From: chiro4u@aol.com (Chiro4U) Newsgroups: rec.music.makers.guitar.acoustic Subject: Carpal Tunnel Syndrome Date: 9 Aug 1996 18:07:21 -0400 I wrote the following article for various music journals and newsletters. It is helpful to the musician. Enjoy! Dr. Timothy Jameson Bayshore Chiropractic Center for Peforming Arts Injuries Castro Valley, CA 94546 510-582-5454 Carpal Tunnel Syndrome: Explanation and Prevention by Timothy J. Jameson, D.C., C.C.S.P. Carpal Tunnel Syndrome (CTS) is a nemesis prevailing throughout the musical professions. It has threatened and has ended careers of many promising and well respected artists. Education within the profession is of vital importance to prevent the occurrence of this disease. This article will explain why musicians are susceptible to developing CTS, the causes of carpal tunnel syndrome, and finally, prevention of these injuries. What makes a musician susceptible to CTS? There are numerous factors that all play an integral part. These injuries are reported more in females than males. The numbers available only tell us who reported the disease, not how many suffer from the disease. This may be two totally different statistics. There are many musicians who do not disclose their suffering in fear of losing their jobs, especially if they are members of orchestras where each position is sought after by many applicants. We have learned that approximately 75% of symphony musicians have suffered at some time in their career with a musculoskeletal injury. Thus the prevalence is extremely high within musicians. It has been suggested that people who are of lesser build and have a smaller body frame are more susceptible to injury due to the forces imposed upon the body by repetitious movements. Symptoms usually result from a sudden increase of practice time, a change of teachers, a change of instruments, and long practice sessions without breaks. Smokers run a high risk because of nicotine's constrictive affect on the blood vessels. Anyone with underlying disease states such as hypothyroidism, diabetes, fibromyalgia, rheumatoid or osteoarthritis, blood vessel disease, and obesity, will be more likely to develop CTS. Pregnant women tend to develop CTS because of fluid retention, but the symptoms usually subside once the pregnancy is over. Nonmusical professions such as computer inputting or programming, and hobbies such as knitting can lead the musician to CTS. Previous neck injury from a car accident, from a bad fall, or from any trauma needs to be evaluated. Previous shoulder injuries, such as dislocations are important to note. A history of broken bones in the arm, forearm, wrist, clavicle, shoulder blade can be a predisposing factor. Finally, the particular instrument played by the musician increases susceptibility. Violinists, violists, guitarists, pianists, and percussionists are most at risk. For those of you who are unfamiliar with CTS, the following is a list of symptoms associated with the malady. CTS leads to pain, numbness, tingling, and when at its worse, weakness in the first three fingers of your hand. Symptoms can occur in the forearm as well. Many sufferers complain of pain in the hand or arm while sleeping. The person suffering from this disease may experience difficulty holding the instrument, clumsiness, drops objects such as glasses, and cannot grip well. When it is severe, the artist loses complete use of his/her hand, and will usually begin using the opposite hand to perform daily activities. It is my opinion that 80% to 90% of "carpal tunnel syndrome" cases are not a direct result of median nerve entrapment in the wrist. (This is the nerve that passes through the small tunnel formed by the bones of the wrist and a ligamentous covering). This is a controversial statement, but my clinical experience has shown that most cases termed "CTS" are a result of a combination of musculoskeletal and neurological problems stemming from the wrist as well as in the arms, shoulders, and neck regions. This is why it is necessary to find a competant doctor who will investigate all these areas to determine the extent of injury. To explain how carpal tunnel syndrome develops, I like to use the following analogy when explaining nerve flow from the neck to the arms. Imagine the nerve in your arms are like garden hoses, with water (energy) flowing at full pressure when working properly. If you have arthritis in your neck, previous whiplash injuries, misalignments of the spine, or spinal curvature problems, this will cause a "kink" in the hose, and decrease the flow of water (energy). This will lead to a 40% - 50% decrease of nerve flow to the arms and hands. The nerves than pass under certain muscles that are tight and constrictive, and the nerve flow may decrease to 30%. It gets kinked as it passes through the carpal tunnel, leaving only 5% or 10% of its normal energy, thus the numbness, tingling, and weakness. This is why I state that performing surgery on the wrist is usually not effective, since many times the problems lie above that area. A predisposing factor to this insult on the nervous system is poor posture while playing the instrument. I will not go too deeply into posture here due to space limitations. Just keep in mind that when your mother told you to sit up straight, it still applies while playing your musical instrument! A hunched forward posture will create pressure on the nerves traveling from the neck down through the shoulder. This is especially important for the acoustic guitarist who leans forward over the instrument while playing, and also the pianist who leans forward to read sheet music. Inefficient use and overuse of the hand and arm musculature while playing the instrument is another major factor. How many of you keep a pinkie pointed outward and extended while playing? How many of you apply great amounts of pressure on to the fretboard or keyboard with your fingers? How many guitarists put a tremendous amount of pressure with their thumb on the neck of the guitar, especially while playing bar cords? These aberrant muscle actions lead to fatigue and soreness. Over a long period of time, the body retains a somatic memory of these positions and it becomes difficult to change them. This is where such techniques as Feldenkreis and the Alexander Method come into play. How does the musician prevent these maladies from occurring? The artist needs to use common sense and increase his/her body awareness. Musicians are compared to athletes because of the amount of training involved to play the instrument, and the repetitive nature of the muscle movement. The big difference is that athletes usually train with the larger more powerful muscle groups. Musicians on the other hand, need fine motor control of the smaller muscle groups of the hands. Consider yourself an athlete preparing to train when you pick up your instrument next time. Have you warmed up your muscles adequately to "train"? Have you increased overall blood flow and heart rate by performing some mild aerobic exercise? Have you stretched the muscles in the arms, hands, and neck? If you have not done these exercises, you are risking injury, just as an athlete who runs a 100 meter race would if he/she did not warm up beforehand. The most important advice I can give is to take breaks at least every 45 minutes. These breaks should be for 10 - 15 minutes in length and should include stretching and self-massage on the arms, hands and shoulders. Become aware of your body's needs. After you are done practicing, rehearsing, or performing, don't just throw the instrument in the case and leave. You need to cool down the muscles. Perform stretching exercises and elongate the tightened muscle groups. The more you as the musician become "in tune" with your body, the better off you will be. Read books on stretching, massage, and proper nutrition. Education, prevention and maintenance are the keys to a pain free career. Do not wait until symptoms arise to begin learning about prevention. Start now - your musical career is depending upon it!