Upper extremity disorders in performing artists - cont.

A progressive program of stretching, strengthening, and conditioning is initiated. Prior to muscular exercise, pre-stretching increases efficiency and work capacity of the contractile components of skeletal muscle. Heat also causes greater enzymatic activity and less metabolism, increasing the efficiency of muscle contraction. There is also an increase in collagen elasticity and the force production capacity of muscle. Essentially, this is the basis of the warm-up.
Many programs have been proposed for return to playing. For example, in 1991, Richard Norris recommended starting with slow, easy pieces and gradually progressing to faster, more difficult ones. Some musicians start with two 5-minute intervals separated by a 6O-minute rest interval, progressing over a period of 30 to 70 days to a maximum of 50 minutes of playing with a minimum of 10 minutes rest in between. Others start with 2 minutes per day for two days, accelerating to 3 minutes daily up to 25 minutes with 5-minute breaks. The common denominator is the onset of a rest period at the first sign of fatigue. Many high-pressure professionals are unable to initiate complete rest for a period of 12 weeks as recommended. They may start with two weeks of complete rest and then a graded returo.16
Close attention must be given to instrument design and the elimination of maladaptive playing styles. This must be done under the auspices of an experienced music instructor. For example, Dorothy Taubman11 observed that playing piano with curled fingers is clearly more stressful than playing with straight fingers. Great masters like Vladimir Horowitz discovered this on their own, and Horowitz played with straight fingers his whole life. Striking a piano key is primarily a flexion of the metacarpophalangeal joint. Doing so with the proximal and distal inter-phalangeal joints flexed pre-stresses and strains the intrinsic muscles. causing extrinsic contraction to the lumbricals and interossei. This predisposes muscle tendon units to fatigue and injury . Attention must be turned toward the correcting of improper posture and the economy of muscle action in the upper extremity eliminating unnecessary and inefficient muscle contractions. This is the basis of the Alexanderl7 and Feldenkraisl8 techniques. Usually, with distal overuse, proximal upper extremity musculature is neglected and needs to be stretched strengthened, and conditioned, including the trapezius, rhomboids, supraspinatus, serratus anterior, and levator scapular muscles. Paraspinal muscles in the neck need to be addressed also.
Extremity or instrumental orthotics may unload compressed areas. allowing instrument weight to be borne by more proximal muscle groups. such as the trunk or the floor. This facilitates playing by allowing the neck or upper extremity to be placed in a more comfortable position. Occasionally, the instrument's shape may be altered to facilitate playing. This may range from playing with a lighter viola to playing with a curved flute. A custom-molded chin and clavicle rest for the violin or viola may make supporting the instrument with the head and neck effortless. reducing the necessity for extreme neck flexion or anterior rotation of the shoulder girdle, which lead to fatigue, pain, and neuropathy. Significant comfort can be achieved by simple modification without compromising performance quality. In

 general, with appropriate treatment, 60% to 90% of these musicians eventually return to full performance schedules.19

Nerve entrapment syndromes
Initially thought to be rare in musicians, nerve entrapment syndromes have surfaced as a major problem. Twenty percent of patients presenting with upper extremity complaints to performing arts clinics in this country have compressive neuropathies.
As peripheral nerves travel from the intervertebral foramen to sensory receptors or motor endplates, they pass through anatomically tight spaces at various levels in the extremity. These spaces are bounded by fibrous tissue and or bone. Peripheral nerves slide back and forth as extremities flex and extend at various joints. For example, chronic repetitive movement of the arm in positions that increase overall pressure in these fiber osseous tunnels leads to local ischemia of the nerve and myelin nerve sheath. Secondary inflammation accentuates the problem, causing formation of a constricting scar around these fibrous tunnels and creating intrafascicular edema within the nerve. If this continues, writing becomes jeopardized and the nerve becomes tethered, causing microtears and stretching injuries. This may cause demyelination, which mayor may not be reversible. Musicians are particularly susceptible to this type of nerve injury.
Maintenance of stressful, proximal muscle girdle postures, while executing rapid finger movement, may cause this problem in violinists and violists. Cervical nerve roots become compressed by bone or disc material that escapes into the intervertebral foramen, where cervical roots exit. Another source of compression is degenerative joint disease in the neck. This is common in violinists because of the tendency to have their necks flexed and turned to the left side.
At the brachial plexus level, nerves may become compressed by a cervical rib or under the tendon of the pectoralis minor known as thoracic outlet syndrome. More distally the ulnar nerve may be compressed at elbow level (cubital tunnel syndrome) or at the wrist's canal of Guyon. At the same time the median nerve can be trapped in the elbow's pronator inlet or more commonly, in the wrist's carpal tunnel. The radial nerve compresses in the radial tunnel of the proximal forearm. This may present with motor palsy of the posterior interosseus nerve or a pain syndrome known as radial tunnel syndrome which may be associated with tendinitis at the origin of the extensor carpi radialis brevis. Digital nerves may become compressed because of their subcutaneous position. A flute or clarinet may cause direct pressure on the side of the finger causing nerve compromise. Playing the English horn, while suspending it in the air, may cause ulnar nerve compression secondary to extreme positions of elbow flexion.
Thoracic outlet syndrome in flutists is quite common. Reducing hyperabduction of the right shoulder and diminishing internal rotation of the left shoulder can be quite helpful. Cervical radiculopathy is found in keyboard players primarily on the right side and in violinists on the left side. This is associated with the neck being tilted four to six hours daily.
Symptoms in these conditions include painful numbness
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