About
10 years ago, through ignorance and inattention, I developed chronic
tendonitis in my wrists and forearms as a result of practicing with my
shakuhachi into pain, recovering and then practicing into pain again.
Eventually my hands became so weak that I couldn't use them to pick up
anything heavier than a fork. I couldn't open doors, reach into the refrigerator,
write etc. I sought help in various places but it was difficult to find
one person who could take me by the hand and put me on the path to recovery.
(Heartfelt thanks to Norman Allard, chiropractor/yogi in Boulder, CO).
If you become injured, don't despair. There is a path to recovery for
most people.
The
holding of tension in the body whilst playing is subtle and harmful.
I had quite a time learning to recognize when tension arose, where, and
what to do about it as I played. This understanding was critical to reforming
my playing style into a healthier way.
RESPECT
I
also learnt that playing injuries are best treated with great respect,
and accorded constant care. If you have become disabled from playing
a few times, with recovery in between, you may have a tendency towards
injury which could be something you'll have to live with as long as you
want to be a musician. You need to become very aware of how you use your
body in everyday activities and learn when 'enough is enough' BEFORE
injury shows up. Examples: reaching into a refrigerator for a carton
of milk. AVOID! Any extension of your arm, to which a weight is attached
(milk) is potentially injurious if you are already in recovery.
Instead
of reaching into the fridge, cosy up to the shelf with your body and
use both hands in a short reach, to grasp the milk. When getting up from
a chair, lean forward with your body and get movement upwards from your
knees without using hands at all. When opening doors, use your shoulder,
not your hands to push open. Don't do any lifting which results in a
biceps 'curl', this can increase trauma to your tendons. Don't spend
hours on a keyboard. If you do, then be mindful of stretching, posture,
and taking decent breaks. This consciousness extends to ALL of your everyday
movements and is critical to your recovery. Don't be discouraged, you
can easily develop comfortable everyday habits which look after your
hands and arms.
RECOVERY
Stretching
is part one of your hand care program. Part two, and equally important,
is to strengthen your shoulders, arms, wrists and hands. You can perform
strengthening exercises which address the trauma without deepening the
injuries. Avoid applying machismo to your strengthening exercises, you'll
only deepen the injury. It's difficult to get good advice about which
exercises can help your specific weaknesses. One set is illustrated below.
Start with light weights and lift every other day, gently. Free weights
are better because lifting programs can be crafted very specifically
to avoid deepening your injuries.
This
is a life-long process, and a great outcome to work towards, is to increase
your 'period of healthy playing' to where you can be satisfied by the
length of time you are able to play. Become very aware of the tiny warning
signs that tell you that you are moving outside the 'period of healthy
playing' into the 'zone of injury'. That's why it is best to practice
for maybe 30 minutes and rest for 10 minutes. Trauma shows up AFTER the
injury has taken place and if you keep playing, you don't give yourself
a chance to notice that trauma is approaching. You will feel it as a
warmth in the wrists, pain in the hands/forearms/elbows, or a general
feeling of weakness in the arms and shoulders.
This
series of exercises is a gentle day-to-day program that can significantly
ease the tensions and trauma arising in the hands of musicians who play
regularly. They promote blood-flow and mobility and can release chronic
tension and pain in muscles, tendons and joints. The exercises are designed
to be used at any time of day, and can become part of your daily musical
practice.
My
disclaimer: I am a musician and a cronic sufferer of tendonitis. I am
not a doctor and I offer this program because I have found relief and
healing (as have many others) and I have dramatically increased my ability
to engage with my instrument. Obviously there are medical conditions
these exercises cannot address. Use them at your own discretion and see
a doctor if pain persists. The exercises are in order.
Don't
grip your instrument.
Allow your fingers to lightly hold the instrument at all times, particularly
when you are working on difficult passages.
Take
regular breaks while practicing.
Relax and stretch for at least 15 minutes per hour, or 5 minutes between
songs. This is key to healthy hands.
Be
aware of your body and posture while
you play. It is your instrument. How all the parts of you stack up
under gravity profoundly affects your breathing and tension.
During
recovery avoid
long pieces. Avoid new pieces. Play
familiar pieces, and try to play them better than ever before. You
don't have to stop playing but you do have to change your playing.
