Florida State University Libraries

Electronic Theses, Treatises and Dissertations The Graduate School

2010

Common Injuries Among CollegeClarinetists: Definitions, Causes,Treatments, and Prevention MethodsJacqueline Kaye McIlwain

Follow this and additional works at the FSU Digital Library. For more information, please contact lib-ir@fsu.edu

THE FLORIDA STATE UNIVERSITY

COLLEGE OF MUSIC

COMMON INJURIES AMONG COLLEGE CLARINETISTS: DEFINITIONS,

CAUSES, TREATMENTS, AND PREVENTION METHODS

By

JACQUELINE KAYE MCILWAIN

A Treatise submitted to the

College of Music

in partial fulfillment of the

requirements for the degree of

Doctor of Music

Degree Awarded:

Spring Semester, 2010

ii

The members of the committee approve the treatise of Jacqueline Kaye McIlwain

defended on March 23, 2010.

____________________________________

Frank Kowalsky

Professor Directing Treatise

____________________________________

Richard Clary

University Representative

____________________________________

Deborah Bish

Committee Member

The Graduate School has verified and approved the above9named committee members.

iii

Dedicated to my husband, Ben McIlwain

iv

ACK�OWLEDGEME�TS

I would like to acknowledge the many people who have helped me throughout

this degree. First, I would like to thank Dr. Frank Kowalsky who has been incredibly

patient and supportive with me and guided me every step of the way. I have been

inspired by his compassion for his students and passion for music. My other committee

members, Dr. Deborah Bish and Professor Richard Clary, have also played key roles

during my time at Florida State University. Dr. Bish has always been willing to share

advice and guidance, and has continually shown her confidence in me. Professor Clary

has been incredibly supportive and has enriched my musical experience at FSU.

The survey for this project was made possible by Dr. Alice9Ann Darrow who

answered my numerous questions about surveys and their analyses. Her gracious

willingness to help me is very much appreciated.

Most of all I would like to thank my family for always believing in me. Their

support has helped me in so many ways and I could not have come this far without them.

Thank you George and Lori O’Kain, John O’Kain, Joanne O’Kain, Whitey Freberg, Don

and Debbie McIlwain, and Brad McIlwain, for your unconditional love and the numerous

sacrifices you have made for me.

A special thank you is expressed to the one who has been my rock for the past

three years, my loving and dear husband, Ben McIlwain. With his encouragement,

confidence, support, and love I have been able to accomplish more than I thought

possible.

v

TABLE OF CO�TE�TS

List of Tables ............................................................................................. vii

List of Figures ........................................................................................... viii

Abstract ............................................................................................... ix

1. INTRODUCTION ................................................................................. 1

2. SURVEY ............................................................................................... 5

Method ....................................................................................... 5

Respondents .......................................................................... 5

The Survey ............................................................................ 5

Procedure .............................................................................. 6

Results ........................................................................................ 6

2.1 Complaints of Pain or Discomfort While Playing

Clarinet ............................................................................ 6

2.2 Complaints of Numbness While Playing Clarinet .......... 7

Discussion ................................................................................... 8

3. CLARINETISTS’ INJURIES AND THEIR DEFINITIONS............... 9

Tendinitis..................................................................................... 9

Carpal Tunnel Syndrome ............................................................ 10

3.1 The carpal tunnel ............................................................. 11

3.2 Tinel’s sign...................................................................... 12

3.3 Phalen’s sign ................................................................... 13

Temporomandibular Joint Dysfunction ...................................... 14

Trigger Finger ............................................................................. 15

3.4 Tendon sheaths and trigger finger................................... 16

De Quervain’s Disease ................................................................ 17

Cubital Tunnel Syndrome ........................................................... 18

3.5 The cubital tunnel............................................................ 19

Bursitis ........................................................................................ 20

Tennis Elbow............................................................................... 20

Thoracic Outlet Syndrome .......................................................... 21

3.6 The thoracic outlet........................................................... 22

Ganglion Cyst.............................................................................. 23

vi

Myofacial Pain Syndrome........................................................... 24

Arthritis ....................................................................................... 25

Focal Dystonia............................................................................. 25

3.7 Focal dystonia ................................................................. 27

Overuse Syndrome ...................................................................... 27

4. CAUSES OF INJURIES ........................................................................ 29

5. PREVENTION AND TREATMENT METHODS................................ 35

Traditional and Modern Medicine............................................... 35

Alternate Therapies and Health Philosophies ............................. 38

Body Awareness Methods........................................................... 40

6. CONCLUSION ...................................................................................... 43

APPENDICES

A.� CLARINETISTS’ INJURY GUIDE BY LOCATION OF PAIN OR

NUMBNESS ........................................................................................ 44

B.� CLARINETISTS’ INJURY GUIDE BY SYMPTOMS ...................... 46

C.� HUMAN SUBJECTIONS COMMITTEE APPROVAL..................... 49

D.� HUMAN SUBJECTS COMMITTEE APPROVAL

(Change of Protocol) ............................................................................ 52

E.� SURVEY.............................................................................................. 54

F.� CONSENT FORM ............................................................................... 58

BIBLIOGRAPHY ............................................................................................... 60

BIOGRAPHICAL SKETCH .............................................................................. 65

vii

LIST OF TABLES

2.1 Complaints of Pain or Discomfort While Playing Clarinet ........................... 6

2.2 Complaints of Numbness While Playing Clarinet ......................................... 7

viii

LIST OF FIGURES

3.1 The carpal tunnel ........................................................................................... 11

3.2 Tinel’s sign .................................................................................................... 12

3.3 Phalen’s sign................................................................................................... 13

3.4 Tendon sheaths and trigger finger ................................................................. 16

3.5 The cubital tunnel ........................................................................................... 19

3.6 The thoracic outlet .......................................................................................... 22

3.7 Focal dystonia................................................................................................. 27

ix

ABSTRACT

The purpose of this project is to define the playing9related injuries common to

clarinetists, list causes, and explore treatment and prevention methods. An online survey

was conducted to yield information of the location and degree of pain and numbness,

diagnoses, what treatment methods were used, and demographic information. The survey

was sent to clarinet professors throughout the United States and requested that it be

forwarded to their university or college students. A total of 601 students responded and

revealed 83% (n=500) experienced pain or discomfort and 37% (n=213) numbness while

playing the clarinet. Twenty9one percent (n=128) of respondents had been diagnosed

with a playing9related injury. Diagnosed injuries are discussed, as well as causes and risk

factors that can provoke or contribute to the injury. Many treatment and prevention

methods are also explored and defined.

1

CHAPTER 1

I�TRODUCTIO�

Injuries are becoming increasingly prevalent among instrumentalists.1 Many

researchers have studied the injuries experienced by professional orchestral musicians

and music students. 2

However, few studies concern woodwinds and even fewer are

specific to the clarinet. Additionally, there are not sources with detailed information on

the injuries to which clarinetists are susceptible. This project will serve as a source of

information for clarinetists and will include a survey, the results, definitions, causes,

treatments, and ways to prevent injuries.

The sources that are geared toward specific instruments often do not apply to

clarinetists. Those that are more general include information on the anatomy of the body,

how to take care of the body, and possible prevention methods, which are helpful when

describing the injuries and ways to prevent them from occurring.

The two most helpful types of sources regarding musicians’ injuries include

books that give information on several topics, and periodical articles, which are usually

more narrowly focused on one injury. In general, the books include more detailed

information regarding anatomy, causes, and treatments, while the periodical articles tend

to focus on problems or solutions in a particular area, such as the thumb, arm, or jaw.

Textbook of Performing Arts Medicine is edited by physicians Robert Thayer

Sataloff, Alice G. Brandfonbrener, and Richard J. Lederman and features several topics

pertaining to musicians, dancers, and actors.3 Each chapter focuses on one specific topic

1 Janet Horvath, Playing (Less) Hurt: An Injury Prevention Guide for Musicians (Kearney, NE:

Morris Publishing, 2002), 19.

2 Michael Thrasher and Kris S. Chesky, “Medical Problems of Clarinetists: Results from the

U.N.T. Musician Health Survey,” The Clarinet 25, no. 4 (July/August 1998): 24.

3 Sataloff.

2

and is written by a different medical physician who specializes in that field. A few

chapters that were useful for this project include “Epidemiology of the Medical Problems

of Performing Artists” by Alice G. Brandfonbrener, “Temporomandibular Joint

Disorders, Facial Pain, and Dental Problems in Performing Artists” by James Howard,

and “Diagnosis and Surgical Treatment of the Hand” by Richard G. Eaton and William

B. Nolan.

Alan H.D. Watson’s The Biology of Musical Performance and Performance(

Related Injury and William Dawson’s and MENC’s book Fit as a Fiddle: The Musician’s

Guide to Playing Healthy contain information about the human anatomy and address

different aspects of rehabilitation, overall health, and how the body functions while

playing an instrument.4 Watson and Dawson both have musical and medical background:

Watson learned the french horn and flute at an early age and is currently a senior lecturer

in anatomy and neuroscience at Cardiff University and Dawson is a bassoonist, retired

hand surgeon, and performing arts medicine specialist.5 The authors address and inform

readers about the way musicians use their bodies and how the body works by including

illustrations of the skeletal and muscular makeup of the neck, arms, wrists, hands, and

back. The importance of emotional health is stressed and suggestions are provided for

achieving a healthier attitude and managing performance9related stress.

Richard Norris, author of The Musician’s Survival Manual: A Guide to

Preventing and Treating Injuries in Instrumentalists, is also medically and musically

trained as a flutist and performing arts medicine physician.6 Various injuries, medical

problems, rehabilitation, performance anxiety, and a list of performing arts medicine

references are all discussed. Illustrations are shown throughout to demonstrate injuries

and therapeutic exercises.

4 Alan H.D. Watson, The Biology of Musical Performance and Performance(Related Injury,

(Lanham, MD: The Scarecrow Press, 2009); William J. Dawson and MENC, The National Association for

Music Education (U.S.), Fit as a Fiddle: The Musician’s Guide to Playing Healthy, (Lanham, MD:

Rowman & Littlefield Education, 2008).

5 Watson, 369; Dawson, 157.

6 Richard Norris, The Musician’s Survival Manual: A Guide to Preventing and Treating Injuries in

Instrumentalists, (Saint Louis: MMB Music, 1993).

3

Jaume Rosset i Llobet and George Odam’s The Musician’s Body: A Maintenance

Manual for Peak Performance describes how the musician’s body functions, what puts it

at risk, how to achieve optimal performance, and provides a troubleshooting guide for

musicians.7 Many instrument9specific problems are addressed including possible

solutions. The illustrations by Axel Oliveres i Gili demonstrate injuries, instrument

hazards, and therapeutic exercises.

Barbara Paull and Christine Harrison’s The Athletic Musician: A Guide to Playing

Without Pain draws many parallels between athletes and musicians.8 Musicians’

anatomy, ergonomics, exercises, practicing suggestions, working environments, and

suggestions for coping with an injury are all discussed in detail. The tone of this book

stresses the fact that musicians use the body in similar ways as athletes, suggesting

similar precautions and care.

