Published in The IHS Online, February, 2007
Justin C. Smith, PT, DPT, RN1
Cate E. Langley, PT, DPT1
Maureen A. Kendrick, PT, DPT1
Jeremy S. Smith, PT, DPT, ATC1
Cara L. Wilkerson, PT, DPT1
John S. Halle, PT, PhD, ECS2
David G. Greathouse, PT, PhD, ECS, FAPTA3
- Students in the Belmont University Doctorate of Physical Therapy Program, Nashville, TN at the time this study was performed. This research was performed in partial fulfillment of their requirements for the Doctorate of Physical Therapy degree.
- Professor and Associate Dean, Belmont University School of Physical Therapy. Clinical electrophysiologist (EMG/NCS), Neurology Clinic, Blanchfield Army Community Hospital, Fort Campbell, Kentucky.
- At the time this study was performed, Dr. Greathouse was Professor and Chairman, Belmont University School of Physical Therapy and clinical electrophysiologist (EMG/NCS), Neurology Clinic, Blanchfield Army Community Hospital, Fort Campbell, Kentucky. He is currently the Director, Clinical Electrophysiology Services, Texas Physical Therapy Specialists, New Braunfels, TX and Adjunct Professor, U.S. Army-Baylor University Doctoral Program in Physical Therapy, Fort Sam Houston, TX.
This study was approved by the Belmont University Institutional review Board.
The authors have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter including in this manuscript.
Online Editors note: The online version of this article was condensed from the original (by the original authors) and lacks the figures and appendix mentioned in the text. For the complete article contact Dr. Greathouse at the address given above.
Median and Ulnar Neuropathies in University Brass Players
Background and Purpose. Peripheral nerve entrapment syndromes of the upper extremities are well documented in musicians. Brass players are at risk for entrapment neuropathies in the upper extremities and are sensitive to mild neurologic deficits. Several university musician populations have been examined to determine the incidence of median and ulnar neuropathies including violinists, cellists, guitarists, pianists, and percussionists. The purpose of this descriptive study was to determine the presence of median and ulnar neuropathies in both upper extremities of university brass players. Subjects. Fourteen volunteer male and female brass instrument players (ages 18-23 years) were recruited from the Belmont University School of Music and the Vanderbilt University Blair School of Music. Individuals were excluded if they were pregnant or had a history of recent upper extremity or neck injury.
Methods. Subjects completed a history form, were interviewed, and underwent a physical examination. Nerve conduction status of the median and ulnar nerves of both upper extremities was obtained by performing motor, sensory, and F-wave (central) nerve conduction studies. Skin temperature at the wrist was maintained at or above 32º C. After completion of the median and ulnar nerve conduction studies (NCS), the brass players were instructed in upper extremity injury prevention exercises.
Data Analysis. Descriptive statistics of the nerve conduction study variables were computed using Microsoft Excel.
Results. One subject (13) reported numbness and tingling in the 2nd, 3rd and 4th digits of both hands and had decreased light touch and pain sensation in the same distribution in both hands. One subject (7) had positive findings on provocative testing (Tinel’s sign) of the left median nerve at the wrist. Otherwise, these brass players had normal upper extremity neural and musculoskeletal function based on the history and physical examinations. When comparing the subjects’ nerve conduction study values with a chart of normal NCS values, all electrophysiological variables were within normal limits for motor, sensory, and central (F-wave) conduction values. However, comparison studies of median and ulnar motor and sensory latencies in the same and opposite hand demonstrated that five of the 14 brass players (36%) had early evidence of median neuropathy at or distal to the wrist. Three of these musicians had early evidence of median neuropathy at or distal to the wrist in both hands. The other nine subjects demonstrated normal comparison studies of the median and ulnar nerves in both upper extremities.
Conclusion/Clinical Relevance. In this descriptive study of a population of 14 university brass players, five musicians (36%) were found to have early electrophysiologic evidence of median neuropathy at or distal to the wrist or carpal tunnel syndrome. Ulnar nerve electrophysiological function was within normal limits for all subjects examined.