Do
all these exercises in a very
relaxed manner:
relax your entire body through each movement. In particular, don't
hold tension in your shoulders or upper arms. Breathe deeply and exhale
well throughout your program.
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1. SHOULDER
STRETCH (30 seconds)
Plant
your feet firmly on the ground, slightly apart. Reach above your
head with palms together, breathing deeply. Feel the stretch throughout
your body, pull upwards as much as you can. Rest and repeat. |
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2. SHOULDER
STRETCH (20 seconds)
Reach
behind with both hands as shown. Go into this stretch slowly. Swap
hands and repeat. If you can't do this one, go as far as you can
into the stretch. After days or weeks, you will increase your reach. |
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3. SHOULDER
STRETCH (30 seconds)
Sit
cross-legged and place your palms on the ground just behind you,
fingers together pointing forwards, hands a shoulder-width apart.
Gently arch your back, arms straight, allowing your chest to push
out and up while your shoulders, arms and wrists feel the stretch.
This is super-nice for blood flow! |
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4. SELF
MASSAGE (one minute)
Allow
your arm to relax, palm upwards on a firm surface. Using a tennis
ball and your other hand, gently massage the tendons through the
forearm and wrist in a circular motion along the length of the
arm. Keep everything relaxed, especially both your hands and shoulders.
If necessary, turn the forearm over and massage the top of the
arm too. Anywhere you have pain, the ball can gently massage. The
exercise is repeated with the ball on the table and the arm/wrist
moving gently, without applied pressure, over the ball. |
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5. FOLDING
FINGERS (8 seconds each)
Lay
your forearms on the table in front of you, palms together pointing
upwards. Take a pair of fingers and cross them. Hold for a few
seconds, cross them the other way and hold for a few seconds. Repeat
with each pair of fingers. All other fingers not being crossed
should remain straight, pointing upwards and together. If this
is too hard with forearms flat on the surface, you can bring your
hands off the table slightly, elbows remaining, to relieve the
posture. Shoulders are relaxed. Over time your mobility should
improve to where you can leave your forearms on the table. |
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6. FOLDING
PAIRS OF FINGERS
Repeat
the above exercise but this time take any two pairs of fingers
and cross them first one way then the other. Pairs can be adjacent
or separated. Try all possible permutations, gently, shoulders
relaxed. All other fingers remain straight and together. |
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7. FINGER
SLIDES
With
palms together and forearms on the table, Take each pair of fingers
and cant the pair, first one way, then the other, keeping the fingers
together so that one finger slides against its opposite. Do this
with each finger pair. This directly addresses the individual tendons
in each wrist. |
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8. FINGER
STRETCH (8 seconds each)
Take
your tennis ball again and whilst standing, place your hand flat
on the table with your arm roughly vertical. (This angle can be
relaxed if the exercise is too difficult). Place the ball under
each finger in turn and feel the stretch for a few seconds. A smaller
ball can be used if necessary. |
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9. WRIST
FLEXION
Stand
and place one hand flat on the table pointing away from your body.
Take your other hand and place it on top, applying a little downwards
holding pressure. Try to pull the bottom hand from under the top
hand whilst simultaneously rotating the wrist of the bottom hand,
first one way then the other (like turning a doorknob). |
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Assist upwards
Curl
downwards |
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10.
STRENGTHENING EXERCISE
A
very effective and gentle weights program for strengthening the
hands and arms/tendons is as follows:
1.
Use a light weight, in one hand at a time (4lbs or less depending
on the severity of the trauma).
2.
Resting the forearm on a knee or low table, palm up holding the
weight, physically assist the hand (with the other) to curl the
weight up without moving the arm or wrist, i.e. the wrist is the
fulcrum.
3.
Remove the assisting hand and allow the hand to curl downwards,
slowly, again not moving the forearm or wrist.
4.
Start with three sets of 4 curls with each hand. Do this every
other day (or longer intervals, you decide). Remember to assist
the weight upwards and freely curl downwards.
5.
After two or three weeks add one extra curl to each hand, and maintain
this for some weeks, and so on up to 3 sets of 12. (This may take
months!).
6.
Once successfully completing 3 sets of 12 at a given weight and
maintaining these sets for up to a month, add a pound to the weight
and start all over again at 3 sets of 4 curls, increasing over
time.