More specialized books are Kate Montgomery’s End Your Carpal Tunnel Pain

Without Surgery: The Montgomery Method, Sharon Butler’s Conquering Carpal Tunnel

Syndrome and Other Repetitive Strain Injuries: A Self(Care Program, and Emil

Pascarelli’s Complete Guide to Repetitive Strain Injury: What You 3eed to Know About

RSI & Carpal Tunnel Syndrome.9 Montgomery discusses Carpal Tunnel Syndrome

(CTS), other repetitive strain injuries, a method she developed to reduce the symptoms of

CTS, and mentions other methods that can be explored. Butler shares her personal

experience with CTS, and the remainder of the book defines terms associated with

Repetitive Strain Injuries (RSI) and numerous exercises with explanations of their

purposes. Body awareness is addressed and other resources are also provided. Pascarelli

discusses how RSI affects emotions, as well as ergonomics, biomechanics, and recovery.

7 Jaume Rosset i Llobet and George Odam, The Musician’s Body: A Maintenance Manual for

Peak Performance, (London: The Guildhall School of Music and Drama, 2007).

8 Barbara Paull and Christine Harrison, The Athletic Musician: A Guide to Playing Without Pain,

(Lanham, MD: The Scarecrow Press, 1997).

9Kate Montgomery, End Your Carpal Tunnel Pain Without Surgery: The Montgomery Method,

(Boulder, CO: Sports Touch, 2004); Sharon J. Butler, Conquering Carpal Tunnel Syndrome and Other

Repetitive Strain Injuries, (Oakland, CA: New Harbinger Publications, 1996); Emil Pascarelli, Complete

Guide to Repetitive Strain Injury: What You 3eed to Know About RSI & Carpal Tunnel Syndrome,

(Hoboken, NJ: John Wiley and Sons, 2004).

4

Another source of interest is Janet Horvath’s Playing (Less) Hurt: An Injury

Prevention Guide for Musicians.10

Horvath discusses the definition and causes of

overuse pain, the rising number of injuries, and warning signs. After these explanations

and definitions, she provides several sets of stretches and exercises to help treat the

problems and prevent further injury.

Periodical articles have been a significant source and come from different journals

of varying specialties including nursing, music education, and the performing arts. Each

article discusses a topic such as CTS, body awareness, overall health, thumb problems,

and overuse injuries. These periodicals are important sources of information about the

injuries clarinetists suffer.

The most pertinent journal is Medical Problems of Performing Artists, which

contains numerous articles on topics such as occupational therapy, hand problems, upper

extremity disorders, and nerve entrapment syndromes.11

This peer9reviewed journal

includes well9documented articles and in9depth studies.

Another source that was used mostly in the fifth chapter includes websites of

various associations. During the discussion of prevention and treatment methods, these

websites were consulted for definitions and clarification of each method from the

associations in which they are directly affiliated.

Taking into consideration the limited research of clarinetists’ medical problems

and lack of a comprehensive list of injuries that have occurred in clarinetists, the goal of

this project is to create such a list with definitions, causes, and prevention and treatment

methods to serve as a resource for clarinet performers and teachers.

10

Janet Horvath, Playing (Less) Hurt: An Injury Prevention Guide for Musicians, (Kearney, NE:

Morris Publishing, 2002).

11

Ralph A. Manchester, M.D. “The Incidence of Hand Problems in Music Students,” Medical

Problems of Performing Artists 3, no. 1 (March 1988): 15918; Richard Lederman, M.D., Ph.D. “Nerve

Entrapment Syndromes in Instrumental Musicians,” Medical Problems of Performing Artists 1, no. 2 (June,

1986): 45948; Barry Knishkowy, M.D. and Richard J. Lederman, M.D., Ph.D. “Instrumental Musicians

with Upper Extremity Disorders: A Follow9up Study,” Medical Problems of Performing Artists 1, no. 3

(Sep. 1986): 85989; Glenn Goodman, MOT, OTR/L and Sheryl Staz, BS, OTR/L, “Occupational Therapy

for Musicians with Upper Extremity Overuse Syndrome: Patient Perceptions Regarding Effectiveness of

Treatment.” Medical Problems of Performing Artists 4, no. 1 (March, 1989): 9914.

5

CHAPTER 2

SURVEY

Method

Respondents

College and university students were chosen as research subjects because studies

determining injuries of professional musicians and college9age students reveal

comparable results. This suggests that age is not considered a risk factor.12

For the

purpose of this study, college and university students were chosen simply to focus on one

demographic.

A list of clarinet professors was compiled by researching each school that was a

member of the National Associations of Schools of Music. Every clarinet professor was

e9mailed a website link of the survey asking them to forward it to their college students.

Of the 310 clarinet professors that were contacted, 36 immediately responded stating they

sent the survey to their students. There may have been more teachers who also forwarded

the survey, but did not reply. A total of 601 surveys were received, revealing 72%

(please note that percentages may be rounded) of respondents were female, 28% were

male, and 87% were undergraduate students and 13% graduate students.

The Survey

This survey was administered online using the website host

www.surveymonkey.com. The questions on the survey were designed to gather

information about clarinetists’ pain and injuries caused by playing their instrument. I

researched what injuries were possible among clarinetists and included these in the

12

Sataloff, 31.

6

answer choices. There was also a write9in option for the questions regarding diagnoses

and prescribed treatment. Questions that asked where pain or numbness was experienced

allowed respondents to choose multiple answers. A copy of the survey is included in

Appendix E.

Procedure

The survey website link was sent via e9mail to clarinet professors around the

United States. The e9mail message included an explanation of the project and research

goals. Professors were asked to send the website link to their students requesting them to

complete the survey.

An informed consent form, approved by the Florida State University Human

Rights Committee, preceded the survey. Each student who completed the survey

affirmed they understood the benefits, minimal risks, and they were 18 years of age or

older. The consent form is included in Appendix F.

Results

According to the results of the survey, a total of 83% of clarinetists experience

pain while playing their instrument. The two most common responses were mild (50%)

and moderate (30%) levels of pain or discomfort, leaving severe and excruciating levels

to 8% of the sample. Of these, respondents reported pain or discomfort in several

locations (see Table 2.1), including 62% in the wrist, 46% in the thumb, 43% in the hand,

followed by pain in the forearm (31%), jaw (25%), back (24%), neck (20%), shoulder

(18%), elbow (8%), and upper arm (4%). Some respondents also reported their lips (5%)

and teeth (1%) hurt while playing.

Table 2.1 Complaints of Pain or Discomfort While Playing Clarinet

n=601

Wrist 299

Thumb 223

Hand 208

Forearm 148

Jaw 119

Back 118

7

Table 2.1 9 continued

Neck 94

Shoulder 87

Elbow 40

Lip 33

Upper Arm 19

Teeth 6

Thirty9seven percent of the clarinetists reported experiencing numbness while

playing their instrument. Most of those reported a mild degree (27%), while 9% declared

moderate and 2% severe and debilitating. The most common location of numbness was

the thumb, which affected 56% of those who have experienced numbness. Other

locations of numbness can be seen in Table 2.2 and include the hand, wrist, forearm, jaw,

lips, shoulder, elbow, neck, back, fingers, and arms.

Table 2.2 Complaints of Numbness While Playing Clarinet

n=601

Thumb 116

Hand 73

Wrist 58

Forearm 32

Jaw 19

Lips 13

Shoulder 8

Elbow 7

Neck 7

Back 5

Fingers 5

Upper arm 4

Of 601 respondents, 21% have been diagnosed with a condition that includes

symptoms of pain, discomfort, or numbness while playing their instrument. The most

prevalent injury was tendinitis with 67%, followed by carpal tunnel syndrome with 23%,

and temporomandibular joint dysfunction (TMJ) with 20%. Other injuries were

significantly less frequent with 6% of both trigger finger and de Quervain’s disease, and

3% of cubital tunnel syndrome, 2% of bursitis, and both 1% of thoracic outlet syndrome

8

and focal dystonia. Respondents also listed diagnoses of ganglion cysts, tennis elbow,

myofacial pain syndrome, arthritis, and overuse syndrome.

Those who sought medical attention for their symptoms received a variety of

treatments including 12% physical therapy, 10% stretch regimen, 10% medication, 2%

occupational therapy, and 1% surgery. The following treatments were also reported:

chiropractor referral, massage therapy, Alexander Technique, yoga, ice therapy, brace,

rest, and steroid injections. Of the respondents who underwent treatment for an injury,

72% reported the pain persisted following treatment.

About half of the respondents, 51%, stated they play their instrument five to six

days a week, followed by 23% who play seven days a week, 20% who play three to four

days, and 5% who played zero to two days a week. The amount of time spent playing the

clarinet per day was much more diverse. Respondents who claimed they play for more

than seven hours a day included 18%, while 15% answered five to six hours, 27% three

to four hours, 32% one to two hours, and 9% zero to less than one hour.

The stress levels among respondents were quite high, including 12% who rated

their stress very high, 40% high, 37% medium, and 11% low and very low.

Discussion

Considering the large percentage (83%) of clarinetists who experience pain while

playing their instrument, it is imperative that these instrumentalists increase their

awareness of prevention methods, injuries that may occur, and the effective treatments.

Simple stretch regimens and awareness techniques, which will be discussed in Chapter 5,

could potentially prevent injury or control and heal conditions that may have arisen.

For the purposes of this treatise only percentages were reported. For those who

might further explore clarinetists’ injuries, it would be interesting to statistically analyze

the survey results to determine if correlations exist. Another possible research topic is to

determine if symptoms differ between the two sides of the body. For example, it is

possible that clarinetists may experience pain in one wrist, but not the other.

Overall, this survey uncovered many unknown facts about clarinetists’ injuries. It

is evident that many clarinetists are plagued with pain and many are not aware of the

causes, prevention methods, or treatment options.

9

CHAPTER 3

CLARI�ETISTS’ I�JURIES A�D THEIR DEFI�ITIO�S

The purpose of this chapter is to serve as a source of reference for clarinetists

when dealing with pain associated with playing their instruments. Injuries will be

discussed in the order of prevalence.

Tendinitis

Tendons are “rope9like bands of fibers” that connect muscle to bone.13

Intense

force or exhaustion can result in microscopic tears and inflammation of the tendons, also

known as tendinitis.14

Tendons of the upper extremities are particularly at risk for

inflammation because of their small size.15

Tendinitis is considered a muscle9tendon overuse injury and can have damaging

effects if it is not treated immediately. When an injury occurs, “compounds promoting

inflammation and hyperalgesia (sensitivity to touch) are formed from the breakdown of

damaged cells at the site of injury.”16

These compounds, which include prostaglandins,

can be blocked by painkillers such as aspirin and ibuprofen that not only reduce pain but

also limit inflammation. This type of medication is often referred to as nonsteroidal anti9

inflammatories (NSAIDs), and is often prescribed in conjunction with rest and ice

therapy to quickly decrease pain and inflammation.17

If inflammation is not quickly

13

Horvath, 25.

14

Ibid.

15

Emil Pascarelli, Dr. Pascarelli’s Complete Guide to Repetitive Strain Injury: What You 3eed to

Know About RSI & Carpal Tunnel Syndrome, (Hoboken, NJ: John Wiley and Sons, 2004), 56.

16

Watson, 15.

17

Watson, 15; Sataloff, 78.

10

reduced, then “any restricted spaces within the tissue through which structures such as

tendons or nerves must slide will become narrower, so that friction is generated by such

movement.”18

This further friction causes additional pain and inflammation, and if left

untreated the compounds that were released at the site of injury will settle and form scar

tissue.19

Many treatment options are found to be beneficial. Anti9inflammatory

medications, ice therapy, and relative rest, which include reducing and/or modifying

activities such as practicing, are recommended first and foremost to allow the injury to

heal, minimize inflammation, and also to keep the musician playing his instrument. More

severe cases may require immobilization if pain is felt in daily activities or the person is

unable to stop using the affected hand. If a splint is used, it is recommended that it be

removed throughout the day to perform pain9free, range9of9motion exercises, which will

prevent stiffness and help the overall healing process.20

Carpal Tunnel Syndrome

The carpal tunnel, as seen in Figure 3.1, is “created by the configuration of the

wrist bones,” and contains the median nerve, nine tendons, and is enclosed by the

transverse carpal ligament. 21

If the tendons controlling finger movements become

irritated and swollen, this can compress or squeeze the median nerve as it passes through

the carpal tunnel.22

This compression of the median nerve due to inflammation is defined

as carpal tunnel syndrome (CTS).23

18

Watson, 71.

