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Preventing/ identifying music related arm pain/dysfunction

By Mairead O’Riordan
Development of music related arm pain in general related to OVERSTRAIN.

Onset occurs most commonly after a burst of prolonged activity, i.e. practicing a complex piece for several hours with minimal breaks, though symptoms may emerge gradually over time also.

Related dysfunctions: music related pain is one of the ‘family’ of upper limb (arm) neurodynamic (involving nerve irritation) presentations. The family of similar presentations includes:

WRULD (work related upper limb disorder)
RSI (repetitive strain injury)
TOS (thoracic outlet syndrome)
CTS (carpal tunnel syndrome)

These diagnoses share similar symptoms and findings on tests and all involve irritation or hypersensitivity of the nerves of the arm, which come from the spinal cord in the neck.

Pain presents often as diffuse or vague, anywhere along the limb, from the neck to the hand, usually one sided, but if untreated often similar symptoms are mirrored on the opposite limb. The pain often has a ’burning’ quality, and may be accompanied by pins & needles in the fingers, occasionally a sensation of weakness in the hand and forearm.

Almost invariably the neck and upper back test positive in terms of being restricted in movement and symptom producing also, though often the person will not be aware of this until tested

In assessing and treating music related pain or WRULD in the young adult, a number of factors appear to contribute to the presentation. Ideally contributing factors should be identified and acted upon by tutors in discussion with individual at-risk students.
Pertinent Issues in development of WRULD:

In prevention of WRULD, the following issues are pertinent:
3.Practice/Playing issues
Posture: Ideal v. less than ideal posture:
Long gangly limbs,
Shoulder blades poking out through the back of a t-shirt.
Head or chin poking forward,
Head held away from midline in playing
Shoulders hunched up or forward
General posture: adoption of an individual body set (usually picked up subconsciously from watching an ‘icon’ at work)
Technique issues:
General posture: adoption of an individual body set (usually picked up subconsciously from watching an ‘icon’ at work)
Excessive power/ force being applied while playing (increased muscle force or torque
Excessive gripping or fingering
Utilisation of excessive flexion angle at wrist while playing
Excessive muscle stress or tension in shoulders while playing (especially obvious if the student is having difficulty grasping the piece)
Speed, playing a large number of notes per minute
Note/ chord complexity
Mismatch between physique of student and chosen instrument ( tall/ big boned male playing tiny stringed instrument / tiny framed female playing double bass)
Practice Issues:
Students must not be asked/ expected to practice for prolonged periods. Liaison within the teaching team is vital to ensure that individual students are not attempting to master several complex/ fast/ technically difficult pieces simultaneously for different lecturers
Promote accuracy of technique over force applied to produce sound
Build up speed gradually over a term and rebuild speed component at the start of each new term/ year
A maximum daily practice/playing time should be agreed for all students to include home/ non college activities. Once agreed, this needs careful monitoring. (Students presenting with RSI type pain/injury almost invariably point to a period of excessive practice workload as the starter of symptom).
Avoid students being in several different bands, across different years in college, especially as many will also gig outside college.
Dealing with onset of symptoms:
Arm/hand pain is the body’s warning sign. LISTEN to the body & respect what you hear.

Often the pain is a by product of excessive playing or overstrain. In any activity, muscle action creates a build up of toxic chemicals within the muscle, which is drawn away by the blood stream both during the activity and in the rest state after. If too high a level of demand is requested of muscles with insufficient rest period, this chemical toxicity can damage the muscle and other soft tissues in the area. An overloaded muscle swells at a cellular level in response to toxicity. If not given the opportunity to clear fully, this swelling seeps out into the region, affecting other tissues. This is the case sporting muscle injury.

In the case of WRULD forearm nerves which pass between muscles become compressed and in response they swell within their casing, so the nerve becomes irritated both from within and outside. Nerve irritation is at the heart of all WRULD/musician pain.

Initial self management of overuse injury, whether from the sporting arena or in music should be addressed in the same way: namely: use techniques to reduce local cellular swelling, i.e. RICE
Rest: stop playing; avoid hand activities once discomfort or pain comes on. Stop practicing/ playing, but do not substitute practice with using a different instrument instead or spending hours keyboarding instead
Ice: to reduce local cellular swelling: Always ice for the 1st 5 days (10-15 minutes every 2 hours throughout the day). Do not use any heat based rubs or applications in the early stages as you may increase swelling and pain.
Compression: wear a tight bandage or wrist sleeve when resting (not so tight as to cut off circulation).
Elevation: keep the limb up rather than hanging down. This helps gravity clear excessive swelling.

Medication: use simple (over the counter) painkillers/ anti-inflammatories at a dosage stated on the box for 3 days
Do not play at all for 2-3 days, then short sessions i.e.
4 x 10 mins sessions over the first day,
8 x 10 mins day 2.
Early stretches for pain reduction:
Commence from 24hours after onset of pain

Irrespective of whether pain is in arm alone, gently but fully stretch your neck fully in all planes every two hours, Hold each extreme position for 3 secs. Repeat 3 times
chin to chest/ back to ceiling
turn fully left/ right
side bend ear to shoulder left/right.
Raise arms over head, keeping upper arms close to ears and elbows fully straight.
Flop wrists forward & back as far as possible for 10 times

Sitting down with elbows bent & tucked in by side, push shoulders down & back as far as possible. Hold for 5 secs. Do 5

Ongoing problems:
If pain discomfort comes on gradually and builds up over time, it is useful to monitor the following
what exact activities cause discomfort
If you can play thorough the pain, or if it worsens the more you do
whether the discomfort stops immediately on stopping playing. If not, note the length of time it takes before the pain disappears each time (pain latency)
Next Steps:

Consult a Chartered Physiotherapist if pain does not fully clear in a week of self-management. A tip to know whether the physiotherapist has experience in treating WRULD is that the assessment must include a full manual palpation assessment of the neck and upper back region.
Mairead O’Riordan, MSC, MISCP, Chartered Physiotherapist, Practice Principal, TherapyXperts Maynooth
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