7.
As strength/healing takes place the weights can be increased. If
it proves to be too much, go backwards in the program for a while. |
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HOT
AND COLD BATHS
To rapidly
address pain, tension and inflammation, hot and cold baths are a marvel.
Find two waste bin size receptacles, deep enough to hold both your hands
and forearms. Fill one with very hot water (you be the judge of 'hot')
and the other with cold water and ice cubes. Plunge your arms into the
cold bath for as long as you can (probably less than 30 seconds) and
then go to the hot bath until you feel the warming effect. Repeat this
for 3 cycles, ending with the hot bath. Do this up to 3 times a day including
just before bedtime...it can be very healing. For chronic sufferers this
can be carried out daily until you cease to feel the direct benefits.
Coupled with the hand exercises it's very powerful.
ROLFING
As we get
older we become owners of deeply embedded tensions that twist and bend
our bodies despite our own best intentions. Rolfing is a fantastic tool
to permanently dissolve many of those tensions and allow the body to
realign itself correctly, under gravity. A rolfing program is 10 sessions
long and the practitioner manipulates much of the connective tissue in
your body to profoundly release tensions that cause distortions and bad
posture. Great for musicians. You can find a licensed practitioner in
your area at this website:
http://www.rolf.org/find/locate.asp
An excellent
book, showing many simple exercises:
"Conquering
Carpal tunnel Syndrome and other repetitive strain injuries" by
Sharon Butler
http://www.amazon.com/exec/obidos/ASIN/1572240393/102-4447016-6736125
 Back
to Top
Carpel
Tunnel Syndrome
(c) 2004 by Dr. Timothy Jameson Doctor of Chiropractic
Castro Valley, CA
A common problem among both acoustic and electric guitar
players, as well as other stringed instrument players,
is the development of forearm pain, tingling, and numbness,
typically on the same side that you fret the instrument.
This column will explain a specific type of repetitive
injury called cubital tunnel syndrome, which affects
the inner side of the forearm and the pinky side of
the hand. Most musicians are probably not familiar with
this syndrome even though the symptoms are experienced
by many. The typical presentation of the syndrome, the
anatomical structures involved, along with prevention
and treatment options will be discussed in this article.
Cubital Tunnel Syndrome typically involves pain and/or
abnormal sensations in the elbow area, along the inner
side of the forearm. The pain can travel downwards towards
the pinky, and can be accompanied by tingling or numbness
sensations to the pinky side of the hand. The forearm
muscles can be achy, sore and painful, and can lead
to a misdiagnosis of tendonitis by an inexperienced
doctor.
This syndrome usually only involves the ring and pinky
fingers, since these fingers receive their nerve supply
from the ulnar nerve. Some variations in the nerve supply
to the fingers may allow for the middle finger to be
involved as well. The ulnar nerve begins from nerve
fibers exiting from the spine in the neck, called the
cervical spine. The nerve traverses down the arm, passing
through the "funny bone" area of the elbow, then travels
down the outer side of the forearm to hand muscles along
with the 4th, and 5th fingers. The purpose of the nerve
is to allow for communication between the brain and
hand, allowing for both motor control of the hand, and
sending sensation from the hand to the brain.
If the syndrome progresses, it can lead to decreased
function of the hand, especially grip strength. It is
common also to experience tingling and numbness in the
fourth and fifth fingers. Wasting or atrophy of the
pad of muscles on the palm side below the pinky finger
can develop as well. Typically, the person notices that
flexing the forearm tends to irritate the symptoms.
Another symptom is the musician beginning to notice
that he/she cannot control the fourth and fifth fingers
very well. It's as if they're trying to control finger
motion, but the hand just is not receiving the signals
and has a œmind of its own.” Loss of dexterity, speed,
and control of the ring and pinky fingers is a hallmark
sign of this syndrome.
The culprit in this syndrome is compression of the ulnar
nerve. Just south of the elbow, the nerve passes through
the flexor carpi ulnaris muscle to travel down to the
hand. A small tunnel forms in this location, and the
nerve becomes surrounded on all sides. In this tunnel,
the ulnar nerve sits on top of the flexor digitorum
profundus muscle. A ligament forms the top layer of
the tunnel. It is important to understand the function
of the muscles in this tunnel, because they play a major
role in the development of the syndrome. The flexor
carpi ulnaris muscle attaches to the inner part of the
elbow, and its function is to flex the wrist and move
the wrist inward towards the pinky. The flexor digitorum
profundus attaches to the medial elbow and inserts into
the tips of the fingers. This muscle's function is to
flex the fingers (especially the tips).
