The Musician’s Hand Ian Winspur
INDEX
Note: Page numbers in bold or italic refer to tables or figures, respectively.
A
Abductor pollicis longus (APL) 51, 53
Acupuncture 80, 121
Adrenalin 188
Alcohol 188, 189
Alexander technique 154155
Allodynia 185
Amitriptyline, for long-term pain 187
Amphetamine 189
Amputation 106, 106
Anconeus 38
Analgesics, for pain 186
Anatomical compromise in surgery 99
Anatomical restoration, surgical 98
Anatomical snuffbox 53
Anatomical variability, hand 155157
Anatomy
carpal tunnel 76
elbow 41, 81, 83
muscles of forearm 38
sensory nerves of hand 86
tendons of finger 95
thoracic outlet 74
thumb 40, 50, 53
wrist 76
Antidepressant therapy 7
for long-term pain 187
Anxiety 4, 133
and tremor 189
and upper limb pain 4
social 178179
Arpeggio technique 36
Arthritis in basal joint of thumb 36
Arthrodesis 3537, 96, 99
Arthroplasty 35, 36
Aspiration, ganglion 45
Aspirin, for pain 187
Atraumatic technique 101
Attribution error 179
dealing with 179, 179
B
Backache from posture 8
Baclofen, in musician's dystonia 144
Bagpipers, problems of 64, 64, 66, 67, 97, 106, 194
Banjo players, problems of 86, 174
BAPAM see British Association for Performing Arts Medicine (BAPAM)
Bassists, problems of 174
Bassoonists, problems of 40, 96, 100, 121
playing-related musculoskeletal discomfort (case) 126128
Bassoons 2627, see Wind instruments
Benzodiazepines 188
Beta-blockers 188189
Biomechanical studies 1619
Body awareness techniques 146
Botulinum toxin 144145
Boutonnière deformity 52, 100, 107108
Boutonnière position 100, 101
Bowler's thumb 48
Brachial neuralgia 91
Brachioradialis 38
Brass players, problems of 174
British Association for Performing Arts Medicine (BAPAM) 2, 4, 121, 133
Buprenorphine, for pain 187
Burnout 180, 180181
priorities for musician recovering from 182
symptoms of 181, 181
C
Caffeine 188, 189
Cannabis 189
Cardiovascular training 153
psychological benefits of 153154
Carpal tunnel syndrome (CTS) 71, 72, 75, 7581, 194
acute positional CTS 7880, 79
classical idiopathic CTS 8081
contraindications for surgery 95
differential diagnosis 7881, 79
flexor tenosynovitis of wrist 80
incidence 72
in musicians 7781
nerve conduction testing 78, 90
Phalen's test 75
sensory and motor disturbances 75
signs and symptoms 75, 78, 78
steroid injection 76, 7677, 77
surgery 77
symptoms 75
Tinel's sign 75, 76
Carpometacarpal joint replacement 35, 35
Carpo-metacarpophalangeal joint (CMC) joint osteoarthritis 121
Cellists, problems of 3, 7, 9, 22, 83, 86, 92, 174
cellist's fingertip 49
hand and arm pain 7
Cello 20, 22
Cerebellar tremor 189
Cervical radiculopathy 91
Cervical spondylosis 31
Chin rest 21
Chronic pain see Pain
Clarinet see Wind instruments
Clarinettists, problems of 9, 2426, 121, 153, 159, 186
Clinical evaluation 57
establishment of trust 5758
examination 5859, 59
history 58
imaging studies 5960
nerve conduction and electromyography testing 60
specialised technical analysis 60
Clonazepam, in musician's dystonia 144
Clostridium histolyticum collagenase 65
Coban wrap 119, 119, 124
Cocaine 190
Cocodamol, for pain 186
Codeine, for pain 187
Collagenase injection 6566
Compartment syndromes 192
Compound analgesics, for pain 186
Compression screw fixation 102, 102103
Conductors 5, 32
Constraint splinting 130
Consulting room facilities 57, 143
Contrabass 20, 22
Core stability 154
deficits in 154
training for 154155
CTS see Carpal tunnel syndrome (CTS)
Cubital tunnel syndrome (CubTS) 81, 81
conservative care 82, 82
nerve conduction test 82
subcutaneous transposition 83
surgical treatment 8283
Tinel's sign 82
D
Deliberate practice 166
Depression 4, 7, 187
De Quervain's tendonitis 40, 40
Finkelstein's test for 41, 41
surgical release of 43
Descending inhibition 186
Diazepam 188
Digital mucous cysts 46, 47
Digital nerve compression 8587, 86
and neuroma 85
sensory nerves to digits 86
sites of 85, 86
treatment 8687
Digital nerve injury, repair of 109
Dihydro-codeine, for pain 187
Dislocation of extensor tendons at MCP level 44
Distal compression neuropathies see Nerve compression syndromes
Distal interphalangeal (DIP) joint 33
ganglions from 46
Dorsal wrist ganglions 4445, 45, 94
Double-lesion neuropathy (double crush) 73
Drummers, problems of 42, 4647, 94,
Drummer boy's thumb (or palsy) 5051
Duloxetine, for long-term pain 187188
Dupuytren's contracture 6369, 9495
bagpipers 64
collagenase injection 6566
complications from surgery 66, 67
conservative fasciectomy 66
Curse of the MacCrimmons 64
history and genetics 6364
Hueston approach 67
indications for surgery 9495
needle fasciotomy 65
open palm technique 67
