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Your wrists throb, your shoulders ache and playing the piano is agony - could repetitive strain injury (RSI) be the cause? Physiotherapist Caroline Rugman looks at RSI causes and cures Copies of the article may be downloaded at [this link] , subject to the Jazzorg Licence 2, described under the 'Copyright' menu tab. You can discuss or comment on this item in the forums. ContentsRecently a young Cambridge undergraduate who was reading music came to see me complaining of painful shoulders, forearms and fingers, associated with feelings of pins and needles and occasional numbness. She found that practising or playing the piano for more than 20 minutes aggravated the condition. She was desperate for advice and effective treatment. She is highly ambitious and planned to train to be a concert pianist - and what did that mean? Hours and hours of practice ahead! After listening to her history and asking pertinent questions, it turned out that I was the third physiotherapist she had approached. The two previous therapists had told her the only real way for her to progress was to reduce her practice time to 15 minutes a day and to gradually, week by week, to increase the time. All three of us correctly diagnosed RSI - repetitive strain injury - a tiresome condition that can be caused by the combination of poor posture, incorrect technique, repetitive action and stress. The acronym PODS sums up the source of typical RSI: P = Poor posture OD = Overuse Disorder S = Stress The combination of these three factors are enough, if repeated long enough (and this varies with every individual), to provoke RSI into rearing its ugly head. This condition has a variety of names - one of the most commonly known is work-related upper limb disorder. RSI is now recognised by the UK Trade Union Congress and even by most general practitioners, but sadly, not by all orthopaedic surgeons. Rheumatologists are usually the specialists for this condition. Musicians are not the only group affected, though: factory workers, legal secretaries and journalists are as well - many jobs involve using a computer. But teenagers love to email and play computer games, and in this technological age, even the elderly keep in touch with loved ones through email. More people are choosing to work at home, if for just part of the week, and reproducing correct ergonomics - the optimal design to achieve maximum safety and comfort - at home with a kitchen table and chair are well nigh impossible. When music students return to college or university for a new term, they often believe that they haven’t practised enough during the break, so they hit the keys with a vengeance just before classes resume. This is a classic RSI scenario. Another common occurrence that results in RSI is when repertoire has been chosen that does not match the student’s technical abilities. For example, Bach and Prokofiev’s music can be quite percussive, and therefore demands a high level of manual expertise and strength to perform. Hence, if the student’s not up to it, he’ll suffer. Switching between different pianos can also be dangerous. The action on some pianos is heavier than others, so if you’re in any doubt, go for a lighter action. And if a pianist is prone to hyperlaxity (very flexible joints), he or she may be more prone to work-related upper limb disease. The pianist is able to stretch a tenth or even a twelfth with ease, but this in time this can cause problems. The solutions are as follows: stick to repertoire that suits you and that does not demand too many stretches; choose your practise piano sensibly; take special care if you’ve got very flexible joints; and perhaps also think of taking a sideways step with your musical studies by taking up composition or singing to break the RSI pattern. What happens when you have RSI? Your median nerve, which is one of the three main nerves supplying the arm and hand, passes through the wrist and into the hand. Normally, any flexion and extension action of the wrist causes this nerve to flick round to the side, thus avoiding any pressure. With RSI, this action doesn’t happen. Why? Well, the nerve's blood supply diminishes with the pressure put upon it from constant practising, and eventually it fails to function properly. This type of pain is called neuropathic pain, that is, pain due to dysfunction and damage in the nervous system. Abnormal sensations very often associated with this type of pain can be:
These are examples of hyperalgesia and allodynia and good indicators that the central nervous system is processing sensory input in an abnormal fashion. The most important thing, for a practising musician, is to understand how to cope and work with RSI as soon as you’ve spotted it. Mindfulness of the factors that can cause RSI can help you avoid the condition altogether and keep you away from the piano. At each practice session, make sure that your posture is correct before you start playing: abdominals gently tightened, chin tucked in and arms gently resting above the keys. Stop playing every half hour for five minutes to stretch, walk around and re-check your posture. These exercises below are called ‘work break’ exercises. Try them. Hold each stretch for 15-30 seconds, and repeat three times.