19

Ibid.; Horvath, 28.

20

Norris, 15.

21

Sharon J. Butler, Conquering Carpal Tunnel Syndrome and other Repetitive Strain Injuries: A

Self(Care Program, (Oakland, CA: New Harbinger Publications, 1996), 12; Norris, 59. 22

Butler, 12.

23

Norris, 59.

11

Figure 3.1 The carpal tunnel24

Movements that can create irritation within the carpal tunnel include extension,

deviation, flexion or pinching of the thumb, index and middle fingers. Excessive,

repetitive motions, and poor positioning of the wrist can also contribute to the onset of

CTS symptoms.25

Symptoms of CTS vary from person to person and can include numbness,

tingling, pain, aching, burning, limited range of motion, and in extreme cases muscle

atrophy.26

These symptoms usually occur in the thumb, index finger, middle finger, and

half of the ring finger.27

Additional discomfort has also been reported in the forearm,

upper arm, armpit, shoulder, and neck.28

Many people who suffer with CTS often

experience their symptoms in the morning or during the night. In more severe cases, loss

of dexterity and maneuvering small objects become increasingly difficult.29

24

Pascarelli, 16.

25

Horvath, 79.

26

Butler, 12913.

27

Norris, 59.

28

Butler, 12.

29

Norris, 59960.

12

CTS is diagnosed by physical examination and electrodiagnostic testing. The

physical examination includes tests such as Tinel’s sign, seen in Figure 3.2, and Phalen’s

sign, seen in Figure 3.3. Tinel’s sign is when the wrist is gently tapped causing the

median nerve to be compressed with each tap. If the patient feels pain or shooting pains

into the hand or arm, they may have CTS. Phalen’s sign is when the wrist is held in a

flexed position for a minute or so and the symptoms are provoked.

Figure 3.2 Tinel’s sign30

Electrodiagnostic testing is used to confirm a CTS diagnosis. 31

This type of

testing includes electromyography (EMG) and nerve conduction velocity (NCV) tests.

The testing process for the EMG includes a “fine, teflon9covered probe, similar to an

acupuncture needle, [to be] inserted into a muscle and the electrical activity is observed

on a screen.”32

The NCV is less invasive as it uses electrodes that are placed on the skin

over the nerve. Electric current is sent through the electrodes and the amount of time the

impulse takes to pass between the two points is measured. If the impulse is slowed, then

30

Montgomery, 22.

31

Ibid., 62.

32

Ibid., 63.

13

there is a sign of nerve compression.33

Figure 3.3 Phalen’s sign34

The most conservative medical treatment for CTS is splinting and anti9

inflammatory medication. A splint should immobilize the wrist in a neutral or slightly

extended position and worn at night while sleeping. Anti9inflammatory medications,

which can be given orally or by injection, are also possible, but have shown limited

success.35

Surgery is recommended only if conservative methods do not work, the

symptoms are present for more than three months, or if motor activity is compromised.

During this procedure, the transverse carpal ligament is cut to alleviate the compression

on the carpal tunnel. Postoperatively, some patients experience relief from night pain and

tingling.36

A few sufferers of CTS have designed their own methods of care and prevention.

The books written by these sufferers focus on educating readers about CTS and providing

stretches and exercises that can help alleviate symptoms. Montgomery’s End Your

33

Ibid.

34

Montgomery, 23.

35

Sataloff, 211.

36

Ibid., 212.

14

Carpal Tunnel Pain Without Surgery: The Montgomery Method discusses alternative

healing methods, such as muscle therapy and acupressure, ergonomics, and her twelve9

step method which includes stretching, releasing, and strengthening techniques. Sharon

J. Butler’s book, Conquering Carpal Tunnel Syndrome and Other Repetitive Strain

Injuries: A Self(Care Program, includes detailed definitions as well as specific

instructions on which stretches or exercises are necessary depending on the activities or

pain location of the reader. Both books provide significant amounts of information,

specific instructions for healing, and many stretches and exercises.

Temporomandibular Joint Dysfunction

Temporomandibular joint dysfunction (TMJ) is a disorder of the “hinge joint that

connects the mandible (lower joint) and temporal bone of the skull.”37

This joint is on

both sides of the head and the functions include moving the jaw open, closed, side9to9

side, forward, and back.38

The hinge joints consist of the condoyle, a small rounded end

of the mandible, and disc, which the condoyle rests against. When they do not work

correctly or the surrounding muscles are tense, pain and tissue damage can result.

Common symptoms of TMJ include headaches, hearing loss and ear pain, blurred vision,

backaches, jaw clicking, sore and tight jaws, facial pain, locking of the jaw, and worn

teeth. 39

The first symptoms of TMJ are most often seen between the ages of fifteen and

fifty, with the ratio of women to men being 8:1.40

TMJ can be caused by buxism

(clenching and grinding of the teeth), repetitive biting of objects, occupational activities

and hobbies, such as playing a musical instrument and singing, and trauma to the jaw.41

37

“Pain Management: Temporomandibular Disorders,” WebMD, http://www.webmd.com/pain9

management/guide/temporomandibular9disorders (accessed December 17, 2009).

38

Horvath, 108.

39

Horvath, 108; Sataloff, 115.

40

Horvath, 108.

41

Sataloff, 12599.

15

People who are double9jointed may have mandibular hypermobility that can also lead to

TMJ.42

Treatments for TMJ range from conservative to extreme, depending on the

severity of the case. The following treatments are used: physical therapy,

pharmacotherapy, modification of chewing, modification of hobbies and habits,

awareness of clenching and grinding, behavioral medicine, trigger point injections of

anesthetic, temporomandibular joint injections of steroids, intraoral therapy (use of a

night guard), temporary mandibular immobilization, and temporomandibular joint

surgery.43

Trigger Finger

Tenosynovitis, inflammation of the tendon sheath, in the thumb or fingers (trigger

finger) is a common injury among musicians. It is more common in women and may be

caused by diabetes, rheumatoid arthritis, and gout. The repetitive motions and extension

of the fingers required of musicians may also be a cause.44

When a finger moves from a flexed to a straightened position, the tendon in that

finger slides through the synovial sheath as seen in Figure 3.2. If the flexor tendon swells

and produces a nodule it makes it difficult for the tendon to slide through the synovial

sheath.45

When the nodule reaches the synovial sheath, it is briefly stopped (“triggered”)

until it suddenly forces its way through producing a snapping sound. If the swelling of

the tendon increases too much, it is possible that it will not fit through the synovial

sheath, causing the finger to be locked in this position known as “locked trigger.”46

42

Horvath, 109.

43

Sataloff, 157962.

44

Sataloff, 216.

45

Watson, 78.

46

Sataloff, 216.

16

Figure 3.4 Tendon sheaths and trigger finger47

Treatments include oral steroids, steroid injections, and surgery. Steroid

treatments usually result in recurrences of symptoms. If symptoms are still present after

three to four weeks of steroid therapy, surgical treatment is required. The surgical

47

Watson, 60.

17

procedure consists of the division of the synovial sheath, which permanently relieves

symptoms.48

de Quervain’s Disease

De Quervain’s disease is tenosynovitis at the base of the thumb. The two tendons

in the thumb are the abductor pollicus longus (APL) and the extensor pollicus brevis

(EPB) and when inflamed can cause pain in most thumb movement, particularly in

“thumb under” motions, as well as “forceful gripping, pinching, squeezing or grasping.”49

Possible anatomical irritants are the fact that these tendons run through the fibro9

osseous tunnel (first dorsal extensor compartment), which is a compartment of “dense

bands of connective tissue,” the radius (one of the bones in the forearm that is near the

base of the thumb) flares at the end, and some people may have extra tendons present.50

In possible conjunction with these risk factors, the causes are repetitive motions,

excessive force or grip, or holding weight with the thumb, which is essential when

playing the clarinet.51

Diagnosis is determined by using a few maneuvers called the “grind” test and the

Finklestein test. The first test is used to eliminate de Quervain’s disease as a possible

diagnosis and is performed by slightly compressing the metacarpal (long bone of the

thumb) toward the wrist and gently moving it back and forth. If the patient does not feel

any pain, then it is not de Quervain’s disease, but may be a sign of radial nerve

entrapment. The Finklestein test is when the patient is asked to form a fist with the

thumb tucked into the palm, then bend the fist toward the pinky finger in ulnar deviation.

If pain is felt, then the patient most likely has de Quervain’s disease.52

48

Ibid.

49

Norris, 67; Sataloff, 216; Horvath, 83.

50

Norris, 67.

51

Pascarelli, 2495; Horvath, 83.

52

Norris, 71.

18

Treatment is usually immobilization with a splint and oral steroids or local steroid

injections.53

If the symptoms persist or recur consistently, these periods of pain can lead

to disability unless the tendons are allowed to fully recover and return to normal. Surgery

is recommended if conservative methods are not effective. The surgical procedure

consists of splitting the first dorsal compartment in order to create more room for the

tendons to move. The success rate is high, recurrence rate low, and the recovery period

requires two weeks of complete immobilization and gradual resumption of activities.54

Cubital Tunnel Syndrome

The ulnar nerve runs from the neck, down the arm, through the cubital tunnel, into

the hand, and ends in the ring and pinky fingers.55

The cubital tunnel, seen in Figure 3.3,

is located in the elbow and has a superficial location that can be felt when the elbow is

bent.56

When the ulnar nerve is compressed by the cubital tunnel, irritation and pain arise

resulting in cubital tunnel syndrome. This compression is mostly caused by bending the

elbow, which can narrow the cubital tunnel, but supinating (twisting) of the arm may also

contribute.57

Sufferers of Cubital Tunnel Syndrome may experience pain of the elbow,

numbness and tingling in the pinky side of the hand, and in severe cases, muscle

atrophy.58

Bending the elbow, wrist, or individual fingers may provoke symptoms in

some patients.59

53

Sataloff, 217.

54

William B. Nolan and Richard G. Eaton, “Thumb Problems of Professional Musicians,”

Medical Problems of Performing Artists 4, no. 1 (March 1989): 22.

55

Horvath, 82.

56

Sataloff, 213.

57

Horvath, 82.

58

Norris, 52.

59

Sataloff, 214.

19

Figure 3.5 The cubital tunnel60

Cubital tunnel syndrome is easiest to treat when diagnosed early by the same

electrodiagnostic tests as carpel tunnel syndrome. To treat cubital tunnel syndrome, a

hinged elbow splint should be used to minimize the bending of the elbow. There are

cuffs for the upper arm and forearm with an adjustable hinge connecting the two. The

adjustable hinge should allow minimal bending at first and later can be adjusted to allow

60

Watson, 63.