Key words: nerve conduction study, brass players, neuropathy, carpal tunnel syndrome
Medical problems, including those involving the muscles and nerves of the arm, may occur with increased frequency among musicians. These medical problems range in severity from incidental, asymptomatic findings among casual and occasional players to serious injuries that significantly disable musicians from practicing or performing.1-21 Several university music department students have been examined to determine the incidence of median and ulnar neuropathies (two main nerves that go down the arm to the hand) including violinists, cellists, guitarists, percussionists, and pianists. 22-26
University age students practice excessive hours and have astonishing dedication in order to achieve performance level play. Similar to athletes, musicians often practice their art several hours a day. Those that may seek help for problems affecting their play may be informed that their pain is due to “technical faults”, thus encouraging the student to practice longer and further exacerbate their condition.20 Many of these performing artists sustain performance-compromising injuries to the wrist and hand.21 These injuries can be due to the repetitive movements of playing along with the prolonged muscular effort required to bear the weight of the instrument in an optimal playing position that may be stressful.18
While brass players are exposed to excessive forces as well as repetitive motions, few studies have been conducted on them. Therefore, the purpose of this study was to determine the presence of median and ulnar neuropathy (nerve disease) in the arms of university brass players.
Fourteen volunteer brass players were recruited from the Belmont University School of Music and Vanderbilt University Blair School of Music. All brass performance majors (n = 21) participating in performance seminars were approached to participate in this study. Seven subjects declined to participate in the study: four due to scheduling conflicts and three who were not interested in participating in the study. The subjects’ ages ranged from 18 to 23 years (mean, 19.7 yrs). Experimental procedures, risks, and subject rights were discussed with all subjects before participation in the study; following this discussion, all subjects signed an institutionally approved written consent form. Individuals were excluded if they were pregnant or had a history of recent (less than one year) upper extremity or neck injury. The study was approved by the Institutional Review Board of Belmont University.
A history (subjective evaluation), physical examination and upper quarter neuromusculoskeletal screen were performed to determine the status of the neural integrity of the median and ulnar nerves in the university brass musicians.
A history was taken from each patient in questionnaire format. The history included information pertaining to demographics, medical history, musical background, playing/practice time, hand dominance, and computer time.
A physical (screening) examination was a part of the evaluation process of each subject. Eight separate areas were evaluated: neck movements, arm movements, muscle tests of the arms, sensory tests of the arms (light touch and pain), muscle stretch reflexes of the arms and legs, pathological reflexes of the arms and legs, special tests to determine the integrity of the nerves, and assessment of the radial pulses with the neck and arms in various positions. Each patient was tested for both arms. If one or more positive findings were identified during the screening examination, this information was recorded and the subjects continued through the rest of the study procedures.
At the time of volunteer solicitation, potential subjects were instructed to abstain from practicing any instrument or exercising for one hour prior to scheduled testing. Skin temperature at the wrist was measured and was maintained at or above 32 degrees Celsius. If skin temperature fell below this value, the wrist, hand, and forearm was warmed with warm water soaks.
The Cadwell Sierra LT electromyograph and stimulator machine (Cadwell Laboratories, Inc., Kennewick WA 99336) was used to measure the compound motor action potential (CMAP) and sensory nerve action potential (SNAP) latencies and amplitudes. The nerve conduction studies followed procedures previously presented.25-29 The median and ulnar nerve conduction studies (NCS) were obtained from both upper extremities. In addition to comparing median and ulnar NCS studies with a chart of normal values, comparison studies between median and ulnar palmar distal sensory latencies (DSLs), digit DSLs, and distal motor latencies (DMLs) in the same and opposite extremities were obtained. Examination of median and ulnar latencies in the same extremity and median and ulnar latencies in opposite extremities has been shown to assist in early electrodiagnosis of carpal tunnel syndrome (CTS).30-32
After the nerve conduction study each brass player received a description and demonstration of exercises and injury prevention guidelines. These exercises included stretching, strengthening, resting, and nerve gliding techniques to assist in the prevention of injury. The exercises focused on the forearm, wrist, and hand. The purpose of providing upper extremity exercises (mobility, strengthening, and stretching) was to increase these brass players’ awareness of possible musculoskeletal problems in musicians, and to the extent possible, provide them with measures that would minimize the future risk of common musculoskeletal problems. Additionally, the subjects were advised to incorporate these exercises into their practice regimen. The preventive exercises presented to the brass players are described in detail in Appendix I.
Fourteen subjects participated in this study (10 males, 4 females). The age of the subjects ranged from 18 to 23 years, and the mean was 19.7 years. Twelve of the 14 subjects were right hand dominant. The subjects were asked the number of years devoted to practicing the brass instrument, with a response range of 4-12 years (mean = 7.6) [Figure 1]. The major brass instrument played by the subjects was the trumpet (10 subjects); however, the french horn (5), trombone (3), baritone (2), coronet (2), tuba (1), and other instruments (2) were played as well [Figure 2]. The majority of subjects practiced one or more brass instruments from one to ten hours per week (8 subjects). Eight of the 14 focused one to two hours per day practicing their brass instrument [Figure 3]. All but two of the subjects practiced more than four days per week.