Now that you've survived the anatomy lesson, let's discuss
in real life how these anatomical structures are affected
with guitar playing. As I stated earlier, this syndrome
typically affects guitarists in the fretting hand, so
in a right handed guitarist, the left hand is typically
involved. If we dissect the playing of a simple barre
chord, we would notice 1) contraction of the thumb against
the underside of the neck of the guitar, 2) a counterbalancing
contraction of the opposing fingers on the top fretted
side of the neck, 3) bending of the fingertips to push
against the strings, 4) flattening of one finger against
the neck to form the bar (usually the first finger),
4) maybe some stretching of the pinky to reach a higher
fret and 5) flexion of the wrist.
Since the ulnar nerve passes between the muscles that
perform flexion of the wrist, bending of the fingertips
and stretching the pinky to reach the higher frets can
irritate the muscles surrounding this nerve. With constant
overuse of these muscles, they can become inflammed,
or actually form "microtears" at the attachments to
the elbow. This is especially evident in guitarists
who have not developed strength in their forearm musculature
in preparation of hours of practice time. The swelling
involved can start squeezing down on the ulnar nerve,
causing the symptoms mentioned above. This is also why
bending the forearm will worsen the complaints. The
ulnar nerve becomes stretched upon flexion of the elbow.
If the nerve already is being pinched, the stretching
is going to amplify the symptoms.
Cubital tunnel syndrome can also occur from other maladies,
such as traumatic injuries to the elbow from car accidents,
falls, elbow fractures, and elbow dislocations. Many
musicians also do computer work on the side, and repeated
keyboarding at the computer with poor posture and little
rest time, and constantly leaning on their elbows while
at the computer can predispose the musician to ulnar
nerve problems. Overall poor health of the musician
is a complicating factor as well. Not exercising, poor
nutritional intake, alcohol and drug consumption, and
preexisting health conditions can weaken the body to
make is more susceptible to neurological insult.
A very important cause of CTS that must not be overlooked
is neck problems. Since the nerve fibers that travel
to the hand must first exit the spine, any problems
with the cervical spine in that vicinity will irritate
the nerves. For example, if you have suffered a whiplash
injury from a car accident " even years previously "
it can predispose you to cubital tunnel syndrome. Chronically
bad posture and forward head tilt can also lead to nerve
compression. Consider your posture while playing your
musical instrument. How many guitarists do you see in
a forward head posture, leaning over the axe, while
playing difficult passages? How about shredders who
are flailing their heads back and forth while playing
their high-speed arpeggios? Chronic poor posture exerts
tremendous strain not just on the neck, but upon the
entire spine and nervous system. Unfortunately in a
majority of cases, you will never experience actual
discomfort in the neck with cubital tunnel syndrome.
ItÆs important to note that only a Doctor of Chiropractic
can determine if the neck is the source of your problem.
Physical therapists and medical doctors do not receive
training in locating and correcting spinal subluxations
" the misalignments that irritate and distort nerve
function.
For those of you who do not have the symptoms mentioned
and would like to prevent them from ever occurring,
there are a few simple steps to take:
1) Give yourself more frequent breaks (about a 10 minute
break after every 45 minutes of playing) during rehearsing
or practice times. The constant playing for hours upon
hours without resting can lead to microtearing of the
muscles and the resulting repetitive strain.
2) Before you play and during your breaks, increase
blood flow to the forearm and hands by stretching and
performing self-massage to the area. (You may want to
visit your library or bookstore and look into some massage
techniques - these help to increase the blood flow to
your arms and flush out toxins.)
3) Begin receiving regular massages by a professional
massage therapist to keep your muscles supple and relaxed.
4) Have an evaluation by a doctor of chiropractic to
make sure the alignment of your neck, shoulders, and
elbows is correct, allowing proper nerve flow to the
muscles of your hands.
5) Enhance your nutrition and use nutritional supplements
so your body has all the building blocks need to cellular
repair and nerve transmission.