20

more flexion of the elbow. It is recommended to wear this splint for ten to twelve weeks

or until symptoms subside.61

Ice therapy, salicylate9based creams, rest, and oral anti9

inflammatory medications are also recommended until sensitivity to the cubital tunnel

has stopped.62

In severe cases, surgery is recommended, though there is disagreement

about the most effective procedure, one that simply decompresses the site of entrapment,

or another that transposes the ulnar nerve to the front of the arm.63

Bursitis

Bursa “are fluid9filled sacs that cushion movement of tendons and ligaments and

facilitate smooth motion by reducing friction between ligaments and bones.”64

When

bursa, located in joints such as the shoulder, elbow, and knee, become inflamed the

surfaces do not move as smoothly as they should.65

This inflammation is called bursitis

and mainly occurs in the shoulder of musicians. It is caused by holding the arm out from

the body, over the head, or at shoulder level for a long period of time. It may also be

caused by lack of warming up before playing and having to hold the weight of the

clarinet while playing. The symptoms of bursitis include pain that radiates down the arm

and possible movement restriction when lifting the arm.66

If bursitis is diagnosed, joint

movement should be minimized, and ice therapy and anti9inflammatory medication are

recommended. If the injury recurs often, recovery will likely be slower.67

Tennis Elbow

Directly above the elbow joint is a “lateral ridge on the lower end of the humerus”

bone that is attached to “a common flattened tendinous structure,” which connects to the

61

Norris, 55.

62

Ibid., 57.

63

Sataloff, 214.

64

Horvath, 63.

65

Watson, 80.

66

Horvath, 63.

67

Watson, 80.

21

extensor muscles of the fingers.68

This area is called the lateral epicondyle and when

inflamed it is called lateral epicondylitis, or tennis elbow. Inflammation can occur from

repeated forceful rotation of the hand and wrist or extension of the wrist while gripping

an object. 69

Most often rest, nonsteroidal anti9inflammatory drugs, and ice therapy are

effective treatments. “Tennis elbow” bands that are placed on the elbow and splints that

prevent wrist extension have also been effective. Surgery is rarely performed on tennis

elbow patients. When pain subsides, physical therapy is needed to strengthen the wrist

extensors to prevent recurrence.70

Thoracic Outlet Syndrome

The thoracic outlet is an area where the neck, chest, and shoulder meet. There is a

passageway, seen in Figure 3.4, which contains the major nerves and blood vessels and

extends through the arm and hand.71

When these nerves and blood vessels (the brachial

plexus nerve, subclavian artery and vein) become compressed, thoracic outlet syndrome

(TOS) can occur.72

There are three locations in which compression can occur: “between the muscles

on the side of the neck (scalenes), especially if these muscles are tight or have an

abnormal configuration (anatomic variation); between the clavicle (collar bone) and the

first rib; and between the pectoral (chest) muscles and the ribs.”73

TOS is usually

provoked by poor posture or varying arm positions. Contributing factors to compression

include an extra rib (cervical rib), “elevation of the arms, low9slung and droopy

shoulders, tight pectoral muscles, collapsed chest posture, tight neck muscles, and by

68

Ibid., 77.

69

Ibid.

70

Sataloff, 83.

71

Norris, 29.

72

David B. Roos, “Thoracic Outlet Syndromes: Symptoms, Diagnosis, Anatomy, and Surgical

Treatment,” Medical Problems of Performing Artists 1, no. 3 (September 1986): 90.

73

Norris, 29.

22

carrying a heavy instrument or bag.”74

Additionally, TOS can be divided into three

categories: neurologic, arterial, or venous.75

Figure 3.6 The thoracic outlet76

The most common of the three categories is the neurologic type – compression of

the brachial plexus nerve. Symptoms that may be present include pain, paresthesias

(burning or tingling feeling), and paresis (partial paralysis). Arterial TOS constricts the

blood flow of the subclavian artery, which is the main source of blood supply in the arm,

and can lead to muscle fatigue, cramping, cold sensation, and pallor (paleness). Finally,

the venous type of TOS arises when the subclavian vein is compressed; the symptoms are

swelling, cyanosis (bluish discoloration of the skin), fatigue, heaviness, and aching of the

arm.77

The symptoms of TOS are positional and can be provoked by elevating the arm or

74

Horvath, 8899.

75

Roos, 9091.

76

Watson, 63.

77

Ibid.

23

placing it behind the body.78

People who have TOS may experience only one category or

a combination of the three.79

Two of the most reliable diagnostic tools for TOS are traction of the affected arm

with internal rotation at the shoulder and the elevated arm stress test (EAST), requiring

the patient to hold the arm above their head in the “stick9‘em9up position.” 80

If

symptoms occur as a result, TOS is diagnosed.81

Treatment consists of posture modification and awareness, stretch regimens,

strength building of the shoulder elevators, and surgical removal of the first rib.82

The

surgery is usually a successful procedure and relieves the symptoms for most patients but

is used if other options fail.83

Ganglion Cysts

A lump, or cyst, under the skin is commonly found on the dorsum, or top, of the

wrist and is called a ganglion cyst.84

These benign, fluid9filled masses are more common

in women than in men, can also grow on other parts of the hand, and may cause aching,

weakness, pain, or no symptoms.85

In addition to these possible symptoms, ganglion

cysts can also compress nerves and may be evidence of an overuse injury.86

If the cyst is not causing discomfort, treatment is not recommended as it will heal

itself. If pain, discomfort, or nerve compression becomes an issue, then draining the fluid

78

Norris, 31.

79

Roos, 9091.

80

Sataloff, 187; Roos, 92.

81

Roos, 92.

82

Sataloff, 187.

83

Roos, 92.

84

Pascarelli, 61.

85

Watson, 78; Horvath, 100.

86

Horvath, 100.

24

from the cyst is the best option. Surgery is the next option if draining the fluid does not

work. Regardless of treatment, ganglion cysts often return.87

Myofacial Pain Syndrome

Myofacial pain syndrome is also known as fibromyalgia and fibrositis.88

It

develops ten times more often in women than in men and its symptoms usually occur

between the ages of 30 and 55.89

Sufferers of this syndrome experience chronic pain in

the ligaments, tendons, and muscles, and often at specific areas of the body called trigger

points.90

The most common trigger points are the neck, shoulders, arms, lower back, and

upper legs.91

Pain associated has been described as “deep muscular aching, soreness and

stiffness.”92

Some patients have also reported muscle weakness, swelling, tightness,

numbness, and tingling, though upon physical and neurological examinations the results

were not significant.93

Symptom aggravators are anxiety, stress, lack of sleep, and cold.

Stiffness is usually felt most in the morning and relieves as the day passes.94

The causes of myofacial pain syndrome include muscular injuries, strains and

trauma, in combination with muscular imbalances and poor body mechanics. Education

of the condition, exercise, relaxation techniques, postural adjustments, and sleep

modifications are the recommended treatments. 95

Medication is also available and has

been effective in decreasing symptomatology.96

87

Sataloff, 85.

88

Horvath, 106.

89

Ibid.

90

Ibid.

91

Horvath, 106; Sataloff, 10495.

92

Horvath, 106.

93

Sataloff, 105.

94

Horvath, 106.

95

Ibid., 107.

96

Sataloff, 105.

25

Arthritis

Arthritis can be caused by wear and tear on the joints and/or genetics.97

There are

two types of arthritis: osteoarthritis and rheumatoid arthritis. Osteoarthritis is solely

caused by the wear on the joint surfaces. 98

This disease disintegrates the cartilage of

joints, thus creating more stress on the surrounding bones.99

The joints used most often

are usually affected first, including the base of the thumb for many musicians.100

Possible treatments are stretching, injection of anti9inflammatory drugs, splints, and

surgical release of tendons if chronic inflammation leads to immobilization of the area.101

Rheumatoid arthritis is an autoimmune disease that can affect joints and

connective tissue of the body. It initially attacks the “membranes that secrete the

lubricating synovial fluid” causing inflammation and then progresses to steady

destruction of the joint cartilages. Anti9inflammatory drugs are used to control the

swelling and surgical release of the tendons is also an option for this type of arthritis.102

Focal Dystonia

Focal dystonia (FD), or occupational cramp, is a neurological injury that provokes

involuntary movement without pain. This rare disease is usually found in the

embouchure or arms of musicians, often ending their careers.103

When FD symptoms

occur only when performing one task, it is called task9specific focal dystonia (TSFD),

which is usually the type from which musicians suffer.104

FD of the arm results in

97

Horvath, 111.

98

Watson, 80.

99

Sataloff, 96.

100

Watson, 80.

101

Ibid.

102

Ibid.

103

Horvath, 101.

104

Stephan Schuele and Richard J. Lederman, "Focal Dystonia in Woodwind Instrumentalists:

Long9term Outcome." Medical Problems of Performing Artists, 18, no. 1 (March 2003): 15.

26

curling of the fingers or retraction of the hand as seen in Figure 3.5, and FD of the

embouchure can lead to tremors, abnormal contractions of the face, involuntary

puckering and closure of the lips.105

Most often these symptoms only occur when

performing or holding the instrument, but may surface when doing similar activities, such

as typing on a keyboard.106

Though the causes are unknown a clinical report by Hans9Christian Jabusch

and Eckart Altenmuller suggests perfectionism and anxiety were prevalent in musicians

with FD.107

Other common associations include “intense and prolonged practice of

complex actions,” tension, change in technique or instrument, or “acute trauma or

overuse.”108

Treatments for FD have been unsuccessful for most sufferers. It is suggested that

the most effective treatment is for the musician to relearn to play the instrument in a

relaxed manner with coaching from an experienced teacher. Periods of rest from the

instrument have not proven to help and some drug therapies have been used with minimal

success. Most sufferers do not regain their prior abilities on the instrument. If someone

is able to adequately play the instrument after diagnoses and treatment of FD, it is

regarded as a successful treatment.109

105

Horvath., 103.

106

Sataloff, 195.

107 Hans9Christian Jabusch and Eckart Altenmuller. “Anxiety as an Aggravating Factor During

Onset of Focal Dystonia in Musicians.” Medical Problems of Performing Artists 19, no. 2 (June 2004): 759

81.

108 Norris, 92; Sataloff, 197.

109

Sataloff, 19798.

27

Figure 3.7 Focal dystonia

“299year9old clarinetist with history (1 ½ years) of difficulty controlling the right little

finger while playing. A: Hand position as she begins to play. B: After playing less than

1 minute, the right little finger begins to curl involuntarily, pulling the finger off the

key.”110

Overuse Syndrome

Overuse syndrome has a few conflicting definitions. One defines it as a blanket

term that includes many kinds of injuries that result from repetitive and excessive

motions and the other is defined as “a condition that occurs when any biological tissue—

muscle, bone, tendon, ligament, etc.—is stressed beyond its physical limit.”111

Both are

similar in definition, but the second is recognized among physicians to be localized in the

forearm, wrist, and hand.112

Therefore, these causes, diagnoses, and treatments will be

discussed.

110

Ibid., 195.

111

Pascarelli, 10; Norris, 1.

112

Norris, 1.

28

The stress that occurs to a biological tissue can cause microscopic tears that bleed

or swell in the affected area.113

A widespread aching feeling in the forearm or pain in the

hand are usually the first symptoms and can escalate to pain in the forearm and shoulder

during and after playing an instrument.114

Physical exams usually produce little results except “mild tenderness in the

forearm muscles, especially the wrist extensors, and the intrinsic hand muscles.”115

Maneuvers are conducted on the patient to determine if a specific tendinitis or bursitis is

the diagnosis. If these tests are negative, then overuse syndrome is the diagnosis.116

Relative rest is recommended at the first sign of overuse syndrome. While

resting, professional medical attention should be sought to determine excess stress or

tension. If either is present, stress management should be addressed including

biofeedback training. Methods such as Alexander Technique and Feldenkrais can be

helpful with both tension and stress9related issues. Ice and heat therapy, stretching

exercises, and anti9inflammatory drugs are also recommended.117

113

Ibid.