postoperative care 68
progression of, rate of 63
recurrence 67
surgical treatment 6668, 67, 68
Z-plasty flaps and interpositional grafts 6769, 68
Dupuytren's diathesis 63
Dynamic stereotypes 138, 144
Dystonia 4 see also Musician's dystonia (MD)
definition of 135
focal 135, 137
generalised 135
segmental 135
E
Ecstasy (MDMA) 189190
Ehlers–Danlos syndrome 9
Elbow positioning for prevention 160
Electromyography (EMG) 60, 89
Electrophysiological methods 145
Embouchure dystonia 135, 135, 141
EMG see Electromyography (EMG)
Endoscope, use of 101
EPB see Extensor pollicis brevis (EPB)
Epicondylitis see Tennis elbow
EPL see Extensor pollicis longus (EPL)
Ergobrass 160, 161
Essential tremor 189
Evaluation of musician see Clinical evaluation
Examination of the musician 5859
Extensor carpi radialis brevis (ECRB) 37, 38
Extensor carpi radialis longus 38
Extensor digitorum 38
Extensor pollicis brevis (EPB) 51
lacerations 107
Extensor pollicis longus (EPL) 50, 51
lacerations 107
rupture 51
Extensor tendons 53
closed injuries to 107108, 108
repair of 107
F
Fabric wrist wraps 124, 124125
Fatigue 7 see also Muscle fatigue
long-term pain and 186
Fédération Internationale des Musiciens (FIM) 191
Fibromyalgia 186
Fiddler's chin 48
Finger curling, musician's dystonia 136, 136
Fingertip injuries, repair and reconstruction 105106, 106
neurovascular flap, use of 106, 106
no bone shortening 106, 106
Finkelstein test 41, 41
Flamenco guitarist's thumb (case) 5154, 53
Flautist's index finger 49
Flautists, problems of
compression in Guyon's canal 82
digital neuroma 85
involuntary finger flexion 143
musician's dystonia in 136, 139
painful shoulder problems 32, 32, 160
wrist problems 159
Flexor carpi radialis sling 36, 36
Flexor digitorum superficialis (FDS) 95, 108109
Flexor sheath ganglions 44, 45, 4647, 94
Flexor tendon repair (case) 130
Flexor tendons, closed injuries to 108109
Flexor tenosynovitis of wrist 80
Flute see Wind instruments
Focal dystonia 60, 96, 130, 135147, 175, 189, 193 see also Musician's dystonia (MD)
therapist's role in 130133
Forward head thrusting 164, 164
Fracture dislocation
DIP (case) 110112
radial and intra-articular (case) 112114
Fractures, management of 102, 102103, 109
G
Gabapentin, for neuropathic pain 187, 188
Ganglions 4447, 45
dorsal wrist 4445, 45
indications for surgery 94
occult 4546
General wellness initiative 132
Giant cell tumours 4748, 97
Graffman, Gary 4
Guitar 23, 21, 2223, 165
Guitarists 5154, 159
carpal tunnel syndrome 7880, 79
fabric wrist support, use of 124
flamenco guitarist's thumb (case) 5154
musician's dystonia 139
other problems of 23, 42, 44, 45, 47, 5154, 157, 163, 165, 174
trigger finger, surgical release of 95, 95
wrist positioning in 159
Guyon's canal 81
H
Hand and arm pain 36, 6
due to technical problems 7, 79
general medical condition and 7
medical evaluation 67
Hand posture 159
Hand span see Keyboard instruments
Hand, swellings in 4448
Hand therapy 117134
Hand tremors 189
Harp 2324
Harpsichord 19, 20
Harpsichord player (case) 195
Health anxiety 177
Health problems 34
Health promotion and injury prevention strategies 151, 151
Heberden's nodes 33, 35
Heroin 190
History taking 58
HMS see Hypermobility syndrome (HMS)
Hyperalgesia 185
Hypermobility, detection of 8
Hypermobility syndrome (HMS) 912
management 12
scoring system for 10, 11
test for upper extremity hypermobility 11
Hypnosis 174175
Hypochondria 177
I
Ibuprofen, for pain 187
IMS needling 121
Incisions, location 96
Indications, surgical 9396
modified 9495
tighter 9596
wider 9394
Industrial arm pain 73
Inhibition, lack of in dystonia 140
Injection technique
bursitis 32
carpal tunnel 7677, 77
flexor tendon sheath 42
joints of the hand 3334, 34
Injury during music education 152
Injury prevention strategies 151
anatomical variability in hand 155
cardiovascular training 153154
core stability programmes 154155
health promotion and 151
independent finger control, training for 157158
kinetic chain, kinetic chain 158159
muscle and tendon variability 155156
music education and 152
physical fitness 152155
posture 159166 (see also Posture)
practice sessions 167168
ranges of joint movement 155, 156
strategic practice 166
tendon interconnections 156157
virtual practice 166167
Instrument weights 24
Intention tremor see Cerebellar tremor
Interface between musicians’ hands and instruments 1528
bassoons and saxophones 2627
cello 22
clarinet and oboe 2426, 25
contrabass 22
flute 26, 26
guitar 23, 2223
harp 2324
keyboard instruments 1516, 1620
keyboard percussion instruments 28
membranophones 28
percussion instruments 16, 28
piano 1620
