Picker Corner-Aches and Pains

Aches and Pains

by Henry D. Childs, MD

From a post on the BGRASS-L October 16, 1998:

Dan Mazer raised the issue of musculoskeletal syndromes in musicians, and there have been a number of helpful commentaries from other listers on this thread. Since I work with these problems professionally (in the course of a preventive medicine/sports medicine/internal medicine practice) I thought I'd weigh in with the following two cents worth (oops - in the current managed care climate that's now 1/4 cents worth...):

There's a new entity - actually old as the hills, but the label is new - called "Repetitive Strain Injury." (RSI). It's growing by leaps and bounds because of the tremendous increase in the past decade alone in the amount of computer keyboard usage in our society at large, both at work and at home. Hours and hours of nonstop work, mostly in a fixed position, concentrating intently much of the time, causes a fair amount of tension in muscles, tendons, fascia, joints, etc. Depending upon a number of highly variable factors, such as ergonomics (often really poor), the individual's age, overall physical condition, other stress levels, level of expertise with the work, prior injuries or not - something finally decides it's had it, and inflammatory symptoms develop. We're seeing all kinds of: low-grade muscle strain with or without spasm, tendinitis, carpal tunnel syndrome, cervical nerve root compressions with pain, numbness or motor weakness or all of the above, fatigue, irritability, etc., etc., etc.

Although the workplace is the prime focus for this currently, you can readily see that the above definition applies perfectly well to playing musical instruments. I'll bet there's hardly a one of us who hasn't emerged from a jam, inspired practice session, or a late night of field picking at a fester without numbness, cramps, spasm and tremor in assorted limbs (but happy nonetheless). Most of us manage to shrug it off, but now and then, for all those assorted individual reasons, things snowball. Then there's enough persisting symptomatology that the denial threshold is crossed and we realize "Hello there - we gotta problem!" This is actually very well known among the ranks of top-end professional musicians, especially violinists, cellists and the few others who have particularly high tension levels inherent in how they play, and how much they practice. There are a few physicians who specialize entirely in treating this very unhappy, demanding and usually well-to-do clientele, which is why they don't advertise among bluegrass musicians...

Short of trekking to New York City, Paris or London with a satchel full of money, there are a few basic principles which can help us more humble (but sometimes equally afflicted) folks not fall prey to these troubles so badly. First, on the prevention side of things: build and maintain a near-daily aerobic exercise program (this is literally the best medicine I know after 23 years as a practicing clinician!); this burns off a lot of that tension which will otherwise cause a lot of RSI symptoms, helps tone and condition all those picking muscles and tendons better, actually helps you play (and sing) better for physical and emotional reasons. Try to take frequent breaks while you're practicing and even if playing onstage or in a jam, and this kind of break is the kind where you stop picking, shift the instrument around, move around for a minute, stretch out neck, back, shoulders, arms, etc. for a full 60 seconds. Cultivate stage patter and a big smile (I'll bet Ron Thomason hasn't had a lick of RSI in his life!) If you're multi-talented, play more than one instrument during a session. Be sure you're eating properly and maintaining a good fluid intake (aside from firewater) because dropping energy curve (more complex than just blood sugar) and dehydration can help deplete physical reserves and set you up for trouble.

If symptoms do develop and something is beginning to hurt persistently or progressively, or get all weak or numb and tingly, etc. - PAY ATTENTION!!!! Persisting pain or disability is meaningful, especially if you're doing all the right preventive stuff. Basic initial treatment of inflammatory symptoms which we can all do (and often don't, or do it only sporadically) is hot soaks 20-30 minutes once or twice a day, also icing 10-15 minutes 3-4 times a day, resting the afflicted area as much as possible (meaning avoiding any painful motions, whether they are musical or anything else). Anti-inflammatory medication is often a good idea, and we use enteric-coated aspirin (such as Ecotrin or generic analog) a lot in sports medicine and Rheumatology because aspirin remains the gold standard in anti-inflammatory Rx to this day, as long as it's used in high enough dose; also because enteric-coated pills are designed not to dissolve in the stomach, but as they travel through the small intestine, which means much less likelihood of stomach irritation or ulceration as well as a time-release effect so that there's a more sustained blood level within the therapeutic range.

Because anti-inflammatory doses of aspirin (three standard 5 grain tabs four times a day) or ibuprofen (800 mg three times a day or 600 mg four times a day) are fairly high, there's definite risk of stomach irritation or bleeding or other organ damage if these meds are used for longer periods of time, and it's not super smart to use these for very long in any higher dosage without discussing it with your doc. An important fact that I've found many of us don't fully understand is that pain is only a symptom, and while we can treat pain with lower dosages of meds and a few other gimmicks, it's usually much more important to treat the underlying cause. That's why true anti-inflammatory effect requires much higher doses than simple analgesia, and why it's IMPERATIVE (in my experience, anyhow) to do all of the right stuff, all together, and long enough. If you gang up on the problem with enough synergizing modalities, you've got a far better chance of getting the problem settled down quicker and better. Lest anyone doubt the importance of doing it right, I'll mention that I have in my own practice several young adults who are permanently disabled from their jobs (computer users all) due to tendinitis of their hands and forearms which was neither prevented nor treated adequately when it first appeared. I've learned to respect tendinitis particularly, as it can be for some unfortunate people a really nasty affliction, and extremely difficult to treat when it's gained a foothold. I don't yet have any bluegrass musicians in this category, I'm glad to say, but it could easily happen.

Nerve root compression syndromes (either in the neck or the low back) are worth a separate comment. When the spinal cord or more commonly a nerve root begins to get pinched enough to cause irritation and then swelling (either by a partially ruptured disc, facet joint arthritic spurring, or spinal stenosis, or combinations of the three) pain and often numbness or tingling will develop in a neurological distribution. Sciatic nerve root irritation causes pain radiating down into the butt, and often down the outside of the thigh, sometimes all the way down the leg and into the foot; with numbness in the area of the great toe quite common. In the neck, nerve root pinches will often cause pain radiating into the top of the shoulder or down the upper and outer arm, sometimes down the forearm and into the hand. Though the pain is unpleasant, a good deal more serious is weakness: if your foot starts flapping on the ground, or you can't raise your arm or move certain fingers so well that usually warrants more vigorous testing and treatment, because you don't want permanent damage to develop. It's easy to understand how a marginally compromised nerve root can get more unhappy when its owner is lugging around twenty or thirty pounds of banjo, or standing for long periods of time (weight of upper body compressing vertebral openings further), etc.

Hope all this is helpful, and in case anyone's wondering, yes, I do practice what I preach! Far from being immune, I've had a terrible time with sciatica, finally requiring surgery two years ago, so I've learned the hard way. I don't carry the banjo so long, sit more, have wheels on all my luggage, etc. And I do play better than I used to, even if it's nothing to brag about...

Hank Childs