114

Norris, 1; Watson, 76.

115

Sataloff, 80.

116

Ibid.

117

Horvath, 899.

29

CHAPTER 4

CAUSES

Each instrument comes with its own risks to the performer. While brass players

tend to have mostly embouchure9related injuries, followed by postural9related problems

and injuries, woodwind players are much more likely to experience problems related to

the repetitive motion required by the fingers. 118

The following risk factors for clarinetists

will be discussed individually: inadequate physical conditioning; abrupt increases of

practice time, instrument weight, poor technique, posture, inadequate rehabilitation of

previous injuries, stressful nonmusical activities, body size and anatomical variations,

gender, equipment set9up, environmental factors, muscle imbalances due to the demands

of playing clarinet, and stress levels.119

Healthy muscles are strong and resilient. If, however, the body is not physically

conditioned, muscles can become “tight and weak” due to lack of use and causes them to

be more susceptible to injury.120

To minimize risk and for optimal muscular health,

exercise should focus on “conditioning, flexibility, endurance, muscle balance, body

alignment, and strength.”121

A sudden change of practice or rehearsal time is a common cause of injury that

often occurs in students who participate in summer festivals or begin preparing for juries

and/or recitals. It is best to gradually increase playing time, which would most likely

prevent pain from occurring.122

118

Robert Thayer Sataloff, Alice G. Brandfonbrener, and Richard J. Lederman, eds. Textbook of

Performing Arts Medicine (New York: Raven Press, 1991), 5498.

119

Horvath, 44; Norris, 296; Sataloff, 30931.

120

Horvath, 38.

121

Norris, 2; Horvath, 3899.

30

The weight of the clarinet can become cumbersome to the body, especially

considering that the instrument rests on the right thumb, which can lead to imbalanced

muscle mass and strain in the right hand and arm. It is important to release the strain of

the small hand muscles and rely on the larger and stronger muscles of the arm and back.

The use of a neck strap (discussed later in Chapter 5) can help alleviate some of the stress

on the right hand. 123

Any technical problem, whether incorrectly learned or simply a bad habit,

requires extra musculature effort from the performer, therefore leading to tension,

overworked muscles, and possible injury. Common technical problems among

clarinetists include excessive pressure used in the fingers to depress the keys, poor wrist

alignment, tension in one or both shoulders, excessive movement while playing, and

tense and locked fingers. The tension caused by these problems is not needed and creates

much more work for the body.124

Posture and body mechanics can also cause unnecessary tension in the body.

Misuse including slouching, overcorrecting, or carrying heavy objects that are not evenly

distributed can leave a clarinetist susceptible to injuries. Increasing body awareness and

distributing the weight of heavy objects such as cases and instruments will often

eliminate these risks.125

Body awareness techniques, which will be discussed further in

Chapter 5, can include methods of relaxation, refining posture, and mind/body exercises.

The stress of carrying an instrument case may not seem noteworthy, but carrying a

clarinet case by its handle for thirty minutes uses more forearm muscle strength than

playing the instrument for several hours.126

To avoid overworking the muscles in your

arms and hands, it is important to hang weight on the shoulders or back when possible by

use of a backpack, frequently change sides if the case only has one strap, and avoid

carrying weight in the hands.127

122

Norris, 2; Horvath, 4091.

123

Llobet, 28.

124

Ibid., 3.

125

Norris, 4; Llobet, 33.

126

Llobet, 28.

31

If an injury is not rehabilitated thoroughly it is likely to recur or create additional

problems. Once symptoms have subsided, it is important to continue treating the affected

area until it is “completely free of pain, has a full range of motion, and has fully regained

endurance, strength, and coordination.”128

It is also imperative to begin a stretch

regimen, increase body awareness, warm9up properly each time the clarinet is played,

and gradually increase practice time after healing from an injury.129

Stressful nonmusical activities such as heavy lifting, sports participation, typing,

and garden work can put the body at an extra risk.130

These activities can create

“tendinitis9like overuse problems” and should be treated with as much care as practicing

the clarinet.131

Many breaks and endurance building should be incorporated.132

Body size and anatomical variations can also be considered a risk factor.

Documented physical traits that may become a hindrance to a clarinetist include thumb

length and joint laxity, but may also include short or long fingers, slender wrists, long

arms, and tendinous interconnections that are experienced in other musicians.133

Thumb

length may be a problem for some people due to the fixed thumb rest and size of the

instrument. With the thumb under the thumb rest, it may be difficult to reach around the

clarinet and freely access the keys.134

Joint laxity is a condition that allows abnormal

flexibility due to the “increased elasticity of the ligaments.”135

Those with joint laxity

attempt to control the elasticity and result in damaging the intrinsic and extrinsic muscles

127

Ibid., 41.

128

Norris, 4.

129

Ibid.

130

Dawson, 131; Norris, 4.

131

Norris, 4.

132

Ibid.

133

Sataloff, 58; Ibid., 63; Horvath, 38; Norris, 5; Ibid., 87.

134

Sataloff, 58.

135

Ibid., 63.

32

of the hand.136

Short or long fingers pose similar problems to those of thumb length and

joint laxity in that it may be difficult to reach around the instrument or compensation may

need to take place. Slender wrists provide narrow passageways for the nerves and

tendons and could possibly cause inflammation from any irritation to the area.137

Long

arms create the potential risk of cubital tunnel syndrome due to the amount of time and

angle in which the elbow must be bent while playing clarinet.138

Tendinous

interconnection is a condition in which the flexor tendons of the ring and pinky fingers

are connected within the forearm or wrist. This connection can cause difficulty and pain

when trying to use the ring and pinky fingers independently, which clarinetists do

often.139

According to studies, young women are more at risk for developing injuries than

men. The reason is unknown, but it is speculated that women’s muscles are often smaller

and thus lack strength and endurance, causing them to be more susceptible. This is most

likely due to the effort required of the fingers, hands, or the weight of carrying the

instrument and its case.140

Instruments or equipment set9ups that require excessive force to be played can

also lead to injury. Leaking instruments, overly hard reeds, or poor quality mouthpieces

require a great amount of effort from the performer. This can cause tension throughout

the face, neck, back, and arms, and can overwork these muscles leading to many kinds of

injury.141

Musicians often do not have control of environmental factors such as the

temperature of the room, stage placement, and lighting.142

Feeling cold while playing

136

Ibid.

137

Norris, 5.

138

Sataloff, 213.

139

Norris, 88.

140

Ibid., 5.

141

Ibid.

142

Horvath, 33.

33

causes muscles to contract and may make a musician susceptible to injury.143

Stage

placement is a risk that can create excess tension and hearing loss. If the space is

crowded, musicians do what is necessary to see both the music and the conductor, such as

leaning to one side while playing. It is also evident, shown by half of professional

classical musicians, that hearing loss can occur because of the close proximity to the

other ensemble members, particularly percussion and brass instruments.144

Poor lighting

conditions can hinder productivity and produce fatigue. Natural lighting that is not too

bright is the best light source for the eyes, but is rarely available in an ensemble setting.

The optimal lighting option for rehearsal situations is “general electric lighting” (ceiling9

based, white, warm fluorescent lighting), whereas the least is “local lighting” (light

attached to the music stand).145

Asymmetric muscle development is a problem among instrumentalists that can

increase the risk of injury. The biggest problem among clarinetists is the over9

development that occurs from holding the instrument with just the right hand. These

muscles may be exercised for several hours a day while the other side does not carry any

of the weight and requires different movements. If the muscles are not compensated with

exercise, then the risk of injury increases.146

Stress can originate from many sources—personal responsibilities, professional

expectations, and psychological traits—and may cause serious health consequences.147

Any stress, regardless of origin, not only affects a person emotionally, but also reduces

the control of fine motor skills due to the constriction of blood vessels and superficial

breathing, leaving muscles and nerves with an insufficient oxygen supply.148

It is

important to recognize the factors that may cause stress, even those that are not directly

related to music performance. Personal responsibilities including relationships, raising

143

Ibid., 23.

144

Ibid., 33; Llobet, 59.

145

Llobet, 5697.

146

Ibid., 25; Horvath, 39.

147

Horvath, 20; Sataloff, 29; Llobet, 29; Watson, 332.

148

Watson, 332; Horvath, 39.

34

children, and financial obligations, can be stressful at times, and can also affect other

aspects of life such as quality and quantity of sleep.149

Performance expectations set by

the performer, teacher, or conductor are continually rising and often lead to over9

practicing.150

Extreme traits of perfectionism, perseverance, sensitivity, introspection,

and tendencies of depression can not only contribute to injury, but also increase pain and

prolong illnesses and injuries.151

149

Horvath, 39.

150

Sataloff, 29.

151

Llobet, 29; Horvath, 21.

35

CHAPTER 5

TREATME�T A�D PREVE�TIO� METHODS

There are many effective options for treating and preventing injury (other than the

injury9specific treatments discussed in Chapter 3). Some musicians choose to seek help

from a physician while others explore alternative therapies and health philosophies. All

are valid options, and while one method works well for one person, another may better

suit someone else. Methods used in traditional and modern medicine will be briefly

discussed as well as definitions of alternate therapies, health philosophies, and body

awareness methods.

Traditional and Modern Medicine

Depending on the injury and its severity, medical treatment of injuries include

rest, medication, ice and heat therapy, corrective exercises, splinting, instrument and

schedule modification, and specialist or therapist referrals.152

Conservative measures are

always pursued prior to discussing more serious forms of treatment such as injections and

surgery.153

Rest is considered to be the most important component to a treatment plan.154

Severe injuries require absolute rest from playing and other activities that may irritate the

affected area until the pain subsides or is minimal, whereas minor injuries usually require

relative rest and shorter practice periods. 155

Regardless of the severity of a person’s

152

Dawson, 9.

153

Sataloff, 216.

154

Ibid., 76.

155

Ibid., 7697; Llobet, 102.

36

injury, playing and performing should be immediately decreased and gradually increased

with short practice periods and many breaks. If symptoms and/or pain have not subsided

after one week, the consulting physician should be notified. 156

Medication including anti9inflammatory drugs and steroids are often prescribed to

relieve inflammation or pain.157

Some over9the9counter medications, such as aspirin and

ibuprofen, provide relief for both, but there are also prescriptions that focus on one or the

other.158

These are usually administered orally but can also be injected into the problem

area if all other conservative measures have failed.159

Ice therapy is often effective to ease pain and inflammation. Placing cold packs

or ice on the effected area reduces the blood flow and numbs the nerve endings, causing

the pain and inflammation to be reduced. Application time should correspond with the

depth of the injury – for small9framed areas (finger or lips) the application time should be

limited to five minutes and larger areas (hip or knee) may take as long as twenty minutes

before the effects are felt. The skin should never come in direct contact with the cold

source; there should always be a cloth between the two. To obtain all of its benefits, it is

important to feel a burning sensation and slight pain followed by stiffness and numbness

before removing the ice pack.160

Heat therapy “relaxes the tissues, decreases joint stiffness, reduces pain, relieves

muscle spasm and increases blood flow.”161

Hot packs or electric heat pads should be

applied between fifteen and twenty minutes in length and checked every five minutes to

prevent burns. It should not be used immediately following an injury, on swollen areas, a

skin injury, or open wound.162

156

Llobet, 102.

157

Sataloff, 211.

158

Llobet, 104.

