Working-Related Musculoskeletal Disorder (WRMD) of Professional Orchestra Musicians) looked at the effect of an acupressure massage [Tunia] on the musculoskeletal problems of individuals playing in a Portuguese orchestra.  “Professional orchestra musicians with a diagnosis of WRMD were randomly distributed into the experimental group (n=39) and the control group (n=30). During an individual interview, Chinese diagnosis took place and treatment points were chosen. Real acupoints were treated by Tuina techniques into the experimental group and non-specific skin points were treated into the control group. Pain was measured by verbal numerical scale before and immediately after intervention. After one treatment session, pain was reduced in 91.8% of the cases for the experimental group and 7.9% for the control group.”  This should give musicians hope — particularly for their most common problems, which are related to TENDINOSIS and / or FASCIAL AHDESIONS.

• These sorts of problems are nothing new for musicians.  This January’s issue of Progressive Brain Research (Alexander Scriabin: His Chronic Right-Hand Pain and Its Impact on His Piano Compositions) published a study on a famous Russian composer / pianist (1872-1915) whose, “overuse injury of his right hand caused a deep crisis and influenced his later composition style in his piano works.”  In the same way that people who use a keyboard for data entry for eight hours a day have a propensity to develop upper extremity overuse problems, it’s that much worse for serious musicians.

• Another January 2015 issue; this one from Frontiers in Human Neuroscience, carried a study called Pain Sensitivity and Tactile Spatial Acuity are Altered in Healthy Musicians as in Chronic Pain Patients.  This study was amazing in that their findings, “suggest that the extensive training of repetitive and highly skilled movements in classical musicians could be considered as a risk factor for developing chronic pain, probably due to use-dependent plastic changes elicited in somatosensory pathways.  Professional musicians frequently experience musculoskeletal pain and pain-related symptoms during their careers”  In English, this means that the neuroplasticity that comes about as the result of training the fine motor skills needed to play music at an elite level, is itself a risk factor for developing serious health-related problems — not just the physically repetitive nature of the playing.  In other words, it’s a “neurological” thing, not simply a “playing-all-the-time” thing.  Any time the word neurological pops up, I have to at least mention the possibility of GLUTEN SENSITIVITY.

• Still another January 2015 issue — this one from Progress in Brain Research — carried a study (Apollo’s Curse: Neurological Causes of Motor Impairments in Musicians) that expounded on this phenomenon.  “Performing music at a professional level is probably one of the most complex human accomplishments. Extremely fast and complex, temporo-spatially predefined movement patterns have to be learned, memorized, and retrieved with high reliability in order to meet the expectations of listeners. To acquire these specialized auditory-sensory-motor and emotional skills, musicians must undergo extensive training periods over many years, which start in early childhood and continue on through stages of increasing physical and strategic complexities. Motor disturbances in musicians are common and include mild forms, such as temporary motor fatigue with short-term reduction of motor skills, painful overuse injuries following prolonged practice, anxiety-related motor failures during performances, as well as more persistent losses of motor control.  Musician’s dystonia, which is characterized by the permanent loss of control of highly skilled movements when playing a musical instrument, is the gravest manifestation of dysfunctional motor programs.”  Unfortunately, all are relatively “common“.

• Musicians are even at a higher risk for FACE PAIN or SKULL PAIN.  The January 2014 issue of the Indian Journal of Dental Research published a study (Degree of Chronic Orofacial Pain Associated to the Practice of Musical Instruments in Orchestra’s Participants) that looked at the degree of Face Pain / TMD in 117 orchestra members.  “The participants were from 15 to 62 years old. Pain degree showed positive correlation for reported symptoms and hours per day of practice. Regarding the prevalence of pain degree, data were: Grade 1 (30.3%), and Grade 2 (15.1%).”   These were 2 to 3 times greater than the pain levels of the control group.

• What about CARPAL TUNNEL SYNDROME?  The December 2013 issue of Medical Problems of Performing Artists (Median and Ulnar Neuropathies in U.S. Army Medical Command Band Members) studied this specific issue.  “Musicians have been reported as having a high prevalence of upper-extremity musculoskeletal disorders, including carpal tunnel syndrome.  Subjects completed a history form, were interviewed, and underwent a physical examination of the cervical spine and bilateral upper extremities. Nerve conduction studies of the bilateral median and ulnar nerves were performed.  29% presented with abnormal electrophysiologic values suggestive of an upper extremity mononeuropathy.  The prevalence of mononeuropathies in this sample of band members is similar to that found in previous research involving civilian musicians (20-36%) and far exceeds that reported in the general population.”   How significant is this and what do these statistics really mean?   In a review of the subject, the April 15, 2011 issue of the American Family Physician stated that, “Carpal tunnel syndrome affects approximately 3 to 6 percent of adults in the general population.”  This tells me that musicians are almost 10 times more prone to this particular problem.

• Because myofacial issues (most specifically Trigger Points) are such a problem in the general population, I thought I would mention a study from the December 2011 issue of Medical Problems of Performing Artists.  The study concerned using “shock wave therapy” to treat chronic Trigger Points in musicians.  Although the therapy itself was not any too successful (“the subjects felt temporarily relieved“), we learned how prevalent this problem is.  “Musicians often suffer from disorders of the musculoskeletal system that are related to their instrument playing. Among the most frequent symptoms are complaints in the shoulder-neck area.”    Out of all the things I have used both for myself and my patients to deal with upper trapezius Trigger Points, THIS SIMPLE TECHNIQUE works as well as anything I have found yet.

• Because forearm pain is so blasted common in musicians, I will mention this study from last year’s issue of Techniques in Hand and Upper Extremity Surgery that concerned something called “Compartment Syndrome” (something that I have not been able to solve in my clinic).   “Chronic exertional compartment syndrome of the forearm is an unusual disease not commonly found in the daily practice of a hand surgeon. This condition is quite rare in the general population but occurs more frequently among musicians…. Traditionally, the treatment of this disease has revolved around trigger activity suspension. The standard surgical treatment consists of an open forearm fasciotomy. This procedure usually requires a lengthy operation period and has a long recovery time before patients can resume their regular activity.”  While this is certainly rare, I firmly believe that Compartment Syndrome (both upper and lower extremity) is more common than we realize.

The real problem is how easy it is in our MASSIVELY INFLAMED society for these problems to become CENTRALIZED.  Will our approach to treatment cause further problem if your pain is Centralized?  ABSOLUTELY NOT.  In fact, THIS is a quick way to rule out a SYSTEMIC PROBLEM (get treated once and see if you improve).  If your problem is Systemic / Centralized, what do I recommend?  Whether your problem is Inflammatory, Neurological (including CHRONIC PAIN), or Autoimmune (or even GENETIC), for most people THIS APPROACH is at least worth looking into.  Oh; and if you know a serious musician, make sure to thank them today for their efforts in providing something beautiful that we all enjoy.