string instruments 16, 2024
trumpet and trombone 27
violin and viola 21, 2122
wind instruments 16, 2428
International Convention of Symphony and Orchestra Musicians’ Survey 3
Intersection syndrome 40, 41, 42
Intra-articular fractures 109
Intrapsychic anxiety 180
Intrinsic muscles, strengthening exercise 82
Involuntary flexion 143, 143
J
Jeep driver's disease 48
Joints
injection technique 3334, 34
painful 33
stiff 3536
swelling 33
unstable 3637
K
Keyboard instruments 1516, 1620
biomechanical studies of piano-playing 1617
changes in keyboard span 1920, 20
hand span and overuse 1719, 18, 19
hand movements and positions 17, 18, 100
psychological problems associated with 174
striking action of piano 20
Keyboard percussion instruments 28
Keyboard players 3
flexor tenosynovitis of wrist 80
problems of 9, 174
Kinesio tape 124, 125, 125, 160, 162
K-wire 99, 110
L
Lateral epicondylitis see Tennis elbow
Learned response 177
Learning-based sensorimotor training (LBST) 131, 146
Lindburg–Comstock syndrome 59, 157
Lister's tubercle 50
LSD 190
Lumbar lordosis (curvature) 164165, 164
M
MacCrimmons, Curse of 64, 68
Mallet finger 107, 108
Maximum theoretical heart rate (MTHR) 153
MD see Musician's dystonia (MD)
Median nerve 72, 75
compression of 78 (see also Carpal tunnel syndrome (CTS))
Medical evaluation, principles of 67
Medicines/drugs 185
musician's dystonia 144
for pain 186188
for performance anxiety 188189
recreational drugs 189190
Membranophones 28
Metacarpal bosses 48, 94
Metaplasticity 139
Micro trauma 192
Misuse 194, 194
psychological aspects 175176
Misuse syndrome 197
and complications (case) 195
Morphine, for pain 187
Motion analysis 1719
MRI angiography 60
MRI scan 5960
Mucous cyst see Digital mucous cyst
Muscle activity study 161
Muscle fatigue 192193
and pain 8
Muscle imbalances 121
Muscle tension and performance 195
Musculoskeletal disorders, playing-related 117123
correct muscle imbalances 121
ergonomic assessment on instrument 118
good practice habits 121, 122
graduated return to full playing 121, 123
pain relief for 119, 121
return-to-playing schedule 119, 120
splinting/strapping for early return to playing 118119, 119
treatment goals 118
Musical instrumental digital interface (MIDI) 60
Musical instruments 15
keyboard instruments 1516, 1620
modification to 15
percussion instruments 16, 28
string instruments 16, 2024
wind instruments 16, 2428
Music education, injury during 152
Musician's dystonia (MD) 135147
abnormal postures 135
botulinum toxin, denervation with 144145
classifications of 135, 135
constraint-induced training 145
diagnosis 142, 142144, 143
differential diagnosis 144
electrophysiological treatment 145
epidemiology 137138, 138
focal tremor 135
immobilisation of hand 145
lack of inhibition 140141
learning-based sensorimotor training 146
medications 144
as network disorder 142
pathophysiological findings 140142
physical and psychological history 140
predisposing factors 138139
prevention 146147
rehabilitation 145146
sensory–motor and psychological triggering factors, interplay of 138, 139
sensory-motor integration, impaired 141142
sensory perception, altered 141
social pressure 140
societal impacts 147
symptoms specific to 136, 136137
triggering factors 139
N
Nail, repair of 105
Naloxone 154
Naproxen 187
Neck, pain in 31 see also Cervical spondylosis
Neck positioning for prevention 162165, 163
Needle aponeurotomy see Needle fasciotomy
Needle fasciotomy, Dupuytren's disease 65
Needle puncture
digital mucous cysts 46
occult ganglion 46
Nerve compression syndromes 7187 see also specific syndrome
carpal tunnel syndrome 75, 7581
diagnosis 73
digital nerve compression 8587, 86
double crush 73
hand and arm pain 71
incidence 71, 7172
mechanism of compression 72
pathophysiology 7273
radial nerve compression 83, 8385
related anatomy 72
thoracic outlet syndrome 7375, 74
ulnar nerve entrapment 8183
Nerve conduction testing 60, 89, 95
Nerve gliding 72
Nerve injuries 109
Nerve laceration 109
Neuralgic amyotrophy see Brachial neuralgia
Neuro-linguistic programming (NLP) 178
Neuroma, digital 8587
Neurophysiological testing 89
brachial neuralgia 91
carpal tunnel syndrome 90
electromyography 89
nerve conduction testing 89
thoracic outlet syndrome 9091
ulnar nerve lesions 90
Neutral posture 118
Night resting splint 124
Nociceptive pain 185
Non-specific arm pain 192
clinical reality 196197
fatigue 192193
misuse 194
overuse 192
overuse syndrome 193194
Nonsteroidal anti-inflammatory drugs (NSAIDs) 187
Norris, Richard 182
O
Oboe see Wind instruments
Oboists, problems of 2426, 97
Obsessive-compulsive disorder (OCD) 138
