Preventing injuries in guitarists - London Hand Therapy

FEATURESTABILITY EXERCISES FOR THE WRIST AND FOREARMThese exercises do not involve any movement but are static and resisted. You must support the length of your forearm on a table or flat surface. You should feelresistance rather than pain, and only use 30% of your maximal effort initially, and as tolerated increase this gently and in a graded manner, up to a maximum of50%. Hold each position for 5-10 seconds and in time as tolerated gently increase the time that the position is held so that a 30 second hold is achieved.© Butler and Coldham 2006Forward bendingWith the palm of your handfacing down and your handforming a light fist, push yourforearm into the table andfeel the resistance right upinto your upper arm.Repeat __ times __ per dayBackward bendingWith your affected wrist ina neutral plane and whilstforming a light fist, place yourunaffected hand over theback of the wrist and resistthe backwards movement.Repeat __ times __ per daySide to sideRest your hand and forearmwith the little finger incontact with the table.Make a light fist and pushthe side of your forearm intothe table.Repeat __ times __ per dayRest your hand and forearmwith the palm facing thetable and make a light fist.Resist movement towards thethumb with the palm of theother hand.Repeat __ times __ per dayTurningRest your hand and forearmwith the little finger in contactwith the table, resist against youraffected side using your otherhand. Place your unaffectedhand over the base of yourwrist. Imagine you are turningyour palm down towards thetable and resist this movementwithout moving the wrist.Repeat __ times __ per dayfree range. Proprioception andretraining exercises can begraded and weight bearing ina neutral position first with theeyes open and then with theeyes closed can be anotherway to increase the difficulty ofthese exercises.When treating musiciansthe musical instrument is usedas a rehabilitative tool whenpossible. In the later stages ofrehabilitation these isometricexercises can be progressedso they are more challengingand the musical instrumentcan be used as resistance. Forexample, the patient is asked tomaintain a neutral joint positionwhile holding the string downon a guitar. 3After months of performingstrengthening exercisessymptoms can improveand it is not uncommon todetect an improvement inligament tautness with jointtranslation testing, which is veryencourgaing to both the patientand the treating therapist.SPLINTSTemporary supports to maintainjoint(s) in a straight (neutral)position are useful in assistinga patient to grade their returnto play. Supports can includelight plastic splints, neoprenewraps, wrist braces, lycra fingersleeves, or Coban wrap (SeeFigure 3). It may take manymonths for stability and strengthto improve and splints or wrapsmay need to be worn for sometime. They should be weaned asstrength increases and symptomsdecrease.MUSICAL INSTRUMENTMODIFICATIONSThe shape of a guitar can attimes present the player withdifficulties. The right forearmmay press on the body of theguitar and cause pain in theforearm and hand, and the leftwrist may feel it needs to bendA“EXERCISES MUSTONLY START WHENTHE PATIENT’SPAIN IS ‘UNDERCONTROL’”forwards in order to access someof the strings.Guitars have been designed withpart of the body of the instrumentrecessed to permit the use of amore neutral wrist and moreoptimal ergonomic position whenplaying. 4 The resultant decreasein left wrist flexion can help avoidthe high pressures associatedwith CTS and minimize frictionFig. 3A. Flexed wrist position utilized by some guitarists to access the lowerstrings; Fig. 3B. Retraining the wrist position using a wrist brace to limit wristflexion and encourage more elbow and shoulder range of motion.Bof the flexor tendons against thetransverse carpal ligament. Someelectric guitars avoid this problemaltogether by virtually eliminatingthe body of the instrument.The lower “bout” of the acousticguitar (the part where the rightforearm crosses the instrument)also can present a physicalobstacle 4 resulting in eitherexcessive right wrist flexion orprotraction of the right shoulderfor the right hand to access thestrings. The larger the body sizeof the guitar or the smaller theplayer, the bigger the problem.Laskin 5 has developed a smallbeveled edge for the classicalguitar where the right forearmcrosses the instrument. Norris 4further developed this idea to amore radical bevel, improvingright-hand access to the stringswith minimal distortion of rightshoulder and wrist position.ADAPTIVE EQUIPMENTFOR THE PHYSICALLYDISABLEDMusical instruments can bemodified or adapted to increasethe ease of playing for individualswith a physical or mentaldisability. Metal picks can befixed to the end of a prosthesis toallow guitar playing.For quadriplegics and peoplewith severe neurologicalNOVEMBER 2011 ACOUSTIC MAGAZINE 77Hand Care_BC.indd 19 23/09/2011 12:00