159

Sataloff, 211.

160

Llobet, 101.

161

Ibid.

162

Ibid.

37

To prevent injuries, alleviate pain, and achieve the highest quality of performance,

it is recommended to first warm9up the body by performing flexibility exercises,

stretches, and/or corrective exercises. The purpose is to improve performance and

elasticity of the muscles, warm9up muscles, tendons and joints, prevent fatigue, prevent

injuries, and correct posture.163

Specific exercises and stretches may be distributed by a

physician to benefit the needs of an individual. General examples helpful for all

musicians to use in their warm9up can be found in many sources including Barbara Paull

and Christine Harrison’s The Athletic Musician: A Guide to Playing Without Pain and

Jaume Rosset I Llobet and George Odam’s The Musician’s Body: A Maintenance Manual

for Peak Performance.

Immobilizing problem areas with braces or splints provides rest and protection for

the area. These are designed to limit movement and stabilize joints.164

The

recommended period of time to use braces or splints is two to three weeks for areas such

as the hand and arm to prevent stiffness from occurring in the joints. Sufferers of TMJ

who have tendencies of bruxism should continue to use a splint or night guard to prevent

damage to teeth and keep symptoms from returning.165

To assist in the healing and preventive process, it is advisable to modify the

instrument and adjust the practice schedule in order to reduce stress on the body. Since

the weight of the clarinet rests on the right thumb, adding an adjustable thumb rest or

neck strap can decrease the stress on the right hand.166

One must be careful, however,

that the neck strap does not create additional tension in the neck. Breaks should be

incorporated frequently into practice and performance schedules. If recovering from an

injury, it is recommended to reintroduce practicing with two five9minute sessions with an

hour break between the two. Gradually increasing the playing time and decreasing the

break time over a period of a few weeks should allow a full recovery, which will

163

Llobet, 92; Dawson, 9.

164

Dawson, 42.

165

Sataloff, 208; Llobet, 103; Sataloff, 16091.

166

Sataloff, 58.

38

eventually permit 259minute practice sessions with five9minute breaks that should be

continued after recovery as a preventive measure.167

Physicians may recommend consultation with a specialist such as an orthopedic

and hand surgeon, rheumatologist, neurologist, podiatrist, physiatrist (rehabilitation

specialist), psychiatrist, or physical or occupational therapist. Health professionals who

specialize in performing arts medicine are becoming more abundant. Additionally, there

are full9service performing arts medicine clinics that can be found in over twenty United

States cities.168

Alternative Therapies and Health Philosophies

Many musicians often do not seek medical attention when suffering with pain, as

shown in the results of the survey taken for this project: 83% of the clarinetists

experienced pain and only 21% sought medical attention. It is common, however, for

musicians to search for practitioners of alternative therapies and health philosophies, as

they are perceived as more familiar with the emotional and physical needs of

musicians.169

These alternative therapies and health philosophies include osteopathic,

chiropractic, and naturopathic physicians; therapists who specialize in massage, dietary

manipulations, and reflexology; and practitioners of body awareness techniques such as

the Alexander Technique, Autogenic Therapy, Feldenkrais Method, and Yoga.170

An Osteopathic Physician (DO) is a fully9licensed medical doctor who focuses on

treating the “whole person” to prevent or treat illness, disease, and injury. 171

Their

training and practice emphasizes “the inter9relationship of the body's nerves, muscles,

bones and organs,” and checks these structural elements during examinations.172

DOs

167

Llobet, 103.

168

Dawson, 9.

169

Dawson, 8.

170

Ibid.

171

“Osteopathic Medicine,” American Osteopathic Association, http://www.osteopathic.org/

index.cfm?pageid=ost_omed (accessed February 9, 2010).

172

Ibid.

39

undergo education similar to medical doctors, are trained to be primary care physicians,

and may practice a specialty.173

Chiropractic physicians focus on the musculoskeletal and nervous systems, and

mostly treat “back pain, neck pain, pain in the joints of the arms or legs, and

headaches.”174

Chiropractors treat patients by utilizing “spinal manipulation,” or

“chiropractic adjustment,” therapeutic and rehabilitative exercises, nutritional, dietary

and lifestyle counseling.175

Naturopathic Medicine is considered to be “a safe, effective, and cost effective

natural healthcare.”176

Naturopathic physicians (NDs) believe the human body has a

powerful ability to self9heal and uses modern medical science and traditional natural

medicine to heal and restore patients’ health. Naturopathic medicine is based on six

principles: let nature heal; identify and treat causes, not symptoms; do no harm by using

low9risk procedures and healing compounds; educate patients; treat the whole person;

prevent illness.177

Massage therapy is becoming increasingly popular for treating muscular pain and

can be recommended by a physician. Therapeutic massage is intended to release tension

in the muscles, increase circulation, and it has also been reported to give the patient a

feeling of “well9being.”178

Massage therapists do not undergo the same intense training

as other types of therapists, but some people prefer massage therapy.179

Dietary changes for medical purposes have become more popular in the last few

decades. It is proven through multiple studies that certain diets, supplements, and herbs

173

Ibid.

174

“What is Chiropractic?” American Chiropractic Association, http://www.acatoday.org/

level2_css.cfm?t1id=13&t2id=61 (assessed February 10, 2010).

175

Ibid.

176

“About Naturopathic Medicine,” American Association of Naturopathic Physicians,

http://www.naturopathic.org/content.asp?pl=16&contentid=16 (accessed February 10, 2010).

177

“What is Naturopathic Medicine?” American Association of Naturopathic Physicians,

http://www.naturopathic.org/content.asp?pl=16&sl=59&contentid=59 (accessed February 10, 2010).

178

Dawson, 98.

179

Ibid.

40

have some medical benefits. Physicians may recommend certain practitioners of dietary

therapy, but it worthy to note that some methods may provoke adverse effects.180

Reflexology is based on the principle that there are “reflex areas in the hands and

feet, which correspond to all of the glands, organs, and parts of the body.”181

Manual

pressure is applied to the reflex areas to stimulate the body’s “bioelectrical energy,” or

sends impulses to body organs via “some type of pathway.”182

People who experience a

reflexology session often feel relaxed, as if they just had a massage.183

Body Awareness Methods

A different study, regarding health attitudes, preventive behavior, and playing9

related health problems among music students at the Freiburg Conservatory, reports

thirty9five percent of the sample claimed to use one or more body awareness method,

most of which were continued after healing as a preventative measure.184

According to

this survey, the most popular of these methods are Alexander Technique, Autogenic

Therapy, Feldenkrais Method, and Yoga.

The Alexander Technique (AT) is a method “that focuses on improving your

awareness of how you move to increase your ease of movement” and release unnecessary

tension.185

One of the primary disciplines is Primary Control, which stresses that the

“neck and head relationship leads quality of motion and response – and this determines

the success of results for good or ill.”186

AT is widely known among musicians and has

180

Ibid., 104.

181

“Facts About Reflexology,” International Institute of Reflexology, http://www.reflexology9

usa.net/facts.htm (accessed February 11, 2010).

182

Dawson, 103.

183

Ibid.

184

Claudia Spahn, Bernhard Richter, and Ina Zschocke, "Health attitudes, preventive behavior,

and playing9related health problems among music students," Medical Problems of Performing Artists 17,

no. 1 (March 2002): 22.

185

“What is the Alexander Technique and What Are the Benefits?” The Complete Guide to the

Alexander Technique, http://www.alexandertechnique.com/at.htm (accessed February 11, 2010).

186

Franis Engel, “The Alexander Technique – What is it?” http://www.alexandertechnique.com/

articles/engel/ (accessed February 20, 2010).

41

helped many improve their body9usage while playing their instrument. By improving the

quality of physical movements, it has helped many musicians recover from injury,

prevent injury, perform more comfortably, and reduce stress.187

Another method of body awareness is Autogenic Therapy, a form of

psychotherapy developed by German psychiatrist and neurologist Dr. Johannes Schultz,

and is “based on the mind/body relationship, engaging mental, and bodily functions

simultaneously.”188

This is a self9generated method of healing that resembles meditation.

Patients are first guided through verbal cues and are eventually able to practice this

therapy on their own.189

These verbal cues induce relaxation by feeling “heaviness in the

musculo9skeletal system, warmth in the circulatory system,” and “awareness of the

heartbeat, breathing, the abdomen and a cool forehead.”190

It is claimed that not only

does Autogenic Therapy improve healing but it also helps manage emotions.191

The Feldenkrais Method was developed as a rehabilitation technique to “improve

the range of body motion and to aid flexibility, coordination, and function.”192

The

program involves verbal and hands9on guidance from the practitioner and uses directions

including thinking, sensing, meditating, and imagining. Some people who have suffered

with neuromuscular disorders, such as multiple sclerosis, stroke, spinal injury, and motor

disorders have experienced success with this method.193

A more widely known method to most people is Yoga, an Eastern discipline that

encompasses many different practices or philosophies. The common thread among these

is the goal to attain nirvana, “enlightenment and complete freedom from tensions,” by

187

“What is the Alexander Technique and What Are the Benefits?” The Complete Guide to the

Alexander Technique, http://www.alexandertechnique.com/at.htm (accessed February 11, 2010).

188

Alice Greene and Ann Bowden, “Autogenic Therapy and Training Overview,” British

Autogenic Society, http://www.autogenic9therapy.org.uk/0001/news909.htm (accessed February 12, 2010).

189

Ibid.

190

Telka Kosa, “What is Autogenic Training?” http://www.autogenictraining.org/what9is9at.html

(accessed February 12, 2010).

191

Ibid.

192

Dawson, 101.

193

Ibid.

42

focusing on posture, breathing, and meditation.194

Yoga is often used in conjunction with

traditional treatment methods to strengthen the body and release tension.195

The treatment and prevention options seem endless when looking at several at

once. It is important to remember that each individual responds differently to treatment

and prevention methods and may prefer one method over another. This is truly an

individual process and may take some experimentation before finding a successful

treatment or prevention method.

194

Ibid.

195

Ibid.

43

CHAPTER 6

CO�CLUSIO�S

Conducting the survey and research for this project has been an eye9opening

experience. Prior to the survey, I expected many clarinetists to have experienced pain

and/or numbness, but I had no idea that 83% of clarinetists are currently suffering in pain

and 37% with numbness. These staggering results have inspired me to make my personal

mission to continue my research in this field and increase awareness of the importance of

injury prevention.

The most popular location of pain was the wrist, which did not surprise me

considering the weight of the clarinet solely rests on the right hand and the effort used

while playing the instrument requires so much repetitive motion. What did surprise me

was the low amount of respondents (21%) who sought medical attention. It amazed me

that the majority of people who were in pain while performing a task that is most likely

needed for their future career did not go to the doctor. It seems as though it is the norm

to deal with the pain. Considering how unhealthy this is, I feel more awareness of

injuries is needed.

Within my clarinet studio, I teach a variety of stretches, relaxation techniques, and

body mapping principles. These are subsequently applied to playing the clarinet. Some

problems I have seen include a large amount of tension in the face, shoulders, hands,

chest, and legs. By learning how to release these tensions, I feel it frees the body and

allows for more expression of the music.

It is fair to say that considering the majority of college clarinetists are in pain, the

issue of prevention needs to be addressed. I believe injury prevention methods should be

discussed within the college curriculum for all instrumentalists and practiced regularly.

In conjunction with this additional curriculum, body mapping (reeducation of the body),

and instrument application should also be incorporated.

