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Violinist Biomechanics - Implications of Wrist vs. Shoulder Pain

                                                                          Virginia Arnette, Doctor of Physical Therapy

Injury rates in professional musicians are high due to the repetitive and demanding nature of practice and performance.1,2  Between 60-84% of professional orchestral musicians report experiencing a performance-related musculoskeletal disorder (PRMD) at some point in their careers.3,4,5


It is common for musicians to continue practicing and performing while experiencing a PRMD. The body is clever! It finds ways to redistribute load to complete a task while minimizing stress on the injured tissue. However, these movement adaptations can lead to compensatory changes in playing biomechanics, which can in time cause dysfunction and pain.6,7

Compared to other orchestral musicians, upper string players including violinists and violists have an increased likelihood of developing a PRMD.8 The back, neck, shoulders and wrist are the most common areas involved.7,9,10

McCrary et al. explored the link between pain location and muscle activation in violinists in a 2016 study “Effects of physical symptoms on muscle activity levels in skilled violinists”.11

During the study, 55 violinists (professional players and university players including undergraduate and graduate students) “performed five 45 second musical excerpts designed to elicit a range of right arm bowing techniques. Surface EMG data were obtained from 16 muscles of the trunk, shoulder, and right arm during each excerpt performance.”

EMG refers to the collective electric signal from muscles, which is controlled by the nervous system and produced during muscle contraction. Surface EMG reads the electrical activity of a muscle’s motor units with an electrode that is placed on the surface of the skin.12


Some takeaways from the study were that:


“Differential changes in muscle activity patterns occur in the presence of proximal compared to distal physical symptoms.”

Proximal means closer to the trunk, and distal means further away, as shown in this diagram below. EMG data showed that violinists with distal symptoms (wrist pain) had different muscle activation patterns than violinists with proximal symptoms (shoulder pain).

“Where right wrist symptoms were present, a global increase in muscle activity was observed”


Violinists with right wrist pain had more muscle activity in general than players without right wrist pain. (By global increase, they are describing an increase in muscle activity across the board, not just those involved in wrist movement). 


“[The] global increase in muscle activity associated with right wrist symptoms may reflect a tension in playing technique that interrupts the normal proximal to distal kinetic chain mechanics and make a performer vulnerable to wrist injury.”

The kinetic chain refers to sequencing of muscle activation from proximal to distal. Impairment of one or more kinetic chain links can create dysfunctional biomechanical output leading to pain and/or injury.13  It was beyond the scope of this particular study to establish causality here- that is, whether it was wrist pain that instigated a change muscle activation patterns, or aberrant muscle activation that led to onset of wrist pain. However, clinically we do see development of chronic wrist pain conditions in violinists and violists. It's important to see a qualified clinician that is able to accurately diagnosis, and thereby accurately treat, the condition. Pain at the front of the wrist could be flexor tendonitis, or carpal tunnel syndrome, or pronator teres syndrome, or even referred pain from nerve entrapment at the neck or thoracic outlet (the space near your collar bone and first rib). Moral of the story- don't ignore it! The path to wellness is not a one size fits all approach.



“…whereas when right shoulder symptoms were present, there was a more nuanced change in other muscles. …there is a reduction of upper trapezius activity …and this reduction is accompanied by compensatory increases in synergistic muscles (pectoralis major, biceps brachii, anterior deltoid)."

Synergistic muscles work together to produce a motion (For example, biceps brachii and brachialis are synergists as they both flex the elbow. In contrast, triceps brachii extends the elbow so it would be considered an antagonist to biceps brachii)


To put it another way…

"The redistribution of muscle load from upper trapezius to pec major, biceps brachii and or anterior deltoid suggests that there may be an alteration of the normal combined movement between the scapula and humerus during arm movements (i.e. scapulohumeral rhythm) with shoulder symptomatic violinists potentially displaying an altered scapulohumeral rhythm favoring relatively more humeral motion during bowing movements."

Did you know ⅓ of the movement that occurs in overhead arm motion comes from upward rotation of the shoulder blade? (at the scapulothoracic joint) The rest comes from the shoulder (at the glenohumeral joint). Commonly, people with shoulder pain are found to have weakness in the muscles that produce the movement of the shoulder blade. This can stress the tissues around the shoulder joint and lead to conditions like functional shoulder impingement and biceps tendonitis.


 

"Concomitant reduced R upper abdominal activation across all exceprts suggested that the right shoulder symptoms relate not only to reduced scapula positioning but also to less trunk support or core stability".

Musicians need core strength! In general, proximal strength (of the core, and shoulder girdle) reduces strain on distal muscles and joints (elbow, wrist and hand).




So, how can upper string players apply this knowledge to help decrease the risk of developing a PRMD?

