Medical Hypotheses WEIGHT-BEARING MANIPULATION: A NEGLECTED AREA OF MEDICAL ‘SCIENCE RELEVANT TO PIANO PLAYING AND OVERUSE SYNDROME Igor Hmelniteky and Nigel Nettheim, NSW State Conservatorium ‘of Music, Macquarie St, Sydney 2000 Australia ABSTRACT Functional anatomy and physiology have naturally attended mainly to, those functions which occur most conaonly in everyday life. Piano playing is a more specialized area, Where functions arise which have so far been neglected in medical science. These functions are here described by a pianist (TH) in the hope that medical researchers will Fespond to fill the gaps. The importance of this lies not only in the understanding of skilled manipulative activity but also in the avoidance of overuse syndrome (OUS) or repetitive strain injury (RSI). INTRODUCTION Medical reference to OUS among pianists began early (21) and continues to the present day (6). We approach this problem, and the converse one of describing skilled playing, by considering the many schools of piano technique. These schools are divided here into two groups: (1) “weight play- ing" and (11) all other approaches, to be called "naive playing". Although the term "naive” is used merely for con- venience and is not intended as pejorative, we will never— theless show weight playing as consistent with a high level of manipulative skili, and naive playing as consistent with ous: WEIGHT PLAYING Weight playing has come to be used by leading art- ists; we wish to avoid polemics and so will merely give a quotations from such artists (Appendix A). These quot- tions are expressed without medical precision, but may Serve the present purpose, It is difficult to describe weight playing in words (11 p38) - it ie easier by personal demonstration with physical contact or biofeedback ~ but this must now be attempted. ‘The upper arm hangs freely, and therefore vertic- 209ally. The forearm is horizontal, the height of the chair having been adjusted accordingly. The forearm ie not held in position by arm muscles (biceps and triceps) as would be naively supposed; instead it is subject only to (1) the resistance of the key- board (iii) ligamentous integrity and (1v) muscle action (mainly flexion) to stabilize the wrist and fingers. The fingers carry out all the manipulation needed to maintain their posture and to convey themselves from one keyboard location to another. Finger flexion uses the flexors digit- orum profundus and sublimus, and these to only a small fraction of their capacity ~ compare work on parallel bars. Apart from this, most of the work is done by the intrinsic muscles, which accordingly become Well developed in such Pianists (10 p13). The lumbricals and interossei play the most vital roles; indeed, "these short muscles are extremely well endowed with special nerve endings which provide then with a positional sense that has no equal elsewhere in the body" (17 p65). We now assume a passage of single notes (one finger at a time) for one hand and describe the raising of the fin- ger that is about to play. This does not use the extensors, as would be naively supposed. Instead, the finger which is presently playing is strongly flexed; this action provides a force tending to raise the hand (and with it the forearm) while the non-playing fingers appear to be raised (perhaps about 18 degrees extension at the metacarpo-phalangeal (MCP) joint) with scarcely any work of their own. This small amount of activity by the non-playing fingers is treated in more detail below in the section on the lumbricals. The arn 80 Will be displaced to some extent or tossed around in a ballistic manner by this activity, so that the observer might nistakenly think that the arm is being ‘used’; its movements are instead passive. Thus the hand, wrist and arm are controlled from the distal end, using the mall muscles of the hand, and not from the proximal end. This will be termed the "disto-prox- imal" ‘theory, by contrast with the naively invoked "proximo— distal" approach. Neurologically too, the disto-proximal direction is the primary one, as the proprioceptive inform ation from the distal parts governs the activity, (Compare the well-known sensory and motor homunculus (20) and see (13 p228)). As the forearm is allowed to ‘fall’, the manipulat- ions are carried out against the resistance of the keyboard. Wow activity against resistance is very different