According to the reported history, several other instruments were played along with the brass instruments. The major instrument played was the piano (n = 9). Other instruments included: bass guitar, bass upright, guitar, clarinet, saxophone, alto, tenor, flute, and drums. Pertaining to the subject’s time spent on the computer: subject 6 reported typing more than 40 hours per week, subject 14 reported 30 hours per week, everyone else ranged from 0-15 hours per week (mean = 11 hours per week). In regards to this demographic information, other instruments played and time spent on the computer may also be factors in determining risk of nerve injury.
From the history only two subjects performed a finger exercise to warm-up prior to playing or a cool down. Most performed some sort of lip/breathing exercises, i.e. scales, long tones, buzzing, etc. Only one subject reported taking no breaks during practice (subject 2). Twelve subjects took breaks every 30 minutes. Only two subjects took breaks every 45 min (subject 6 and 11).
When asked to describe his or her level of performance: three subjects stated they had a vocational interest in brass instruments (subjects 3, 9, and 12), nine were performance majors, and two considered themselves amateurs (subjects 5 and 8). These responses indicated that the majority of subjects that participated in this study considered themselves above the amateur level.
When asked to describe their general health: eleven subjects considered themselves to be in good health, three subjects described themselves as being fair health (subjects 6, 7, and 10), and none stated being in poor health. None of the subjects reported having a history of nerve disease, renal disease, peripheral vascular disease, or diabetes. One subject (2) reported thyroid disease. One subject (10) reported arthritis of multiple joints.
When considering the results of the subjects’ history, physical examination, and upper quarter screen, other than subject 13 (numbness and tingling in the volar surfaces of digits 2-3-4 in both hands and decreased light touch and pain sensation in the same distribution bilaterally) and subject 7 (positive Tinel’s sign over the left median nerve at the wrist), there were no symptomatic indicators or clinical evidence of median and ulnar neuropathies in either upper extremity of the brass players tested.
The results of the nerve conduction studies are presented in Table 1. The values for these electrophysiological variables for each subject were compared to a chart of normal values (Table 2). This chart of normal values was developed in the Clinical Electrophysiological Laboratory, Neurology Clinic, Blanchfield Army Community Hospital, and revalidated at the Electrophysiological Laboratory, School of Physical Therapy, Belmont University. This chart of normative values was developed for the 18-50 age group. When the results of the NCS study were compared with the chart of normal values, there was no electrophysiologic evidence of median or ulnar neuropathy in this population of university brass players.
When comparing median nerve to ulnar nerve in the same arm, and comparing median nerve arm to arm, the following was found: there was electrodiagnostic evidence of early median neuropathy at or distal to the wrist in five of the 14 (36%) brass players. (Table 3). Otherwise, in these university brass musicians, there was no evidence of median or ulnar neuropathy at or distal to the wrist, in the forearm, or across the elbow.
After reviewing the results of the histories and examinations, there was no consistent indication of median or ulnar neuropathies in these musicians. A thorough history (subjective) and physical examination are good screening tools for detecting signs and symptoms of peripheral neuropathy.30-32 To determine whether certain entrapment neuropathies are present, nerve conduction measurement is often performed on the median and ulnar nerves.18,30-32 Nerve conduction measurement is considered the gold standard in determining certain entrapments of the nerves.18, 30-36 There was electrodiagnostic evidence of early median neuropathy at or distal to the wrist in five of the 14 (36%) brass players.
When considering the results of the subjects’ histories and physical examinations in this study, there were possible indicators or evidence of median neuropathies in two subjects. From data collected from the history, subject 13 had numbness and tingling in the volar surfaces of digits 2-3-4 in both hands. From the results of the physical examination, subject 13 also had decreased sensation of light touch and pain in the palmar surfaces of digits 2-3-4 in both hands; and subject 7 had a positive Tinel’s sign over the left median nerve at the wrist.