1. Get curious. Pay attention to your body. Take notice. Are you tightening in ways that aren’t serving a functional purpose in your playing? If so, take 3 deep breaths. Be patient with yourself. Sometimes exaggerating the tension momentarily and then releasing it can help. For example, shrug your shoulders up, scrunch your face, make a fist- and then let it all go. Feel the contrast between tension and relaxation.  Some players find visual feedback helpful, such as practicing in front of a mirror or reviewing a video recording.  If it's a particular passage bringing on the tension, can you break it down into manageable parts? Slow it down. Only increase the tempo once you've been able to play it multiple times accurately and with ease.  Give yourself plenty of breaks. Get up and move around. Try shadow practicing, visualization and singing the passage. Practice smart, not hard!  

2. Bring your attention proximally. Notice your core musculature and how it gently engages when you sit with an upright posture. Allow your belly to relax when you breathe in and notice how it contracts when you breath out. Notice how a bit of core engagement can help you feel buoyant and centered when you sit. Now note the feeling of your shoulder blade on your back. Notice how you can bring it forward (protraction), backward (retraction), up (elevation), and down (depression). Try these motions and combinations of them. (up and forward, down and back, etc.) Visualize your shoulder blade moving on your trunk as you do these motions. Feel the stability in your shoulder and arm as you engage the muscles around your shoulder blade (periscapular muscles). See what it’s like to play a passage of music with your attention there instead of in your wrist or fingers.

3. Cross-training exercise. Find a physical therapist to help create a cross training exercise program tailored for you. Oftentimes strengthening the periscapular muscles can help restore scapulohumeral rhythm and take some load off of the shoulder joint. However, there are many personal variables that can affect the biomechanics of the shoulder girdle. The mobility of your spine, laxity or stiffness of your connective tissue, length and strength of your muscles, your movement patterns and the other activities you engage in regularly can all influence what exercises would be most beneficial for you.






References

1. Chan C, Ackermann B. Evidence-informed physical therapy management of performance-related musculoskeletal disorders in musicians. Frontiers in Psychology. 2014;5:706. doi:10.3389/fpsyg.2014.00706.

2. Kaufman-Cohen, Ratzon; Correlation between risk factors and musculoskeletal disorders among classical musicians, Occupational Medicine, Volume 61, Issue 2, 1 March 2011, Pages 90–95,

3. Chimenti, R. L., Van Dillen, L.R., Prather, H., Hunt, D., Chimenti, P.C. and Khoo-Summers, L. (2013). Underutilization of worker’s compensation insurance among professional orchestral musicians. Med. Probl. Perform. Art. 28, 54-60.

4. Ackermann, B. J., Kenny, D. T., O'Brien, I., & Driscoll, T. R. (2014). Sound Practice—improving occupational health and safety for professional orchestral musicians in Australia. Frontiers in psychology, 5, 973.

5. Leaver R, Harris EC, Palmer KT. Musculoskeletal Pain In Elite Professional musicians From British Symphony Orchestras. Occupational medicine (Oxford, England). 2011;61(8):549-555. doi:10.1093/occmed/kqr129.

6. Ackermann B, Driscoll T, Kenny DT. Musculoskeletal pain and injury in professional orchestral musicians in Australia. Medical Problems of Performing Artists 2012;27:181.

7.McCrary, James Matthew. "Effects of muscle fatigue, pain and warm-up on elite performance." PhD diss., 2016.

8. Mizrahi J. Neuro-mechanical aspects of playing-related mobility disorders in orchestra violinists and upper strings players: a review. Eur J Transl Myol. 2020 Aug 4;30(3):9095

9. Steinmetz A, Scheffer I, Esmer E, Delank K, Peroz I. Frequency, severity and predictors of playing-related musculoskeletal pain in professional orchestral musicians in Germany. Clinical Rheumatology 2015;34:965-73.

10. Lindstrom L, Magnusson R, Petersen I. Muscular fatigue and action potential conduction velocity changes studied with frequency analysis of EMG signals. Electromyography 1970;10:341.

11. McCrary, J. Matt, Mark Halaki, and Bronwen J. Ackermann. "Effects of physical symptoms on muscle activity levels in skilled violinists." Medical Problems of Performing Artists 31.3 (2016): 125-131

12. Chowdhury RH, Reaz MB, Ali MA, Bakar AA, Chellappan K, Chang TG. Surface electromyography signal processing and classification techniques. Sensors (Basel). 2013 Sep 17;13(9):12431-66

13. Sciascia A, Cromwell R. Kinetic chain rehabilitation: a theoretical framework. Rehabil Res Pract. 2012;2012:853037. doi: 10.1155/2012/853037. Epub 2012 May 14.