from ac~ tivity ‘in mid-air! or with a partially withdrawn forearn. Rather little medical literature 1s devoted to resisted ac- tivity: most writers either assume tacitly that there 1s no resistance, or that resistance is the exception rather than 210the rule; in either ci weight playing. The function of the wrist will now be treated brief- ly. Finger flexion is strongest when the wrist is extended (8"pié2); but constant wrist extension strains the tendon: and may Contribute to carpal tunnel problems, 20 relief is ovided by frequent vertical wrist movement. Such movement [s needed also to allow the passing under of the thunb to facilitate motion across the keyboard. Wrist extension is achieved not by the extensors (together with antagonistic flexion) but by gravity (the “unseen muscle", "the only in- exhaustible source of energy" (16 p206,171)) acting on the forearm, while the integrity of the MCP joint is maintained by flexion. The opposite (upward) wrist movenent is achieved by increased flexion against the resistance of the keyboard. such literature is inapplicable to The above description of weight playing may be app- lied to perhaps ninety per cent of a pianist's taske; a full Solid chord, for example, may provide an occasional excep- tion with the wrist and fingers somewhat fixated and the triceps supplying additional downward force as accelerator synergist to gravity, analogously to the act of stamping one's foot. A HYPOTHESIS ON THE FUNCTION OF THE LUMBRICALS We refer again to the earlier description of the raising of the finger that is about to pl nt me opinion appears to be that extension at the MCP joint is a function solely of the extensors. Our hypothesis is that the mall amount of such extension occurring in the weight-bear- ing piano-playing situation {6 a function not primarily of the extensors but of the lunbricals, with the assistance of the elasticity of the interosseous hood and the proximal gliding of the MCP fibrous girdle. The interosseous hood has been described (24 p42) a: “the transverse or proximal part of the superficial insert— fons of all types of interosseous muscles. This structure migrates proximally during digital extension and distally during digital flexion (Fig 1-26)." Now the finger that is currently playing is bearing the weight of the forearm; the resistance thus suffered causes the hood to migrate proxii ally. At the same time the fibrocartilaginous palmar pia and associated formations are stretched. The location of point of insertion of the lumbricals of all fingers will thus move dorsally beyond the midline (compare a similar phenomenon at the inter-phalangeal joints (9 p201-2 fig &5)). As @ regult of the different bias thus set up, the lumbrical will now extend at this joint, whereas in’ the ab- ence of weight-bearing it would have fiexed. The extensors in the forearm thus contribute only as weak accessories, 50 that a prime cause of OUS is removed. an{A slight difference occurs in pianiseimo playing. For in playing above pianissino level the hand ie held well arched, with the McP knuckles rather prominent (usually re- ferred to as playing "with curved fingere") and the hood gs described above. In pianissimo playing, however, ched, the MCP knuckles legs prominent and fingers flatter; in this case the hood will migrate less, but correspondingly less extension at the MCP joint is required. The normal tonus of the lumbricals and extensors may alone suffice to produce thie minimal extension.) The MOP extension of which the lusbrical te thus geptble letrather alight” in kten¢, ana not powerful.” But iie*contribution to the playing of ‘the next hove is merely Preparatory: the extension te fot an end in itself. “thie stinetion between a preparatory anda deliberate action is important; 1 nay be seen. ip the action of etamping” the. foot on’the ground “the leg de firee raised, ‘out only in the Sight, weak, preparatory manner, not in’ the deliberate man- ner of goose-step marching. A warning may be needed here that the dynamice of fast playing cannot be studied in stat~ ic situations; the full implications of this remark are re~ aerved for a future paper. Neurologically, the biaeing of Muscle receptors is a function of the gamma loop (22'p225) , (12. peer); again we defer fuller discussion (22 pegs)" (12 pse7) NAIVE PLAYING In “naive playing" some of the features of weight playing are