[Reasons why musicians consult hand surgeons]. / Motifs de consultation des musiciens en chirurgie de la main.

PURPOSE OF THE STUDY: Musicians occasionally consult orthopedic surgeons, particularly upper limb specialists. We wanted to learn more about the reasons why musicians attend orthopedic clinics. MATERIAL AND METHODS: We analyzed retrospectively 227 case files of musicians who consulted our center between 1994 and 2001. We noted patient related factors (age, gender, musical experience, level of performance, daily practice schedule) and their reasons for consulting (pain, discomfort, advice). We studied the medical history of the patients and searched for predisposing or triggering elements. We also recorded therapeutic options proposed. RESULTS: Our series included 119 men (52%) and 108 women, mean age 35 years with 27 years of musical experience on the average. Instruments played were mainly the piano (41%), the violin (19%), and the guitar (15%). Patients playing wind instruments, who consult more often for ENT problems, were exceptional. On the average, the patients played their instrument 4 hours daily. One-third of the patients were high-level amateurs, one-third were professionals, and one-quarter were lower-level amateurs. There was a small proportion of soloists or professors. Two-thirds of the musicians presented disorders of the musculoskeletal system, particularly trauma sequelae. Signs of overuse were present in 18% of the patients, mainly women, signs of misuse due to inappropriate or defective technique in 8.8%, and dystonia in 5.7%. Psychological problems were noted in 4 patients. More than one half of the patients had obtained medical advice prior to consulting an orthopedic surgeon and the very large majority had been referred by specialized physical therapists. A surgical procedure was proposed for only 19% of the patients presenting an orthopedic disorder. DISCUSSION: This study presents a diversified panel of musicians consulting orthopedic surgery clinics. Practicing schedules varied in the study population from one to five hours daily. More than half the patients complained of pain but 18% consulted because they perceived a problem when playing and 17% consulted simply for advice. Our findings recall that musicians comprise a sensitive population requiring careful overall management. Unlike series published to date, we had a majority of men. Problems involving an orthopedic disorder or trauma and trauma sequelae predominated. In the literature, diagnosis has been oriented by the specialty of the consulting physician. We found that our patients who suffered from overuse had often recently changed their habitual practicing methods or conditions. The diagnosis of misuse was facilitated when the patient was examined with his/her instrument. The low rate of dystonic disorders was probably related to the fact that nearly half of our patients were followed regularly by a physical therapist. We did not observe any case of excessive laxity or Linburg Comstock syndrome which exceptionally have functional impact. The very large majority of our patients were referred by physical therapists and when surgery was necessary, the procedure was performed in accordance with accepted rules concerning the therapeutic management of musicians.

[Occupational arm ailments in musicians]. / Les affections professionnelles du membre supérieur chez les musiciens.

We began our specific interest in this subject in 1975 and to date have seen and treated over 600 musicians with functional problems of the upper limb. These are common problems affecting over one third of instrumental musicians. Every instrument may have its own specific repercussions. However certain factors may influence their onset: intensive practice; a technique requiring non-physiological positioning; a change in technique, instrument or habits; pre-existing trauma; psychological predisposition; inappropriate physique. The presentations are varied and the limits imprecise. Muscles, tendons, joints and nerves may be involved. The commonest, and easiest to cure are due to pain resulting from overuse syndromes cover a multitude of sins resulting from marked physical effort in excess of the normal physiological capacity of the body. Joint instability and degenerative disease pose their own specific problems. Peripheral nerve lesions can be related to overuse syndromes or to the adoption of non-physiological or harmful positions. The most difficult problems to deal with are those related to a loss of motor control when performing the same repetitive movement--functional dystonia. Their origin remains obscure with the major discussion revolving around either a neurological or organic aetiology. Our intensive experience of instrumentalists with these problems secondary to bad positioning or posture, has led us to propose a therapeutic regime based on structured re-education and relaxation. The great majority of sufferers overuse syndromes or functional dystonias have been able to resume their professional activities. It is clear that functional dystonias are curable if treatment is instituted early and that the lesions are not too long standing.

[Functional dystonia in musicians: fundamental principles of the rehabilitation]. / Les dystonies de fonction chez les musiciens: principes fondamentaux d'une rééducation.

The basic principles of rehabilitation of dystonia in musicians are designed to restore overall functional movement, but must also take into account the musician's often obsessive and anxious metal state. Rehabilitation is based on fundamental postural physical education and movement physiology. It must also develop a language to explain the dysfunction and to make it acceptable to the patient. The exercises themselves become the basis for a new behaviour. More than just a rehabilitation technique, we have tried to develop a personalized "self-correction" which could be the basis for real prevention.

[Hand disorders in pianists]. / Pathologie de la main du pianiste.

During the past 10 years numerous studies have been devoted to the pathology of musicians. A few of these studies exclusively concern pianists. From a questionnaire filled and returned by 44 pianists we were able to determine the type and frequency of the symptoms encountered. Pain and stiffness are the principal symptoms, the 4th and 5th fingers being those most affected. Three pathologies predominate in the literature: overuse syndrome, entrapment neuropathy and functional dystonia. The often long and difficult curative treatment rests on rehabilitation. Training in the fundamental postures the pianists must adopt should enable them to reduce the occurrence of these pathologies.

[Functional cramps or functional dystonias in writers and musicians]. / Les "crampes" fonctionnelles ou "dystonies de fonction" chez les écrivains et les musiciens.

The clinical evaluation in the "dystonies of function" or "impaired dexterity" reveals certain physical anomalies which either appear spontaneously or are triggered by specific tests: abnormal postures involving the trunck, head, and upper limb. During the professional gesture the physiological "pulley effect" on flexor tendons is accompanied with an interference effect produced by the displacement of the segments; this, adds up to an unbalance of the digital kinetic chain, building a locked functional system. The antagonist muscles begin to supply the deficiency of the agonist muscles. In addition, patients with a characteristic psychological ground suffer a more acute "disorganization" or a performing career.

[Physiotherapeutic approach to so-called occupational functional cramps]. / Approche kinésithérapique des crampes fonctionnelles dites professionnelles.

The management of "functional" cramps known as professional cramps is often considered as very disappointing. Minor objective anomalies which can be detected upon clinical evaluation are common findings: rigidity of antagonist muscles, abnormal postures involving the proximal limbs, trunk and head, poor subjective perception of muscular contraction and relaxation, and coordination abnormalities during motion. In addition, patients have a distinctive psychological status. Rehabilitation should be principally psychomotor, including: psychotherapy based on analysis of the personality, rectification of abnormal postures and rehabilitation of the impaired motion bearing mainly on the antagonist muscles. Removable ortheses may be useful adjuncts. Analysis of results in 31 patients: 6 writers, 13 pianists, 10 guitarists, 1 conductor and 1 flutist.

Occupational "cramps" of the upper limb.

Problems involving the coordination of movements of the hand analogous to the "writers cramp" have been seen in musicians and other professions. They occur in individuals with muscular imbalance, who assume abnormal body postures affecting not only the involved limb but also the spine and pelvis. These patients also often have a particular psychological make up. Treatment is based on the re-training of their muscular actions and on teaching the patients to avoid assuming abnormal stances or postures.