Occult ganglion 4546
Open palm technique in Dupuytren's contracture 67
Open reduction and stable fixation 102, 102
Opioids, for pain 186187
Orchestral musician, life of 3
Osteoarthritis 33, 36, 121, 129
‘Overuse’ syndrome 173, 193194
P
Pain,
types 185186
drug therapy 186188 (see also individual drugs)
Paracetamol (acetaminophen), for pain 186
Parkinson's tremor 189
Parsonage–Turner syndrome see Brachial neuralgia
Pedagogical retraining 146
Percussion instruments 16, 28
keyboard percussion instruments 28
membranophones 28
musculoskeletal disorders 28
Percutaneous needle fasciotomy see Needle fasciotomy
Perfectionism 133, 177
Performance anxiety 4, 177181, 188
incidence 177
and learned responses 177178
social anxiety 178179
symptoms of 188
treatment of 188189
Performance psychologist 182
Performance psychology 173
instrumentalists, problems of 174
performance anxiety 177181
physical loss of function, problems of 175177
psychological loss of function, problems of 174175
team approach to treatment 181182
Performers’ health, risks factors for 152
Performers’ life, problems inherent in 12
Performing Arts Medicine Association 121
‘Personal injury’ 176177
Phalen's test 58, 59, 75, 78
Phenytoin, in musician's dystonia 144
Physical endurance 153
Physical fitness 152153
cardiovascular fitness 153
cardiovascular training 153154
core stability, training for 154155
muscle strength and tone 153
Physical loss of function, problems of 175177
focal dystonia 175
overuse–misuse syndrome 175176
personal injury victims 176177
psychological therapies and counselling 177
Physical warm up 167
Pianists
attitude to injury 1
composite arthroplasty with sling in 36, 36
compromised distal joint in 99
flexor tendons repair 129
hand span and overuse among 1719, 18, 19
life of 12
musician's dystonia in 135, 136, 137
performance-related injury, avoiding 2
problems of 174
physiotherapy 2
susceptibility to tendonitis 42
ulnar nerve entrapment 82
Piano 1620
Pilates exercises 154
Postoperative recovery 9899, 99
Postural training 154
Posture 159
elbow positioning 162, 160, 161
general 166
hand positioning 159
neck positioning 162, 163, 164
seating 165
shoulder positioning 160, 162, 163
standing and sitting 164165
supporting the instrument 165
wrist positioning 159
Practice
cool down 168
good practice habits 122
sessions, organisation 167168
strategic 166
warm up 167
Pregabalin, for neuropathic pain 187, 188
Prevention see Injury prevention strategies
Primidone, in musician's dystonia 144
Pronator syndrome 78
Proximal interphalangeal (PIP) joint 107108
Psychological loss of function 174175
Psychological self care 132, 153
Psychological triggers for musician's dystonia 139140, 139
R
Radial nerve compression 83, 8385
points of compression around elbow 83, 83, 84
radial tunnel syndrome 84, 8485
Radial nerve entrapment 38, 39
Radial tunnel syndrome 38, 38, 84, 8485
conservative treatment 85
pain on palpation directly over radial nerve 84, 84
surgical decompression 85
symptoms and clinical signs 84
Recreational drugs 189190
Rehabilitation, after trauma and surgery 125126
Repair and reconstruction 105
amputation 106
closed tendon injuries 107109
fingertip injuries 105106, 106
fracture 109
musical needs, focus on 110114
nerve injuries 109
tendon lacerations 106107, 107
Repetitive strain injury (RSI) 175, 191
Return-to-play schedule 119, 120
Rheumatoid arthritis 3233
inflammation of tendons in 39
unstable joint in 36
Robert Schumann syndrome 137
Rotator cuff lesions 3132
RSI see Repetitive strain injury (RSI)
S
‘Sabotage’ 177
Saxophones 2627
Scalene tension 164
Schuman, Robert 50
Seating 165
Sedative drugs, for anxiety reduction 188
Segovia arpeggio 51, 52
Self care tables
attribution errors, dealing with 179
practice habits 122
psychological self care 132
recovering from burnout 182
return to play schedule 120
Sensory integration and praxis tests 131
Sensory perception, alteration in dystonia 141
Sensory trick phenomenon 141142
Shadow playing 126
Shoulder rest 8, 21
Shoulder positioning, preventative 160, 163
Sitting and spinal curvature 164
Sleep disturbances 4
Sling arthroplasty 36, 36
Slow down exercise 131
Social anxiety 178179
Somatisation 174
Spinal curvature sitting and standing 164
Splinting see Thermoplastic splinting
Stage fright 4, 177, 188
Standing and spinal curvature 164
Steroid injection
carpal tunnel syndrome 76, 7677, 77
digital neuromas 8687
flexor tenosynovitis of wrist 80
Heberden's node 33
rotator cuff lesions 32
into small joints of hand 33, 34
tendonitis 42, 42
Stiff joints 3536
Strategic practice 166
Stretching 167
Stress reported by musicians 4