FEATUREPREVENTING INJURIES IN GUITARISTS“NON-SURGICAL TREATMENT SHOULDALWAYS BE TRIED FIRST...[TO] SOLVE THEPROBLEM RATHER THAN SURGERY”impairments, sip and puffcontrols can be adapted tothe computer and used inconjunction with one of anumber of musical softwarepackages to allow compositionand playback.Guitarists with left hand orshoulder problems can placea capo on the third fret, thusdecreasing the amount ofcombined wrist, forearm andshoulder rotation when playingon the first three frets. Becausethe distance between the fretsdecreases as one goes higherup the neck, the finger spreadrequired for chords or intervalsis also decreased. 6SURGERYSurgery on musicians must beentered into cautiously. Winspur 7reports that of the musicianspresenting with recognisableorthopaedic or rheumatologicconditions in the upper limb4-6% will be candidates forsurgery. Non-surgical treatmentshould always be tried first andit should not be forgotten that insome situations adjustment ormodification of the instrument orplaying technique (the interface)may solve the problem ratherthan surgery.The implications of surgery aregreat for a musician, whose handsare their livelihood. Thus respectfor their hand and career must beparamount. Accurate diagnosis,References1. Simmons, DG, Travell, JG and Simons, LS.Myofascial Pain and Dysfunction. The TriggerPoint Manual Volume 1. Upper Half of Body, 2ndEd. 1999, Lippincott Williams and Wilkins.2. Brandfonbrener, A. The epidemiologyand prevention of hand and wrist injuries inperforming artists. Hand Clinics, 1990; 6(3): 365-77.3. Warrington J. Hand Therapy for the musician:instrument-focused rehabilitation. In: WinspurI & Tubiana R (ed). Hand Clinics, The Musician’sHand. Philadelphia, Pennsylvania: W.B.SaundersCompany 2003 (19:2), 287-301.4. Norris RN, Dommerholt J: Appliedergonomics, Orthop Phys Ther Clin North Am6:159, 1997.analysis of need and disability,and precision in planning areneeded to ensure optimaloutcome of surgery. In the areaof acute trauma, techniquesthat will permit early return tofunction (such as rigid fixation offractures and early rehabilitation)are often advantageous.Electrodiagnostically documentedcarpal/cubital tunnel syndromeand ligamentous injuriesleading to instability that havenot responded to activitymodification or nonoperativetherapy can be consideredappropriate surgical conditions inthe musician’s hand. 8Winspur 9 states that thereare four areas that must beidentified and specificallyaddressed when planningsurgery on a musician’s hand.1. The exact location of incisionsavoiding critical tactile areas(Fig 4A)2. Anatomic repair andreconstruction3. Adjustment of any anticipatedanatomic compromise tothe musician’s specificmusical needs4. The need for an early return tolimited playing. (Fig. 4B).A large series of professionalmusicians operated on by asingle surgeon are presented byButler and Winspur. 11 Of the totalnumber of musicians undergoing5. Laskin W: Classical guitar “arm rest,”Guitarmaker 14:36, 1992.Fig. 4A. Because of the need to retain full control of the tip of thedigit when in complete fl exion, rather than dividing the A1 pulleywhich has been shown to have detrimental effects in guitaristswith trigger fi nger, the ulnar slip of FDS was removed to allow morespace under A1 pulley of left ring fi nger, without sacrifi cing thepulley. 10 ; Fig. 4B. Guitarist playing 4 days after surgery for triggeringaffecting the left ring fi nger.hand surgery 12.3% wereguitarists, this is a lot lower thanpiano/organ players (35.7%) andstring players (34.6%), however,the frequency of piano and stringplayers represents the popularityof these instruments rather thana vulnerability of the players.Of the 130 patients, 127 (97.7%)returned to full time professionalwork or were able to completetheir final year music collegeexaminations. The period of ‘timeoff the instrument’ followingsurgery is kept to a minimum andthen there is a graded return toplay programme that is initiatedas soon as possible.SUMMARYThe musicians hand is intricateand beautiful. What a guitaristis required to do with their6. Butler, K & Norris, R. Chapter 142 Assessmentand treatment principles for the upperextremities of instrumental musicians. In:Skirven TM, Osterman Al, Fedorczyk J, AmadioPC, ed. Rehabilitation of the Hand and UpperExtremity, 6th ed. Mosby Elsevier; 2011: 1855-1877.7. Winspur I. Surgical indications, planning andtechnique. In: Winspur I & Wynn Parry CB (ed).The Musician’s Hand a Clinical Guide. Abingdon,Oxon: Martin Dunitz, 1998: 41- 52.8. Amadio PC. The Role of Surgery. In: TubianaR & Amadio (ed). Medical Problems of theInstrumentalist Musician. London: MartinDunitz, 2000: 421- 431.Awhole body is complex, and itis paramount that the musician,music teacher, educationalfacilities, health professionalsand instrument makers allwork together to prevent anddecrease the possibility of injuriesdeveloping. Simple warm up, cooldown and strengthening exercises,a careful analysis of the playingposition and an ergonomicapproach to the instrument canassist the musician in decreasingthe possibility of an acquired injuryand facilitate a more enjoyableperformance experience.9. Winspur I. Special operative considerationsin musicians. In: Winspur I & Tubiana R (ed).Hand clinics, The Musicians Hand. Philadelphia,Pennsylvania: W.B.Saunders Company, 2003(19:2), 247-258.10. Ragoowansi R and Winspur I. Solutions totwo difficult surgical problems in musicians.Medical Problems of Performing Artists, 2008;23: 16-19.11. Butler K, Winspur I ‘Retrospective casereview of time taken for 130 professionalmusicians to fully return to playing theirinstruments following hand surgery’ HandTherapy, 2009, 14: 69-74.B78 ACOUSTIC MAGAZINE NOVEMBER 2011Hand Care_BC.indd 20 23/09/2011 12:00