Upper extremity disorders in performing artists - cont.

setting. Even a mild injury can set musicians off from most of their repertoire.
Historically, there has been a lack of communication between the musician and physician. Frequently, the difficulty is simple jargon. Physical findings may be sparse and easily missed by the physician, especially those without a musical background. There is a need to watch musicians play, as symptoms may appear only during a performance. Even slight neuromuscular weaknesses can render finger joints unstable. Technical idiosyncracies can confound the evaluation of dystonia, compressive neuropathy, or overuse syndrome. There have been misconceptions on the part ofthe medical community that musicians are overemotional and that many of the presenting symptoms are psychosomatic. As more is learned, many problems are coming into sharper focus, and appropriate diagnosis and treatment are more frequently made today.
To date, relatively few epidemiologic studies have been conducted on this group of patients. The work has been primarily retrospective and descriptive, and little analytical work has been done to delineate problems. This too, however, is slowly changing. In 1988, Manchester1 examined 246 university students and found 8.5 episodes of performance-related pain per loo musicians. The male to female ratio was 2:1, and the keyboard/string to woodwind/brass ratio was 3: 1. Tendinitis was seen in 16%. Overuse was seen in 50%. Seventy-one had an identifiable cause of performance-related pain, including increased playing time and changes in techniques and repertoire. Stress was a vital factor as problems increased close to recital times, in early fall at the beginning of the semester, and in late spring close to performance evaluations. These maladies occurred primarily in the 25- to 35-year-old age range, with hand and wrist problems encompassing 41% of the problems; neck. 38%; shoulder, 35%; forearm, 11%; and elbow, 10%.
In 1986, Martin Fishbein2 surveyed 4,025 musicians. The response rate was 55%. Fifty-eight of the respondents reported musculoskeletal problems severely affecting performance, females more frequently than males. String players experienced greater difficulties than woodwind or brass. Of 1,378 string players, 10% had hand problems, primarily in the left hand. Wrist, forearm, and elbow problem distribution, however, was equal between left and right.
There is increased incidence of neck and shoulder problems in violinists and violists compared with cello and bass players. Seventy-five percent of pianists experienced right hand problems, while 34% had bilateral problems. Seventy-five percent of string instrumentalists had left hand problems, while 13% of flute and plucking instrumentalists experienced bilateral problems. Seventy-nine percent of woodwind instrumentalists had problems due to direct pressure on the right thumb. Forty-eight percent had entrapment neuropathy, 27% had overuse injury , and 15% had movement disorder.

Overuse syndromes

In 1992, Bengston and Schutt3 reviewed a retrospective series of 73 musicians and found musicians' most common presenting diagnoses were overuse syndrome, tendinitis, focal dystonia, and

 nerve entrapment. This review will focus on overuse syndrome, tendinitis, and nerve entrapment in the upper extremities. Lederman4 described overuse syndrome as a constellation of symptoms associated with activity that exceeds the tissue's biological limits and leads to motor dysfunction. The most common symptoms are pain, weakness, tingling, fatigue, stiffness, and decreased dexterity.
Three concepts have been proposed to explain the cause of musculotendinous overuse. The first. advanced by Fry ,5 involves injury to muscles, tendons, ligaments, and joint capsules, and tendon sheath inflammation. Lederman4 advocated the concept of injury to the musculotendinous junction secondary to overstretching of contracting muscles, known as eccentric contraction. Hochberg6 advocated actual inflammation of the tenosynovium. The true nature of the pathology remains obscure as no pathologic dissection of the upper extremities has yet been done on musicians. What is known regarding overuse syndromes is that there is glycogen depletion in muscle, degeneration in muscle fiber, and edema. There is a relative increase in type I muscle fibers and a decrease in type II muscle fibers. Maximal voluntary contraction is diminished.7
A muscle is able to produce maximal work through its contraction when beginning at its resting length.8 Furthermore, as one increases preload on a given muscle by exerting an external stretch, work capacity of the muscle decreases while potential for fatigue and eventual failure increases. Failure of muscle tendon units as a result of overuse usually can be detected at the musculotendinous junction.9 Chronic submaximal stress may cause microtears at thisjunction, evoking a painful inflammatory response.
Predisposing factors include intrinsic and extrinsic phenomena. Intrinsic factors include the performer's physical strength, flexibility, size, anatomic variations, performing level, and playing style. For example, a long neck may present problems for violinists and violists. Small hands may get injured handling large instruments or playing pieces by Rachmaninoff, Paganini, Brahms, or Liszt. Many of these works were written for performers with large hands and hyperextensible joints. Hyperextensible joints, however, may be a problem since increased muscular effort is required to stabilize the distal joints of the hand, and this may cause musculotendinous overuse. Extrinsic factors, such as time and intensity of playing or size and shape of the instrument, may affect the distribution of work load to the muscle groups involved. A sudden increase in practice time and intensity may stress and diffusely increase muscle tone. There may be a sudden change in technique. teacher, or instrument. Poor practice technique is also a culprit.
Excessive repetition to master particularly difficult passages in along program or continuous repetition of an entire program to learn the whole piece at once may be disastrous. A sudden change in repertoire--such as when a musician accustomed to the closed finger position of Mozart is suddenly confronted with the wide finger stretches of Brahms or Liszt--may also be detrimental. Music students may be misled into believing a
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