On the history portion of the examination, subject 13 had numbness and tingling on the volar surfaces of digits 2-3-4 in both hands that is suggestive of median neuropathy or nerve injury at or distal to the wrist. These subjective findings were confirmed on the physical examination portion when this subject’s sensation to light touch and pain were decreased in the same distribution of both hands as the numbness and tingling. Subject 13 also had electrophysiologic evidence of early median neuropathy of the median nerve at or distal to the wrist with prolonged differences in the comparison studies of the median and ulnar DMLs in the same hand for both hands. Thus, in this subject, evidence of median neuropathy at or distal to the wrist was found on the subjective (history), physical examination, and electrophysiologic evaluation (NCS).
Subject #7 had objective findings on the physical examination suggestive of median neuropathy at or distal to the wrist, but his NCS studies and comparison studies were normal. While both a positive Tinel’s sign at the wrist and a positive Phalen’s test may be compatible with median neuropathy at or distal to the wrist31, these tests were negative in these five subjects. Special tests such as the Tinel’s sign and Phalen’s test may be predictors of early stages of median neuropathy in this population. They are subjective evidence, though, and not diagnostic.30-32
It should be noted that subject #14, although having a history and physical examination not suggestive of median neuropathy at or distal to the wrist, stated that he used the computer keyboard for over 30 hours per week. Subject 14 also had early electrophysiologic evidence of median neuropathy at or distal to the wrist with prolonged differences in the median and ulnar digit DSLs in the same hand bilaterally and a prolonged difference for the median and ulnar DMLs in the left hand. Perhaps in subject #14, the extended time on the computer keyboard may be a factor in his early median neuropathy at or distal to the wrist.
Knowing that certain activities cause certain injuries makes it easier to make a plan to prevent the injury. In addition, diagnosis can be reached earlier and treatment can begin earlier lending to quicker and better recovery. Additional studies can also be performed on a specific group in order to give more information on how to deal with their ailments.37 Franzblau and Werner stated that NCS testing of persons without symptoms of CTS is critically important because it permits assessment of the overall relationship between results and other clinical features of CTS such as symptoms and physical examination findings.38
To sum up this article, 14 young adult university brass players were examined. The population of university brass players was of particular interest because of the repetitive stress placed on the wrist and hand while playing their instruments. One subject had subjective findings suggestive of median neuropathy or nerve injury at or distal to the wrist. Two subjects had findings on the physical examination that were suggestive of median neuropathy at or distal to the wrist. The remainder of the subjects had normal upper extremity neural and musculoskeletal function based on extensive evaluation, including history and physical examination. However, five of the brass players (36%) had electrophysiologic evidence of median neuropathy at or distal to the wrist (CTS). Otherwise, in the other nine university brass musicians, there was no evidence of median or ulnar neuropathy at or distal to the wrist, in the forearm, or across the elbow. This article is important in the fact that it demonstrates some negative affects playing brass instruments can have on the body, what types of injuries to be on the look out for, and ideas of what may be causing them. In addition it describes effective methods of diagnosis of some of the nerve related problems in the arms of brass players and provides preventive exercises that may prevent musculoskeletal or nerve injuries in musicians.
1. Liu S, Hayden GF. Maladies in Musicians. South Med J 2002;95(7): 727-734.
2. Zaza C. Playing-related musculoskeletal disorders in musicians: a systematic review of incidence and prevalence. Can Med Assoc J 1998;158(8):1019-1025.
3. Knishkowy B, Lederman RJ. Instrumental musicians with upper extremity disorders: a follow-up study. Med Probl Perform Art 1986;1:85-89.
4. Hochberg FH, Leffert RD, Heller MD, et al. Hand difficulties among musicians. JAMA 1983;249:1869-1872.
5. Zaza CH. Musicians’ playing-related musculoskeletal disorders: an examination of physical, psychological, and behavioural factors (dissertation). Waterloo, Ontario, University of Waterloo; 1995.
6. Zaza C, Farewell VT. Musicians’ playing-related musculoskeletal disorders: an examination of risk factors. Am J Ind Med 1997;32:292-300.
7. Lederman RJ. Neuromuscular and musculoskeletal problems in instrumental musicians. Muscle Nerve 2003;27: 549-561.
8. Cayea D, Manchester RA. Instrument-specific rates of upper extremity injuries in music students. Med Probl Perform Art 1998;13:19-25.
9. Morse T, Ro J, Cherniack M, Pelletier SR. A pilot population study of musculoskeletal disorders in musicians. Med Probl Perform Art 2000;15:81-85.