44

APPE�DIX A

CLARI�ETISTS’ I�JURY GUIDE BY LOCATIO� OF PAI� OR �UMB�ESS

45

LOCATIO� OF PAI�

OR �UMB�ESS

POSSIBLE I�JURIES PAGE

Jaw Temporomandibular Joint Dysfunction (TMJ) 14

Hand Carpal Tunnel Syndrome 10

Trigger Finger 15

Cubital Tunnel Syndrome 18

Thoracic Outlet Syndrome 21

Ganglion Cyst 23

Arthritis 25

Focal Dystonia 25

Overuse Syndrome 27

Thumb Carpal Tunnel Syndrome 10

Trigger Finger 15

De Quervain’s Disease 17

Arthritis 25

Overuse Syndrome 27

Fingers Carpal Tunnel Syndrome 10

Trigger Finger 15

Cubital Tunnel Syndrome 18

Arthritis 25

Focal Dystonia 25

Forearm Tendinitis 9

Carpal Tunnel Syndrome 10

Overuse Syndrome 27

Arm Thoracic Outlet Syndrome 21

Myofacial Pain Syndrome 24

Back Temporomandibular Joint Dysfunction (TMJ) 14

Myofacial Pain Syndrome 24

Arthritis 25

Elbow Cubital Tunnel Syndrome 18

Tennis Elbow 20

Shoulder Bursitis 20

Thoracic Outlet Syndrome 21

Embouchure Focal Dystonia 25

46

APPE�DIX B

CLARI�ETISTS’ I�JURY GUIDE BY SYMPTOMS

47

I�JURY SYMPTOMS PAGE

Tendinitis 7 pain and inflammation surrounding

tendons (usually of the forearm)

9

Carpal Tunnel Syndrome 7� numbness, tingling, pain, aching,

burning, limited range of motion,

and in extreme cases muscle atrophy

7� these symptoms usually occur in the

thumb, index finger, middle finger,

and half of the ring finger

7� discomfort has also been reported in

the forearm, upper arm, armpit,

shoulder, and neck.

7� symptoms often occur during the

night or morning.

10

Temporomandibular Joint

Dysfunction (TMJ)

7� include headaches, hearing loss and

ear pain, blurred vision, backaches,

jaw clicking, sore and tight jaws,

facial pain, locking of the jaw, and

worn teeth

14

Trigger Finger 7� difficulty straightening a finger

7� a “popping” sound when

straightening a finger

15

De Quervain’s Disease 7� pain at the base of the thumb while

stationary or engaged in movement

17

Cubital Tunnel Syndrome 7� pain of the elbow, numbness and

tingling in the pinky side of the hand,

and muscle atrophy

7� bending the elbow, wrist, or

individual fingers may provoke

symptoms

18

Bursitis (of the shoulder) 7� pain that radiates down the arm and

possible movement restriction when

lifting the arm

20

Tennis Elbow 7� pain and inflammation surrounding

the elbow

20

Thoracic Outlet Syndrome 7� pain, paresthesias (burning or

tingling feeling), paresis (partial

paralysis), muscle fatigue, cramping,

cold sensation, pallor (paleness),

swelling, cyanosis (bluish

discoloration of the skin), fatigue,

heaviness, and aching of the arm

7� symptoms of TOS are positional and

can be provoked by elevating the

arm or placing it behind the body

21

48

Ganglion Cyst 7� lump under the skin on the top of the

wrist

7� may cause aching, weakness, pain

23

Myofacial Pain Syndrome 7� chronic pain in the ligaments,

tendons, and muscles

7� pain often occurs at specific areas of

the body called trigger points

7� pain has been described as deep

musculuar aching, soreness and

stiffness

7� muscle weakness, swelling,

tightness, numbness, and tingling

have also been reported

24

Arthritis 7 inflammation and pain of the joints 25

Focal Dystonia 7� involuntary movements of the

embouchure, hand, or fingers while

playing

25

Overuse Syndrome 7� aching in the forearm or pain in the

hand

7� can escalate to pain in the forearm

and shoulder

27

49

APPE�DIX C

HUMA� SUBJECTS COMMITTEE APPROVAL

50

Human Subjects Committee

Tallahassee, Florida 3230692742

(850) 64498673 · FAX (850) 64494392

APPROVAL MEMORANDUM

Date: 10/14/2009

To: Jacqueline McIlwain

Dept.: MUSIC SCHOOL

From: Thomas L. Jacobson, Chair

Re: Use of Human Subjects in Research

The Top Five Injuries Among College Clarinetists: Definitions, Causes, Treatments, and

Prevention Methods

The application that you submitted to this office in regard to the use of human subjects in

the proposal referenced above have been reviewed by the Secretary, the Chair, and two

members of the Human Subjects Committee. Your project is determined to be Expedited

per 45 CFR § 46.110(7) and has been approved by an expedited review process.

The Human Subjects Committee has not evaluated your proposal for scientific merit,

except to weigh the risk to the human participants and the aspects of the proposal related

to potential risk and benefit. This approval does not replace any departmental or other

approvals, which may be required.

If you submitted a proposed consent form with your application, the approved stamped

consent form is attached to this approval notice. Only the stamped version of the consent

form may be used in recruiting research subjects.

If the project has not been completed by 10/13/2010 you must request a renewal of

approval for continuation of the project. As a courtesy, a renewal notice will be sent to

you prior to your expiration date; however, it is your responsibility as the Principal

Investigator to timely request renewal of your approval from the Committee.

You are advised that any change in protocol for this project must be reviewed and

approved by the Committee prior to implementation of the proposed change in the

protocol. A protocol change/amendment form is required to be submitted for approval by

the Committee. In addition, federal regulations require that the Principal Investigator

promptly report, in writing any unanticipated problems or adverse events involving risks

to research subjects or others.

By copy of this memorandum, the Chair of your department and/or your major professor

is reminded that he/she is responsible for being informed concerning research projects

51

involving human subjects in the department, and should review protocols as often as

needed to insure that the project is being conducted in compliance with our institution

and with DHHS regulations.

This institution has an Assurance on file with the Office for Human Research Protection.

The Assurance Number is IRB00000446.

Cc: Frank Kowalsky, Advisor

HSC No. 2009.3366

52

APPE�DIX D

HUMA� SUBJECTS COMMITTEE APPROVAL (CHA�GE I� RESEARCH

PROTOCOL)

53

Office of the Vice President For Research

Human Subjects Committee

Tallahassee, Florida 3230692742

(850) 64498673 · FAX (850) 64494392

APPROVAL MEMORANDUM (for change in research protocol)

Date: 11/10/2009

To: Jacqueline McIlwain

Dept.: MUSIC SCHOOL

From: Thomas L. Jacobson, Chair

Re: Use of Human Subjects in Research (Approval for Change in Protocol)

Project entitled: Common Injuries Among College Clarinetists: Definitions, Causes,

Treatments, and Prevention Methods

The form that you submitted to this office in regard to the requested change/amendment

to your research protocol for the above9referenced project has been reviewed and

approved.

Please be reminded that if the project has not been completed by 10/13/2010, you must

request renewed approval for continuation of the project.

By copy of this memorandum, the chairman of your department and/or your major

professor is reminded that he/she is responsible for being informed concerning research

projects involving human subjects in the department, and should review protocols as

often as needed to insure that the project is being conducted in compliance with our

institution and with DHHS regulations.

This institution has an Assurance on file with the Office for Human Research Protection.

The Assurance Number is IRB00000446.

Cc: Frank Kowalsky, Advisor

HSC No. 2009.3638

54

APPE�DIX E

SURVEY

55

1.� Rate the average level of pain or discomfort you have experienced while playing

your instrument in the last month. If you choose a, go to question 3.

a.� I did not experience pain

b.� Mild

c.� Moderate

d.� Severe

e.� Excruciating

2.� If you have experienced pain or discomfort while playing your instrument in the

last month, where did it occur?

a.� Jaw

b.� Hand

c.� Thumb

d.� Wrist

e.� Forearm

f.� Elbow

g.� Upper arm

h.� Shoulder

i.� Neck

j.� Back

k.� Other ________________

3.� Rate the average degree of numbness you have experienced while playing your

instrument in the last month. If you choose a, go to question 5.

a.� I did not experience numbness

b.� Mild

c.� Moderate

d.� Severe

e.� Debilitating

4.� If you have experienced numbness while playing your instrument in the last

month, where did it occur?

a.� I did not experience numbness

b.� Jaw

c.� Hand

d.� Thumb

e.� Wrist

f.� Forearm

g.� Elbow

h.� Upper arm

i.� Shoulder

j.� Neck

k.� Back

l.� Other ________________

56

5.� Have you ever been diagnosed with a condition that includes symptoms of pain,

discomfort, or numbness while playing your instrument? If you choose b, go to

question 7.

a.� Yes

b.� No

6.� If yes, what was the diagnosis?

a.� Carpal Tunnel Syndrome

b.� Cubital Tunnel Syndrome

c.� Tendinitis

d.� Thoracic Outlet Syndrome

e.� Temporomandibular Joint Dysfunction (TMJ)

f.� Focal Dystonia

g.� Bursitis

h.� Trigger Finger

i.� de Quervain’s Syndrome

j.� Other _______________________

7.� If you have sought medical attention for pain or numbness associated with playing

your instrument, what treatment(s) did you receive? If you choose a, go to

question 10.

a.� I did not seek medical attention

b.� Physical therapy

c.� Occupational therapy

d.� Stretch regimen

e.� Medication

f.� Surgery

g.� Other ________________________

8.� If you sought medical attention for pain caused by playing your instrument and

received treatment for it, did the pain persist after treatment?

a.� Yes

b.� No

9.� If you sought medical attention for numbness caused by playing your instrument

and received treatment for it, did it heal your numbness?

a.� Yes

b.� No

10.�Over the last week, how many days did you play your instrument?

a.� None

b.� 192 days

c.� 394 days

d.� 596 days

e.� 7 days

57

11.�Over the last week, how many hours per day did you play your instrument?

a.� None

b.� Less than 1 hour

c.� 192 hours

d.� 394 hours

e.� 596 hours

f.� More than 7 hours

12.�What is your gender?

a.� Male

b.� Female

13.�Rate your stress level over the last week.

a.� Very little

b.� Low

c.� Medium

d.� High

e.� Very high

14.�What year in school are you?

a.� Freshman

b.� Sophomore

c.� Junior

d.� Senior

e.� First year Master’s

f.� Second year or later Master’s

g.� First Year Doctoral

h.� Second Year Doctoral

i.� Third Year or later Doctoral

58

APPE�DIX F

CO�SE�T FORM

59

This survey is the first step of a project to determine clarinetists’ injuries. Since there are

limited resources for clarinetists who suffer with pain or discomfort due to playing their

instrument, this project will serve as a source and guide with a listing of common clarinet

injuries among university and college students, their definitions, causes, treatments, and

prevention methods. As a clarinetist yourself, this research may become useful in the

future as a performer and/or educator, or could shed light on different treatments if you

currently have an ailment due to the clarinet. The risks of completing this survey are

minimal and may include answering medical questions. All participants must be 18 years

of age or older.

The following survey will take no more than five minutes of your time. To complete the

survey, please answer each question by clicking on the button next to the corresponding

answer. If applicable, you may have two or more answers per question. All surveys are

anonymous and the data gathered will be kept in the strictest confidence to the extent

allowed by law and protected by a password entry. If you choose to participate or

discontinue your participation, there will be no penalty whatsoever and this will be

considered your refusal of consent. By clicking the ‘next’ button, you are affirming that

you understand the benefits and minimal risks of this survey and that you are the age of

18 or older.