String instruments, positions and movements for play 16, 2024, 100
cello 22
contrabass 22
guitar 23, 2223
harp 2324
lower 2021
and movements 21
plucked 21
upper 20
violin and viola 21, 2122
String instruments, psychological problems associated with 174
String players 3, 5
digital neuromas 86
flexor tenosynovitis of wrist 80
problems of 3, 174
shoulder problems in 160
ulnar nerve lesions 90
Students
problems of 5
susceptibility to tendonitis 42
Subacromial bursitis 31
Surgical planning 96, 109
anatomical compromise 99101
anatomical restoration 98
early return to playing 9899, 99
location of incisions 9798
Surgical synovectomy, in rheumatoid arthritis 32
Surgical treatment 93 see also Surgical planning
contraindications 9396
indications 9396
technique modification 101103
Swellings in hand 4448
ganglions 4447, 45
giant cell tumours 4748
metacarpal boss 48
Synovectomy, in rheumatoid arthritis 32
Synovial swelling, reduction in 33
T
Talking cure 174
Taping 124125, 124125
Temazepam 188
Temporal discrimination thresholds (TDT) 141
Tendonitis 3944
chronic 43
De Quervain's 40, 40
Finkelstein's test 41, 41
inflammatory diseases and 39
local steroid injection 42, 42
mechanical factors and 40
and numbness in adjacent areas 41
surgical treatment 4344
triggering in, sites of 40
of wrist extensor tendons 42
Tendon lacerations, repair of 106107, 107
Tendon linkages 4950
extensor tendons 5051
flexor tendons 4950
Tennis elbow 3739
conservative treatment 38
indications for surgery 95
nonsteroidal anti-inflammatory drugs in 38
radial tunnel syndrome and 38, 38
steroid injections 38
surgical treatment 39
symptoms 37
Tenosynovitis 39
Therapeutic management 117
focal dystonia, therapist's role in 130133
playing-related musculoskeletal disorders 117123
rehabilitation after trauma and surgery 125126
specific conditions, case studies on 126130
splinting/strapping for early return to playing 123125
Thermoplastic splinting 123, 123124
Thoracic outlet syndrome (TOS) 7375, 74
dynamic TOS/disputed TOS 74
incidence 72
neurophysiological testing 9091
physiotherapy 75
vascular and neurogenic 74
Thoracic spine problems 31
Thumb base arthritis 36
osteoarthritis (case) 129
Thumb spica splint 124
Tinel's sign 75, 76, 78
Tobacco 188
TOS see Thoracic outlet syndrome (TOS)
Trait anxiety 153
Tramadol, for pain 187
Transactional analysis (TA) 178
Transcranial direct current stimulation (tDCS) 145
Tremor 135, 136, 143, 189
essential 189
focal 143
other causes 189
physiological 189
Trigger fingers 40, 44, 95
contraindications for surgery 95
release 43, 43
Trihexyphenidyl, in musician's dystonia 144
Trombone see Wind instruments
Trombone players, problems of 28, 22, 160
musician's dystonia in 136
Trumpet see Wind instruments
Trumpeters, problems of 159, 160
Tubiana, Raoul 58
U
Ulnar nerve 72
entrapment 8183 (see also Cubital tunnel syndrome (CubTS))
lesions 90
nerve conduction testing 90
surgery, contraindications and indications for 95
Unstable joints 3637
Upper limb pain 4, 5
V
Video recording 60
Villonodular synovitis see Giant cell tumours
Viola 20, 2122
Viola players, problems of 83, 141, 160, 162
fracture dislocation, management of (case) 110, 110112, 111
Violin 20, 21, 2122, 118
Violinists 8
musician's dystonia in 135, 136
problems of 174
right base of thumb osteoarthritis (case) 129
surgical release of trigger finger 95, 95
tendonitis, susceptibility to 42
thermoplastic splinting for 123, 123124
wrist fracture, severe comminuted intra-articular (case) 112114, 112114
Virtual practice 166167
Visual feedback 146
Volar wrist ganglions 44, 45
W
Wartenberg's syndrome 84
Weights of instruments 24
Wind instruments, positions and movements for play 16, 2428, 100, 100101
bassoons and saxophones, support of 2627
brass instruments 24
clarinet, support of 2426, 25
flute, support of 26, 26, 86
flute adaptations 2627, 32, 162
and hand movements 24
hand position and fingering technique for 27, 2728
oboe, support of 2426, 25
trombone, support of 27
trumpet, support of 27
weight of various types of 24
woodwind instruments 24
Wind player, problems of 3, 174
Woodwind instruments 9, 100
Wraps 124125, 126
Wrist arthroscopy 101102
Wrist flexor tenosynovitis (FTS) 80
Wrist fractures 109
Wrist positioning, preventative 159
X
Xanthomas see Giant cell tumours
X-ray 59
osteoarthritis 33
×
Chapter Notes

Save Clear


The Musician's Hand
Second Edition
The Musician's Hand
Second Edition
Edited by Ian Winspur FRCS Ed FACS LL M Consultant Hand Surgeon, London and Honorary Lecturer in Performing Arts Medicine at University College London, UK
© 2018 JP Medical Ltd.
