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,
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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.
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9781909836815
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A catalogue record for this book is available from the British Library
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Publisher: Richard Furn
Managing Editor: Alison Whitehouse
Editorial Assistant: Katie Pattullo
Design: Designers Collective Ltd
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 Hand – A 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
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.