If you have questions regarding this research and your rights during this project, you can

contact me, Jackie McIlwain, via phone (615.406.7967) or e9mail (jko07c@fsu.edu). My

major professor is also available at 850.644.5813 or kowalsky@fsu.edu, as well as the

Institutional Review Board at 850.64.7900 or jth5898@fsu.edu.

Thank you for you time.

60

BIBLIOGRAPHY

“About Podiatry.” American Podiatric Medical Association. http://www.apma.org/

mainmenu/aboutpodiatry.aspx (accessed February 10, 2010).

“About Naturopathic Medicine.” American Association of Naturopathic Physicians.

http://www.naturopathic.org/content.asp?pl=16&contentid=16 (accessed February

10, 2010).

Andrews, Elizabeth. Muscle Management for Musicians. Lanham, MD: Scarecrow Press,

2005.

Bengtson, Keith A., and Ann H. Schutt. Medical Problems of Performing Artists 7, no. 2

(July 1992): 44947.

Berger, M. R. and Avrum I. Froimson. "Hands that Hurt: Carpal Tunnel Syndrome." The

American Journal of 3ursing 79, no. 2 (Feb., 1979): 2649266.

Brandfonbrener, Alice G. “Joint Laxity and Arm Pain in a Large Clinical Sample of

Musicians.” Medical Problems of Performing Artists 17, no. 3 (Sept 2002): 1139115.

________. “Joint Laxity and Arm Pain in a Large Clinical Sample of Musicians.

(Report).” Medical Problems of Performing Artists 15, no. 2 (June 2000): 72974.

________. "Performing Arts Medicine: An Evolving Specialty." Music Educators

Journal 77, no. 5, Special Focus: Music Education and Medicine (Jan., 1991): 37941.

Butler, Sharon J. Conquering Carpal Tunnel Syndrome and Other Repetitive Strain

Injuries: A Self(Care Program. Oakland, CA: New Harbinger Publications, 1996.

Dawson, William J. “Hand and Upper Extremity Problems in Musicians: Epidemiology

and Diagnosis.” Medical Problems of Performing Artists 3, no. 1 (March 1988): 199

22.

________. "Playing without Pain: Strategies for the Developing Instrumentalist." Music

Educators Journal 93, no. 2 (Nov. 1, 2006): 36941.

________. "The Role of Surgery in Treating Upper Extremity Problems in Musicians."

Medical Problems of Performing Artists 7, no. 2 (July 1992): 59962.

61

________. “Upper Extremity Injuries in High9level Instrumentalists: An End9result

Study.” Medical Problems of Performing Artists 5, no. 2 (June 1990): 1099112.

________. and MENC, The National Association for Music Education (U.S.). Fit as a

Fiddle: The Musician's Guide to Playing Healthy. Lanham, MD: Rowman &

Littlefield Education, 2008.

De Alcantara, Pedro. Indirect Procedures: A Musician’s Guide to the Alexander

Technique. New York: Oxford University Press, 1997.

Franis Engel, “The Alexander Technique – What is it?” http://

www.alexandertechnique.com/articles/engel/ (accessed February 20, 2010).

“Facts About Reflexology.” International Institute of Reflexology.

http://www.reflexologyusa.net/facts.htm (accessed February 11, 2010).

Frederickson, Karen B. "Fit to Play: Musicians' Health Tips." Music Educators Journal

88, no. 6 (May, 2002): 38944.

Fry, Hunter J. H. "How to Treat Overuse Injury: Medicine for Your Practice." Music

Educators Journal 72, no. 9 (May, 1986): 46949.

Goode, David J. and Sarah9Patsy Knight. “Identification, Retrieval, and Analysis of Arts

Medicine Literature.” Medical Problems of Performing Artists 6, no. 1 (March

1991): 397.

Goodman, Glenn and Sheryl Staz. “Occupational Therapy for Musicians with Upper

Extremity Overuse Syndrome: Patient Perceptions Regarding Effectiveness of

Treatment.” Medical Problems of Performing Artists 4, no. 1 (March, 1989): 9914.

Greene, Alice and Ann Bowden. “Autogenic Therapy and Training Overview.” British

Autogenic Society. http://www.autogenic9therapy.org.uk/0001/news909.htm

(accessed February 12, 2010).

Horvath, Janet. Playing (Less) Hurt: An Injury Prevention Guide for Musicians. Kearney,

NE: Morris Publishing, 2002.

Jabusch, Hans9Christian, and Eckart Altenmuller. “Anxiety as an Aggravating Factor

During Onset of Focal Dystonia in Musicians.” Medical Problems of Performing

Artists 19, no. 2 (June 2004): 75981.

Knishkowy, Barry and Richard J. Lederman. “Instrumental Musicians with Upper

Extremity Disorders: A Follow9up Study.” Medical Problems of Performing Artists

1, no. 3 (Sep. 1986): 85989.

62

Kosa, Telka. “What is Autogenic Training?” http://www.autogenictraining.org/what9is9

at.html (accessed February 12, 2010).

Lederman, Richard J. “Entrapment Neuropathies in Instrumental Musicians.” Medical

Problems of Performing Artists 8, no. 2 (June, 1993): 35940.

________. “Nerve Entrapment Syndromes in Instrumental Musicians.” Medical

Problems of Performing Artists 1, no. 2 (June, 1986): 45948.

________ and Leonard H. Calabrese, D.O. “Overuse Syndromes in Instrumentalists.”

Medical Problems of Performing Artists 1, no. 1 (March, 1986): 7911.

Llobet, Jaume Rosset i and George Odam. The Musician’s Body: A Maintenance Manual

for Peak Performance. London: The Guildhall School of Music and Drama, 2007.

Manchester, Ralph A. “The Incidence of Hand Problems in Music Students.” Medical

Problems of Performing Artists 3, no. 1 (March 1988): 15918.

Mayers, Hillary and Linda Babits. "A Balanced Approach: The Alexander Technique."

Music Educators Journal 74, no. 3, Focus: Music and Movement (Nov., 1987): 519

54.

Montgomery, Kate. End Your Carpal Tunnel Pain Without Surgery: The Montgomery

Method. Boulder, CO: Sports Touch, 2004.

Morse, Tim, Jennifer Ro, Martin Cherniack, and Stephen R. Pelletier. “A Pilot Population

Study of Musculoskeletal Disorders in Musicians. (Report).” Medical Problems

Artists 15, no. 2 (June 2000): 81985.

Nolan, William B. and Richard G. Eaton. “Thumb Problems of Professional Musicians.”

Medical Problems of Performing Artists 4, no. 1 (March 1989): 20924.

Norris, Richard. The Musician’s Survival Manual: A Guide to Preventing and Treating

Injuries in Instrumentalists. Saint Louis: MMB Music, 1993.

Novak, Christine B. “Conservative Management of Thoracic Outlet Syndrome in the

Musician.” Medical Problems of Performing Artists 8, no. 1 (March 1993): 16921.

“Osteopathic Medicine.” American Osteopathic Association. http://www.osteopathic.org/

index.cfm?pageid=ost_omed (accessed February 9, 2010).

Ostwald, Peter. “Historical Perspectives on the Treatment of Performing and Creative

Artists.” Medical Problems of Performing Artists 9, no. 4 (December 1994): 1139

118.

63

“Pain Management: Temporomandibular Disorders.” WebMD. http://www.webmd.com/

pain9management/guide/temporomandibular9disorders (accessed December 17,

2009).

Pascarelli, Emil and Deborah Quilter. Repetitive Strain Injury: A Computer User’s Guide.

Hoboken, NJ: John Wiley and Sons, 1994.

Pascarelli, Emil. Dr. Pascarelli’s Complete Guide to Repetitive Strain Injury: What You

3eed to Know About RSI & Carpal Tunnel Syndrome. Hoboken, NJ: John Wiley and

Sons, 2004.

Paull, Barbara and Christine Harrison. The Athletic Musician: A Guide to Playing

Without Pain. Lanham, MD: The Scarecrow Press, 1997.

Quarrier, Nicholas F. “Survey of Music Teachers: Perceptions of Music9related Injuries.”

Medical Problems of Performing Artists 10, no. 3 (September 1995): 1069110.

Roach, Kathryn E., Marcelo A. Martinez, and Nicole Anderson. “Musculoskeletal Pain in

Student Instrumentalists: A Comparison with the General Student Population.”

Medical Problems of Performing Artists 9, no. 4 (December 1994): 1259130.

Roos, David B. “Thoracic Outlet Syndromes: Symptoms, Diagnosis, Anatomy and

Surgical Treatment.” Medical Problems of Performing Artists 1, no. 3 (September

1986): 90993.

Sataloff, Robert Thayer, Alice G. Brandfonbrener and Richard J. Lederman, eds.

Textbook of Performing Arts Medicine. New York: Raven Press, 1991.

Schuele, Stephan, and Richard J. Lederman. "Focal Dystonia in Woodwind

Instrumentalists: Long9term Outcome." Medical Problems of Performing Artists 18,

no. 1 (March 2003): 1596.

Smutz, W. Paul, Allen Bishop, Howard Niblock, Maria Drexler, and Kai9Nan An. “Load

on the Right Thumb of the Oboist.” Medical Problems of Performing Artists 10, no.

3 (September 1995): 94999.

Spahn, Claudia, Bernhard Richter, and Ina Zschocke. "Health attitudes, preventive

behavior, and playing9related health problems among music students." Medical

Problems of Performing Artists 17, no. 1 (March 2002): 2298.

Thrasher, Michael and Kris S. Chesky. “Medical Problems of Clarinetists: Results from

the University of North Texas Musician Health Survey.” The Clarinet 25, no. 4

(July/August 1998): 24927.

Trollinger, Valerie. "Performing Arts Medicine and Music Education: What Do We

Really Need to Know?" Music Educators Journal 92, no. 2 (Nov., 2005): 42948.

64

Watson, Alan H.D.. The Biology of Musical Performance and Performance(Related

Injury. Lanham, MD: The Scarecrow Press, 2009.

“What is the Alexander Technique and What Are the Benefits?” The Complete Guide to

the Alexander Technique. http://www.alexandertechnique.com/at.htm (accessed

February 11, 2010).

“What is Chiropractic?” American Chiropractic Association http://www.acatoday.org/

level2_css.cfm?t1id=13&t2id=61 (assessed February 10, 2010).

“What is Naturopathic Medicine?” American Association of Naturopathic Physicians.

http://www.naturopathic.org/content.asp?pl=16&sl=59&contentid=59 (accessed

February 10, 2010).

Zaza, Christine. “Prevention of Musicians’ Playing9Related Health Problems: Rationale

and Recommendations for Action.” Medical Problems of Performing Artists 8, no. 4

(December 1993): 1179121.

__________. “Research9Based Prevention for Musicians.” Medical Problems of

Performing Artists 9, no. 1 (March 1994): 396.

65

BIOGRAPHICAL SKETCH

Jacqueline Kaye (O’Kain) McIlwain received her Doctor of Music with an

emphasis in Clarinet Performance from The Florida State University in 2010 where she

served as a Graduate Teaching Assistant and College of Music Fellow. She received her

Master of Music degree from Indiana University in 2007 and Bachelor of Music, Magna

Cum Laude, from Middle Tennessee State University in 2005.

Dr. McIlwain has given numerous recitals in a variety of styles, played in many

ensembles, and performed internationally in over half a dozen countries in Europe and

the Far East serving the role of principal clarinetist. She enjoys teaching clarinet and

hopes to share her passion and inspire many clarinetists throughout her career.