10. Lockwood AH. Medical problems in musicians. N Engl J Med 1989;321:51-53.
11. Lederman RJ. Peripheral nerve disorders in instrumentalists. Ann Neurol 1989;26:640-646.
12. Lederman RJ. Entrapment neuropathies in instrumental musicians. Med Probl Perform Art 1986;1:45-48.
13. Bejjani FJ, Kaye GM, Benham M. Musculoskeletal and neuromuscular conditions of instrumental musicians. Arch Phys Med Rehabil 1996;77:406-413.
14. Winspur I. Nerve Compression Syndromes, In: Windspur I, Wynn Parry CB (eds): The Musician’s Hand: A Clinical Guide. London: Martin Dunitz; 1998:9-11, 24-26, 85-98.
15. Quarrier NF. Performing arts medicine: the musical athlete. J Orthop Sports Phys Ther 1993;17:90-95.
16. Fry HJ. Incidence of overuse syndrome in the symphony orchestra. Med Probl Perform Art 1986;1:51-55.
17. Fishbein M, Meddlestadt SE, Ottati V et al. Medical problems among ICSOM musicians: Overview of a national survey. Med Probl Perform Art 1988;3:1-8
18. Lambert CM. Hand and upper limb problems of instrumental musicians. Br J Rheum 1992;31:265-271.
19. Mandel S. Overuse syndrome in musicians. Postgrad Med 1990;88:111-114.
20. Fry HJH. Prevalence of overuse (injury) syndrome in Australian music schools. Br J Ind Med 1987;44:35-40.
21. Brandfonbrener, AG. The epidemiology and prevention of hand and wrist injuries in performing artists. Hand Clin. 1990; 6(3):365-377.
22. Bowie E, Brimer K, Kidder M, et al. Median and ulnar nerve conduction studies in young adult violinists. Med Probl Perform Art 2000;15:123-128.
23. Logue EJ, Bluhm S, Johnson MC et al. Median and ulnar neuropathies in university cellists. Med Probl Perform Art 2005;20:70-76.
24. Doose ML, Hancock JJ, Hewgley JW et al. Median and ulnar neuropathies in university percussionists. Percussive Notes 2005;60-66.
25. Kennedy RH, Hutcherson KJ, Kain JB et al. Median and ulnar neuropathies in university guitarists. J Orthop Sports Phys Ther 2006;36:101-111
26. Gohl AP, Clayton SZ, Strickland K et al. Median and ulnar neuropathies in university pianists. Med Probl Perform Art 2006:21:17-24
27. Harkins G, Jayne D, Masullo L, et al. Effects of gender and handedness on neural conduction in humans. J Clin Electrophysiol 1989;1:10-13.
28. Ayotte KS, Boswell LL, Hansen DH, et al. A comparison of orthodromic ring, antidromic ring, and Roth techniques for obtaining sensory neural conduction latencies and amplitudes for the median and ulnar nerves in healthy subjects. J Clin Electrophysiol 1992;4:12-18.
29. Ayotte KS, Boswell LL, Hansen DH, et al. A comparison of orthodromic and antidromic sensory neural conduction latencies and amplitudes for the palmar branch of the median nerve in healthy subjects. J Clin Electrophysiol 1990;2:9-12.
30. Dumitru D, Amato A, Zwarts M: Electrodiagnostic Medicine (2nd ed). St. Louis, MO:Hanley & Belfus, 2002.
31. Kimura J: Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice (3rd edition). New York:Oxford University Press, 2001.
32. Oh SJ. Clinical Electromyography in Nerve Conduction Studies. Baltimore, MD, Williams & Wilkins, 1993.
33. Ferry S, Pritchard T, Keenan J, et al. Estimating the prevalence of delayed median nerve conduction in the general population. Br J Rheumatol 1998; 37:630-635.
34. Scelsa SN, Herskovitz S, Bieri P, et al. Median mixed and sensory nerve conduction studies in carpal tunnel syndrome. Electroenceph Clin Neurophysiol 1998;109:268-273.
35. Katz JN, Larson MG, Sabra A, et al. The carpal tunnel syndrome: diagnostic utility of the history and physical examination findings. Ann Intern Med 1990; 112:321-327.
36. Salerno DF, Franzblau A, Werner RA, et al. Median and ulnar nerve conduction studies among workers: normative values. Muscle Nerve 1998;21:999-1005.
37. Atroshi I, Gummesson C, Johnsson R et al. Prevalence of CTS in a general population. JAMA 1999;282:153-158.
38. Franzblau A, Werner R. What is carpal tunnel syndrome? JAMA 1999;282:186-187.