Published by JP Medical Ltd,
83 Victoria Street, London, SW1H 0HW, UK
Tel: +44 (0)20 3170 8910 Fax: +44 (0)20 3008 6180
The rights of Ian Winspur to be identified as editor of this work have been asserted by him in accordance with the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission in writing of the publishers. Permissions may be sought directly from JP Medical Ltd at the address printed above.
All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the editor assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.
Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity.
9781909836815
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
A catalog record for this book is available from the Library of Congress
Publisher: Richard Furn
Managing Editor:  Alison Whitehouse
Editorial Assistant:  Katie Pattullo
Design:  Designers Collective Ltd
Foreword
Few pursuits are as dynamic and enjoyable as making music. For those who do it professionally, however, research suggests that pain and ill health are widespread and that healthy approaches to training and working in music are far from uniform internationally. Indeed, the effort needed to reach and maintain the highest performance levels can expose musicians to a wide range of health problems, such as pain, weakness, numbness or tingling. International surveys report that these problems affect between 40 and 90% of professional musicians, with the majority of studies citing figures in the upper portion of this range.
When The Musician's Hand was first published in 1998, it was at the forefront of a new movement that was beginning to identify, investigate and address these problems systematically. Readers, health professionals and musicians alike, could turn to this pioneering book to learn more about age-old ailments – health concerns which, although widely and profoundly experienced by musicians, had hitherto been absent from research and public discourse. Prior to its publication, musicians had felt compelled not to reveal weaknesses in their physical and mental state for many reasons, not least of which being the precarious nature of their employment and the public image of invincibility deemed necessary to win work and attract audiences. These external factors explain only part of the story, however. Musicians love what they do and derive tremendous meaning and value from doing it. After years of pursuing their art – sometimes from as early as 2 or 3 years old, all the while cultivating a high degree of self-sufficiency and a firm internal locus of control – the experience of potentially career-threatening health problems can be devastating to one's core identity. It can also affect how (and whether) musicians seek help to address their problems. This rather bleak state of affairs has started to change, and The Musician's Hand has played no small part in bringing this about.
Health professionals can turn to this updated edition for the very latest developments in performing arts medicine. From prevention to treatment, physical health to mental health, optimal use to misuse, the book engages directly with state-of-the-art research and clinical practice. For musicians, the book has helped dispel myths that performance-related ill-health is rare, that those who suffer must do so in solitude, and that health professionals do not understand the opportunities and challenges that musicians face in their day-to-day lives. It is now possible, although not in every country, for musicians to discuss health and wellbeing in artistic, educational and occupational contexts and to engage with health professionals who understand and work directly with and for artists.
We are now at a point where musicians and the music profession are ready to embrace targeted health support. While there is clearly a need for individual musicians to develop their own healthy approaches to making music – in order to prevent and treat pain, injury and other health problems – this must be accompanied by comprehensive health promotion within the intensive environments of specialist training programmes and the workplace. For this to happen, educators, employers, managers and policy makers can use this new edition of The Musician's Hand as a source of inspiration for positioning health as a driver, rather than the consequence of, music making and performance enhancement, building supportive environments where health and wellbeing are considered integral to expert practice.
While the hand is, to paraphrase Immanuel Kant, the visible part of the brain, for musicians and their audiences it is so much more. It is the vehicle by which musicians move us and make us move. With its comprehensive account of medical advances, The Musician's Hand is well placed to inform and guide health professionals in their support of and help for musicians, ensuring that they are, indeed, in good hands.
Aaron Williamon
Professor of Performance Science, Royal College of Music, London, and Director of the Centre for Performance Science, London
May 2018
Preface
It is nearly 20 years since the publication of The Musician's HandA Clinical Guide. Not all has changed in the intervening years but medical science has advanced, particularly in imaging and in pharmacology, and this has significantly influenced our understanding and treatment of musicians’ disorders. Along with two decades of additional experience this justifies an update of what has proved to be a popular and useful book for many doctors, music teachers and, indeed, musicians.
