First Aid for RSI in Pianists and Others

Jill, thank you so much for inviting me to post here again. I am often asked what to do in case you experience a repetitive strain injury (RSI) of one kind or another while playing the piano. This is the first in an ongoing series presenting information about their cause and treatment. RSIs are very common among musicians, and they strike students as well as working professionals with equal regularity (1), (2). They strike the high and low, the famous and the not-so-famous. For instance, we have all read or heard about what happened to Leon Fleischer and Gary Graffman in the 1960s and 70s, where RSI severely hampered or curtailed their celebrated careers while they were still young and healthy.(3) RSI also affects the amateur playing piano in their home.(4) Musicians don’t generally like to talk about their injuries, which is why there is so little information available about them. And if you’re a professional who performs regularly, there can be internal and external pressures to hide an injury no matter how severe it is. The nature and cause of RSI are very well understood. Pianists get RSI for several of the same reasons professional athletes get injured(5), a comparison we will explore further on: 1- Unvarying repetitive movement patterns 2- Excessive force 3- Intrinsic factors such as awkward postures, poor form or incorrect technique, inadequate preparation 4- Extrinsic environmental factors such as extreme cold, poor condition of equipment, incorrect seating height, inadequate lighting, etc. Both athletes and pianists experience soft tissue injuries such as tendinitis, tenosynovitis, stenosis, bursitis, and others because of these reasons. Sport injuries have a very specific protocol for their treatment that requires immediate First Aid when an injury occurs. This same protocol can be helpful to musicians with recent, sudden-onset injuries. The first round of treatment sports coaches or trainers administer most often follows the RICE protocol Rest Ice Compression Elevation REST eliminates further trauma to the site of injury. ICE causes arterioles and capillaries to constrict, limiting the spread of edema. COMPRESSION stabilizes any joints that are affected, and can help further limit edema. ELEVATION of the injury above the heart helps speed the flow of oxygen- and nutrient-starved venous blood and other fluids back to the trunk, further helping to reduce swelling at the injury site. Over-the-counter pain medication can also be very helpful in speeding recovery. Not only do aspirin and ibuprofen help with pain and discomfort, they also have anti-inflammatory properties that help with swelling. If you use them, follow the instructions on the packaging. It’s very clear why this protocol works well. The initial stage of injury causes, among other things, the breaking of mast cells that release histamine into the surrounding tissues and fluids. This causes edema, drawing more fluids to the injury site that bring antibodies, nutrients and oxygen to the site of injury. That’s good, because those things speed healing and help prevent infection. But the swelling can progress to surrounding tissues, ultimately impairing circulation. If circulation is compromised, the blood fluids can become exhausted of oxygen and nutrients at the injury site, and also limit the transit of carbon dioxide and waste products out of the affected area. The edema also makes the cells water-logged, affecting their structural integrity and making them more prone to re-injury. If an injury is relatively recent and not severe, then home care can be the option of choice. A home care program should look something like this: 1- Rest. Stay away from playing until the acute symptoms (pain, swelling, loss of mobility) subside. 2- Cold. Use an ice or cold gel pack on the affected area to reduce swelling. Keep it on only long enough to cool the skin to the touch. Repeat as often as two or three times an hour. Don’t put ice directly on the skin as it can cause frostbite. 3- Elevate. If swelling is pronounced, hold the injury slightly above the level of the heart. 4- Compression is probably not necessary for most RSIs of the upper extremity. 5- Retrain. Once you’ve recovered, work with a teacher who can help change your technique so you don’t injure yourself again. How do you know you’re recovered? Simple: it won’t hurt to play. If it just plain hurts to play, at all, then you are probably not recovered enough to start yet. If the acute symptoms have subsided but it still hurts to play a particular passage, then avoid that passage or texture until you’ve worked with a teacher to retrain the technique. Playing through the pain is always a bad idea. The RICE protocol is intended for recent, sudden-onset pain or injury. You will need to see a doctor if your symptoms don’t improve in a few days, or a week at the outside. Greg Dempster is a concert pianist known for his work rehabilitating injured musicians. He is also an expert consultant in ergonomics and industrial safety, and the principal of Triangle Associates, a consulting group based on the West Coast. This blog post is adapted from his forthcoming book, “The Mechanics of Piano Playing”. Notes--- 1- Zaza, Christine. 1992. "Playing-related health problems at a Canadian music school," Medical Problems of Performing Artists, 7: 48-51. 2- Numerous studies support this view e.g.: Driscoll T, Ackermann B, Kenney D, “Sound practice: Injury occurrence and surveillance in orchestral musicians”, [abst.] 28th Annual Symposium on Medical Problems of Performing Artists Proceedings, Denver, CO: PAMA/Rocky Mt. Health Plans (Thu). 3- Yeung E, Chan W, Pan F, Sau P, Tsui M, Yu B, Zaza C., “A survey of playing-related musculoskeletal problems among professional orchestral musicians in Hong Kong”, Med Probl Perform Art, 1999: 14(1):43-47. 4- Ackermann B, Driscoll T, Kenny DT., “Musculoskeletal pain and injury in professional orchestral musicians. Australia, Med Probl Perform Art., 2012: 27(4):181-187. 5- Dawson, W.J., “The dedicated amateur instrumentalist with upper extremity difficulties [abst.]”, 19th Annual Symposium on Medical Problems of Musicians and Dancers Proceedings: Education Design (Thu)