6) Begin and/or maintain a weight training regimen that
concentrates not only on the major muscle groups, but
the forearm and hand muscles as well. The stronger those
muscles are, the less chance of fatigue and injury.
If you do have the symptoms mentioned in this article:
1) If you simply have some forearm muscle soreness,
use heat on the forearm before practicing, and ice the
elbow and forearm area after playing. The heat will
encourage more blood to the tissues while playing, and
the ice will discourage swelling afterwards. Perform
stretching to the forearm three to four times daily.
2) If you are experiencing nerve related symptoms like
tingling and numbness, burning sensations, muscle fatigue,
and lack of coordination of the fingers, see a Doctor
of Chiropractic immediately who is experienced in treating
musician's injuries. Many musicians make the mistake
of seeing their general medical practitioner who is
not trained in caring for repetitive strain injuries.
Most musicians who go the medical route receive dangerous
medications that may actually worsen your condition.
Even something as simple as ibuprofen can damage the
kidneys and liver. With this in mind, do not become
an anti-inflammatory junkie. Repeated use of antiinflammatories
will simply mask a more serious underlying problem,
and can lead to organ problems.
3) Always try conservative measures first, such as chiropractic,
massage therapy, or acupuncture. Give yourself at least
six to eight weeks to heal.
4) If you notice symptoms worsening, or weakness occurring
in the hands, even with the conservative care programs
provided to you with chiropractic and massage, your
health care provider should refer you to a neurologist
for a consultation and neurological testing. In my experience
in working with musicians via chiropractic care, this
rarely happens. I would estimate 90% of patients who
present to my office with these symptoms overcome them
with natural, conservative chiropractic wellness care,
and become healthier, more creative musicians in the
long run.
Finally, donÆt œhope the problem with go away.” If you
are a guitarist or musician of any instrument, and begin
noticing changes in the function of your hands, do not
wait to have them evaluated. The faster you receive
care for them, the faster they will heal. Musicians
who put off receiving treatment for cubital tunnel syndrome
risk the more serious consequences of hand muscle wasting,
numbness, loss of ability to play their instrument,
and chronic disability. Treat your body as a temple,
and care for it daily.
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Biography of
Dr. Timothy Jameson, D.C., C.C.S.P.
Dr. Timothy Jameson is a 1984 graduate of Syracuse University
with a Bachelor of Science degree in Biology. He continued
his postgraduate education at Los Angeles Chiropractic
College, and graduated with honors as a Doctor of Chiropractic
in December of 1988. Upon graduation, Dr. Jameson worked
in a busy practice in New Jersey for one year, then
moved to California in 1990, where he married and started
his own Chiropractic practice. His wife, Dr. Laurie
Gossett, is also a chiropractor as well as a Bradley
natural childbirth educator. In 1992, Dr. Jameson completed
a 300 hour postgraduate program in the diagnosis, treatment,
and rehabilitation of sports injuries, and became certified
as a Chiropractic Sports Physician by the American Chiropractic
Association.
Over the past few years, Dr. Jameson has channeled his
energies towards the treatment and rehabilitation of
repetitive strain injuries, also known as cumulative
trauma disorders. He recently completed a book entitled
"Repetitive Strain Injuries: The Complete Guide to Alternative
Treatments and Prevention," which is now available in
bookstores across America. The publishing company is
Keats Publishing in New Canaan, Connecticut.
Besides chiropractic, Dr. Jameson enjoys music, and
is a pianist and guitarist. This has led him to work
with musicians who suffer from RSIs. (See web page:
http://www.gbase.com/chiro/ for musician-related RSI
articles.)
Dr. Jameson enjoys lecturing on the topics of repetitive
strain injury prevention techniques and ergonomic principles
to businesses who want to take a proactive approach
to injury prevention for their employees. If you are
interested in this service, please email Dr. Jameson
at the address mentioned in this web page. Dr. Jameson
also responds to your RSI-related questions via e-mail.
E-mail Dr. Jameson at Chiro4U@aol.com.
Dr. Jameson can be contacted at the two California offices
listed below or via e-mail.
Bayshore Chiropractic Holistic Health Center
3319 Castro Valley Blvd.
Castro Valley, CA 94546
510-582-5454
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