Musician's focal dystonia is one example of significant change: it has been a conundrum for over 200 years but with the new techniques of functional brain scanning we have begun to unfold some of the mystery and formulate therapies based on scientific understanding rather than witchcraft. Botulinum toxin has become available in the last 20 years and while its principal usage is in temporary cosmetic improvement, it does have a clearly defined role in disorders of motor control, including focal dystonia. Collagenase, another enzyme derived from a Clostridium, has also become available and is particularly useful for musicians with early Dupuytren's contracture. Our surgical experience has advanced too; while the techniques used are not in themselves new, their application to specific difficult situations in musicians may surprise many surgeons but nevertheless have been shown to be effective. This edition of The Musician's Hand addresses all these developments, reflecting current knowledge in the revision and reorganisation of many chapters and the complete rewrite of others, such as the chapter on musician's dystonia.
Not everything has changed, however. Musicians still suffer for their art, trying to please demanding teachers and conductors. Their lifestyles remain uncertain, demanding and in some circumstances chaotic, and this can have a considerable impact on their physical wellbeing and fitness. The non-ergonomic design of many instruments has not been revised. Faulty techniques and mismatches still remain. The psychological strains of performance and of professional insecurities still exist. Hence portions of the original book still pertain and are as applicable today as when they were first written. In particular, contributions on such issues by the late Dr Kit Wynn Parry, my previous co- author, are retained with his permission. He was a pioneer in recognising and highlighting the specific nature of musicians’ hand and arm problems and wrote classically about them in the first edition.
We have come a long way medically in the understanding and care of musicians and, I believe, musicians have also travelled far in understanding their own problems and in trying to prevent serious injury. Musicians now, I hope, have more trust that doctors and surgeons understand their specific needs and have sufficient skill, in many circumstances, to salvage careers.
Ian Winspur
May 2018
Preface to the first edition
An apology for this book from a physician and a surgeon is that we not only love music but believe it to be fundamental to civilized living. Plato wrote that ‘Education in music is most sovereign because more than anything else rhythm and harmony find their way to the soul in most and take strongest hold upon it, imparting grace if one is rightly trained. Music reduces to order and harmony and disharmony in the revolutions within us’. The Greeks considered that instructions in singing and playing the lyre should be a regular part of education for every freeborn citizen. The tradition has been persistent: Handel remarked to Lord Kinoull after the first London performance of Messiah ‘I should be sorry, my Lord, if I have succeeded in entertaining them – I wished to make them better’.
In a study of New York children aged 2–6 years who had played in Alexander Blackman's Orchestra, it was found that all the children who had had this opportunity were well ahead of their classmates in all subjects when they entered school. Dance, and therefore music, is fundamental in all traditional cultures. One has only to read The Songlines, where Bruce Chatwin (1987) describes the way in which territorial boundaries and links with neighbouring tribes are sung and danced to realize the supreme importance of music as an integral part of social life.
In many countries, not least the United Kingdom, politicians have sidelined the Arts as tangential and far from fundamental to living. The steady withdrawal of funding for music in British schools is to be deplored, and the generation of musicians who benefited from the enlightened attitude to music in schools thirty years ago will not be duplicated if present attitudes to the Arts persist.
We wholeheartedly agree with Antony Storr (1992) when he says ‘Music is a powerful instrument of education which can be used for good or ill and we should ensure that everyone in our society is given the opportunity in participating in a wide range of different kinds of music’. The philistinism of so much of Britain today could be transformed in one or two generations if every child were given the opportunity to play an instrument as part of school activities.
The kernel of this book is the medical and surgical care of the musician's hand. However, the whole of the upper extremity is necessarily discussed. Similarly, one cannot divorce the musician's physical problems from his or her lifestyle, temperament and psyche. Hence, the many different aspects covered by the contents of this book.
We would like to thank all the contributors for their hard work inside deadlines. Finally, we would like to thank all musicians – friends, patients and performers – for providing the inspiration and encouragement to complete this book.
IW
CBWP
London, 1997
Chatwin B (1987) The Songlines. London: Jonathan Cape.
Storr A (1992) Music and the Mind. Riverside, N J: Free Press.
Contributors
  • Eckart Altenmüller MD MA
  • Professor of Music Physiology, Institute of Music
  • Physiology and Musician's Medicine, Hannover
  • University for Music, Drama and Media,
  • Hannover, Germany
  • Imogen Cooper
  • Concert Pianist,
  • London, UK
  • Andy Evans
  • Performance Psychologist, Performance and Media
  • Coaching, Kensington,
  • London, UK
  • André Lee MD
  • Doctor for Neurology and Musicians’ Medicine,
  • Department of Neurology, Rechts der Isar Hospital,
  • Technical University of Munich,
  • Munich, Germany
  • Christos I Ioannou Dis MA MSc PhD
  • Post-doctoral Researcher, Institute of Music
  • Physiology and Musicians’ Medicine, Hanover
  • University of Music, Drama and Media,
  • Hannover, Germany
  • Naotaka Sakai MD PhD
  • Director of the Sakai Orthopedic Clinic, and
  • Professor of the Biomechanics Laboratory,
  • Utsunomiya University,
  • Tokyo, Japan
  • Michael Shipley MS MD FRCP
  • Honorary Consultant Rheumatologist, Centre for
  • Rheumatology, University College Hospital London
  • and Honorary Senior Lecturer Performing Arts
  • Medicine, University College London,
  • UK
  • Joan Warrington BScPT CHT ATCL (piano)
  • Hand Therapist, Calgary, Canada
  • Alan HD Watson BSc PhD
  • Reader in Anatomy and Neuroscience, School of
  • Biosciences, Cardiff University,
  • Wales, UK
  • The late Christopher B Wynn Parry MBE MA DM
  • Oxf DPhysMed Eng FRCP FRCS
  • Rheumatologist, Consultant in Rehabilitation
  • Medicine and co-founder of the British Association
  • for Performing Arts Medicine (BAPAM)
  • Bryan Youl BMedSc MD FRCP FRS Mus
  • Consultant in Clinical Neurophysiology,
  • Royal Free Hospital,
  • London, UK
The Touch of Professional Care
Can I entrust my hand to you?