Whether you’re a pianist tinkling the keys or an office worker clicking away at the computer keyboard, work break exercises must be done. European Union law requires all workers to take appropriate breaks so there should be no guilt attached! If pain in the fingers, arms and shoulders or even neck starts - then stop! It’s most important to make a note of the time, so you can see how you’re progressing as the days go by. When you’ve had a good break of, say, 20 minutes, resume playing. If all goes well, then add two to three minutes to your practice blocks each week. Sounds disastrous? Believe me - hammering on the keys in an effort to continue the allotted practice time would prove most disastrous, as unfortunately RSI does not just disappear. The pain is only too eager to rear its head again if you overdo practice, do not take work breaks, and resume your poor postural habits. There’s no quick fix for this condition, and it’s a condition, not a disease, as my undergraduate musician eventually found out. Actually, she went on to seek help from another health professional who promised her complete pain relief in two weeks and she believed him, for those two weeks anyway, until the full implication of RSI finally hit her and the pain just didn’t vanish. RSI can be an extremely emotive problem for all concerned. There are a host of other problems also caused by repetitive movements, but because they can usually be relieved by cortisone injections, they are not strictly classified as RSI. But they can be put under the RSI umbrella, even though this is a hotly debated subject. Carpal Tunnel Syndrome: This again affects the median nerve. If the nerve is compressed as it passes beneath the fibrous band at the wrist edge, then numbness, burning and tingling occur in the first three fingers and the inner edge of the fourth finger. Pain increases with repeated movements and prolonged wrist flexion can produce the symptoms. The tendons can become inflamed causing restriction within this tunnel with the aforesaid symptoms. Treatment may include: rest- with appropriate wrist support with the wrist in neutral position, there is obviously less pressure within the tunnel; local corticoid steroid injections - you can have up to three of these at appropriate intervals; surgery - which involves stretching the ligament by separating it from its wrist attachments and Vitamin B6 - may facilitate healing. De Quervain’s Tenovaginitis: Originally the main complaint of washerwomen, this was traditionally thought to be an inflammatory condition caused by friction of the lateral thumb tendons in their sheaths. Specialists are now leaning towards the view it is more of a degenerative condition where thickening of the synovial lining of the sheath occur, particularly where the tendons pass over the lateral bony wrist protuberance. There is pain on restricted thumb extension and abduction; in addition, pain can be caused by bending the wrist away passively which stretches the tendon and the sheath. You can get clicking on repeated movements as well. Treatment includes: physiotherapy - which can involve frictional massage to the stretched tendon; splint - immobilising the thumb in a splint; corticoid steroid injections into the sheath - this again can be done up to three times, but should be reserved for more persistent cases. Tenosynovitis: Again, a repetitive finger action that can cause swelling of the tendon sheath. Rest, ice and general stretches can relieve the symptoms. Tenosynovitis is less serious than De Quervain’s Tenovaginitis. Tennis Elbow: This is really a blanket term to cover all painful areas around the outside of the elbow joint. Specialists cannot agree at the exact site of the lesion! Some 30 different elbow conditions are attributed to Tennis Elbow so it’s a rather complex subject. I would define it as a lesion of the common extensor tendon; this is the large tendon from which all the main wrist extensors take their origin. Scar tissue may form on the tendon; repeated activity can cause micro trauma with new tissue forming - these appear to contain a large number of free nerve endings, hence the painful nature of the condition. The major problem is that the new tissue does not programme quickly into a mature form, so healing fails to take place - a sort of non-union of the tendons. Pain can build up slowly, or maybe the result of a single incident, and increases with the repeated wrist extension movements, also accompanied with supination (this is the action where you turn your hand over so that the underarm is upper-most). Gripping causes pain so you see how racket sports involve this action but also occupational stresses can cause it. The ache may decrease when the stressful activity is stopped but can gradually increase as the condition progresses and the ache becomes constant. The grip weakens and even the wrist extensors begin to waste. Treatment includes: physiotherapy - can include an epicondylar brace, which is a tight strap that is placed around just below the elbow which creates a lateral pressure when an object is gripped. Here you can see the objective is to disperse and re-direct the load to adjacent healthy tissue and allows a more normal muscle contraction. Treatment might also comprise stretching exercises, as the scar tissue formed are useful, particularly after warming the affected area. Strengthening exercises, particularly with something suitable like flexi band (this is an elastic latex band which comes in different strengths) are also good. Finally, manual therapy - which includes frictions, manipulating and mobilisations - should be done. Corticoid steroid injections - as described for all the other soft tissue inflammatory injuries - are also a treatment option If any of the physical symptoms that I’ve discussed strike a chord, seek help from your local physiotherapist (or, as they’re called in the United States, physical therapists). A full assessment by a physiotherapist will involve a look at your technique, and the examination of neck, shoulders, arms and hands. Very often, RSI sufferers have tender spots around the shoulder blade perimeter, shoulder bulge (deltoid muscles), elbows, forearm extensors and the margins of the wrist. The main belly of the thumb and sometimes fingers as well will also be tender. Neck and shoulder movements may be restricted and grip strength can be weakened. Note though, that if there is a visible swelling, you should seek medical help because this could be an altogether different diagnosis. What sort of treatments can you expect to receive from a physiotherapist? There are heat treatments - wax or wheat packs, for example - which will help you relax. Acupuncture, ultrasonic therapy, manual and neural mobilisations also help enormously. A physiotherapist will work with an RSI sufferer to find alternative positions for work and sleep. Exercise, walking, treadmill, jogging and swimming is a must. Sometimes a wrist support worn in travelling times or at night (however unromantic!) can relieve the symptoms. This also shows others that there’s a problem. One of the annoying thing about RSI is that there is nothing to show what the sufferer is undergoing: tingling, numbness, a feeling of swelling, cramping and acute to chronic pain. However swollen your wrist or forearm or fingers may feel, if the diagnosis is RSI, it is not visible. |
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