Journal Article Review, July 2020

Betzl J et al: Overuse Syndrome of the Hand and Wrist in Musicians: A Systematic Review. J Hand Surgery European, 2020; 45(6):636-642.

Investigators in Munich just published a systematic review of overuse syndrome in musicians’ hands and wrists. Their search strategy resulted in 42 articles, 22 of which had original data or case studies. These studies comprised a total of over 1300 performing artists and university-level students. The other publications (including 15 overviews and three comments) were included because they contained interesting clinical observations and directions for future research.
A standard definition of overuse syndrome is lacking, although the Performing Arts Medicine Association’s attempt is worth noting. “Overuse occurs when using anatomically normal structures … in a so-called normal manner but to a degree that has exceeded their biological limits.”
Overuse syndrome must be differentiated from focal dystonia, which is a central nervous system defect leading to loss of control over a single muscle or muscle group and which is typically painless. This is contrasted to overuse syndrome where the symptoms, which usually include pain, are confined to the affected area.
By pooling data from the collected studies, the investigators in the present paper indicate that at any point in time, approximately 40% of musicians have playing-related musculoskeletal problems and that the lifetime prevalence ranges in different studies from 67% to 89%. Wrist symptoms occur more often than forearm symptoms occur more often than finger symptoms, and symptoms at any level are equally present in men and women and spare no age group.
There are no reports of biopsy results in musicians, although they would likely be similar to the findings in other individuals with overuse syndrome. Those findings have mimicked old polio lesions with over-exercised surviving muscle fibers and biopsies taken from weightlifters, dancers, and marathon runners.
Identified risk factors include intense, repetitive practice, increase in practice time before auditions and concerts, recent changes in conductors and teachers, psychological stress, faulty technique, and joint laxity. Pianists with small hands are at particular risk.
Typical symptoms include pain, weakness, stiffness, and loss of fine motor control during or immediately after playing. In more severe cases, pain can occur at rest and at night and interfere with daily activities. The dominant hand is not necessarily more involved. Sensory changes, including distorted perceptions, yet without changes on physical or electrodiagnostic examinations, are possible.
Over one-third of musicians with overuse syndrome seek no treatment at all but find their own pain reducing methods. Others seek advice from their teachers or peers. Only 28% reported being successfully treated by a medical professional.
Treatment with enforced rest from all pain-inducing activities for weeks or months has changed in recent years to a more individual rehabilitation program. This may include yoga, enhanced general physical conditioning, and changing to a less-demanding instrument.
Prevention advice includes performing warmup exercises, taking breaks during practice sessions, and avoiding prolonged repetitive exercises. The investigators note, however, that such recommendations “rely more on the authors’ clinical experience and subjective views of patients than on any scientific validation.” Perhaps the most important key in prevention is general physical conditioning. One study showed a statistically significant relationship between diminished physical activity and upper extremity joint pain in musicians. Whether the lack of conditioning caused the pain or the pain caused diminished conditioning remains unclear.
COMMENT: I found the review interesting although not offering any new, specific treatment recommendations for this vexing condition. The investigators did their best in summarizing a disparate group of articles that did not even agree on a definition of overuse syndrome. Finally, the researchers throw down the gauntlet to you. “There is a need of further investigations that go beyond the personal experience and opinion of clinicians and that can be based on evidence regarding all aspects of the disorder. Prospective studies of a prevention and/or treatment scheme would be especially welcome.”