Says the musician to the surgeon.
The source of my livelihood;
Engaged in breathtaking performances,
Producing tunes of admirable eloquence.
A priceless part of my being;
Worth more than riches or gem,
Striving with positive assurance,
To put my humble name to fame,
Leaving the hearts of many,
Indelible memories of melodious sound.
Would I dare contemplate,
The agony of a reconstruction,
Whilst gripped with my fears of uncertainty?
Lo, I watch my performance dwindle,
To a point I feel significant loss of control.
My deeply troubled thoughts
Create a sense of justifiable doubt.
I wish your hand had stayed the same,
In flawless shape and excellent state,
To continue with proven ease of display
And creative rhythm of great flamboyance,
Replies the surgeon with a genuine
Touch of professional care.
The task at hand is challenging.
Aimed for precision with targeted goal;
A course not suited for unwilling hearts,
Either on your part or mine
But championed by a focused determination
To fix it right as much as we can.
Together we shall try again,
To sail the turbulent waters
Of reconstruction and rehabilitation.
And when we reach the shore afloat
We'll climb the mountain to its peak
And dance the music to the stars.
Rosemary Chukwu-Lobelu
Acknowledgements
I am grateful to all the contributors for their hard work completing these new and extremely current chapters within time constraints, and I hope this second edition fills the gaps left by medical advances and the unavailability of the original edition. I wish to thank Ella Alwyn for providing motivation and ongoing encouragement and Ana Calvo for editing the manuscript. I wish to thank Richard Furn and Alison Whitehouse of JP Medial Publishing for their sage advice and editorial help. And lastly I wish to thank all musicians for providing such inspiration and pleasure for us.
Ian Winspur
The editor and publisher extend particular thanks to the following for their generosity in supplying additional text:
John Williams (classical guitarist, London, UK) for his analysis of the cases presented in Chapter 4
Michael Freyhan (pianist and musicologist, London, UK) for his thoughts on physical and muscle tension in playing, and description of his injury, in chapter 16
Rosemary Chukwu-Lobelu (trainee hand surgeon, London, UK) for the poem on page xiii
For original photographs, we thank:
Raj Ragoowansi (Consultant Plastic and Hand Surgeon, London, UK) for Figures 4.11, 4.12, 4.13a–c, 9.6, 10.2, 10.3a, 10.3b, 10.3c
Aya Kanazuka (student of performing arts medicine. London, UK, and Chiba, Japan) for the photograph of the British Association for Performing Arts Medicine Clinic in Figure 5.1
Joan Warrington (Hand Therapist, Calgary, Canada) for Figure 13.1
Sally Bromfield (photographer, California, USA) for Figure 16.1a.
Andy Thoms (architect and piper, Dunoon, Scotland) for Figure 16.1b.
For illustrations previously published by JP Medical Ltd:
The photos used in Figure 4.5b, 4.15 and 7.10 were originally published in Pocket Tutor Surface Anatomy (© 2012 JP Medical Ltd) and are reproduced courtesy of Sam Scott-Hunter, London, UK.
Figures 4.6, 4.7, 4.10a, 4.10b, 4.14, 7.1, 7.3, 7.6, 7.8 and 9.1 are reproduced with thanks from Chung KC (2015) Essentials of Hand Surgery. London: JP Medical Ltd. The photograph in part b of Figure 7.1 is by courtesy of Martins Kapickis, Consultant Plastic, Hand and Reconstructive Microsurgeon, Riga, Latvia.
For previously published photographs reproduced with permission from their publishers and authors:
Figure 3.11 is from Norris RN (1993) The Musician's Survival Manual: A Guide to Preventing and Treating Injuries in Instrumentalists. St Louis: MMB Music. Revised electronic edition 2011 published by www.musicianssurvivalmanual.com.
Figure 3.12 is from Boyette J (2005) Splinting for adaptation of musical instruments. Work 25:99–106. With permission from IOS Press.
Figures 10.4 to 10.12 are from Winspur I, Warrington J. The instrumentalist's arm and hand – surgery and rehabilitation. In Sataloff R, Brandfonbrener A, Lederman R (eds), Performing Arts Medicine, 3rd edn. Narberth, PA, USA: Science & Medicine, 2010.