not present. The forearm is held in position by the arm muscles: it is ‘withdrawn’ instead of being allowed to drop. Thus finger flexion is opposed antagonistically to extension rather than to the gravitational force, Sone ac- tivities of flexion which were possible against the resist- ance of the keyboard are no longer possible, and typically are replaced by activity of the extensors. ‘Thus the fingers are raised by means of the extensors, where pain frequently occurs. There is a relatively close-packed position at the Joints (shoulder, elbow, and wrist) which inhibits mobility, A lower level of manipulative skill may also be the result of congenital anatomical differences, in the light of our analysis. Yor example, in 50% of people the dorsal in- terosseus inserts into bone, while in the other S0x it in- serts into the extensor mechanism (2 p33): in the former case the mechanism proposed for the lubricals will not be al XAMPLE OF PLAYING REPEATED WES: The above 1d of repeated ‘octaves are now illustrated in the playing by the thumb and little finger of one 212=a. Fig 1, Withdrawn (proximo-distal) playing. Pig 2, Weight-bearing (disto-proximal) stance & ewing. hand simultaneously playing keys requiring a etretch near the maximum (see Figs i, 2). Fig 1 shows the naive approach: (a) arm activities and (b) wrist extension are pictured, either one or both of Which may be used. Here the agonist and antagonist muscl of the shoulder girdle contract to stabilize the humerus in its activities, those of the humerus to stabilize the fore: arm, and finally those of the forearm to stabilize the wriat and’ fingers. It is suggested that thie may lead to OUS. Since key dip is only 9.5 - 10 mm in total, and 2- 2.5 mm suffices to return the jack under the roller for repetition, the large movements are redundant. (Regrettably, however, such methods are often taught (19 p259-261), (23 po3-99).) 213Fig 2 shows weight playing: here the shoulder is relatively open-packed (which incidentally facilitates quick lateral curvilinear relocation across the keyboard), while tension is reduced to passive synergism (5 p43é-9)in re lation to powerful flexion against gravity; full bio-mechan- ical details are however not known at present. CONCLUSIONS. Digital manipulation when the fingers bear the weight of the forearm (which has been found to be the most advantageous mode in piano playing) has been given little or no attention in the medical literature. A mechanism ie pro- posed for extension at the metacarpo-phalangeal joint; the Proposed mechaniom depends essentially upon the weight-bear- ing usage. Overuse syndrome could be prevented (unless a congenitai or other physical anomaly is present) by adopting the appropriate usage. ACKNOWLEDGEMENTS ‘The authors thank especially Dr. A Ganora, Director, Illawarra Rehabilitation Centre, for his encouragement in these researches over many years: for medical advice Prof.T Arnold, Dr. WJG Burke, Dr.c McKellar, Dr.PD Middleton, & Dr.L Rassaby; and for ance the Alfred $ White Music Beques John Painter, and the NSW State Conservatorium of Music. APPENDIX A. QUOTATIONS FROM PIANISTS RELATING TO WEIGHT BEAYING Hofmann (7 p9-10) : by concentrated thinking you should endeavour to transfer the display of force to the finge: of holding the tension in your arm. For this produces fatigue, while the way I suggest will lead you to de~ velop considerable force through the hands and fingere alone and leave the arm practically limp and loose." ky (4 "In weight playing the fingers seem to mould the piano keys under them; the hand and arm are relaxed but never heavy." Godor Horowitz (8 p163): “Now the ideal equipment for the pianist consists in movement in the wrist and relaxation in the arm. The touch itself must reside in the finger.” Neuhaus (18 p100-101 "I compared the arm from shoulder to fingertip with a hanging bridge, one end of which ie fixed to the shoul- der joint and the other to the fingers on the keyboard. 214. this sane bridge I every direction, mes made the pupil swing in me This simple experiment showed € pupil in practice how great can be the flexibility, re Biiience and freedom of movement of the whole arm, while the finger reats on the keyboard with full confidence, accuracy and firmne: APPENDIX B. ANNOTATED LES. THE MEDICAL LITERATURE (4) Duchenne (3 p33): "With the knowledge of the exact individual action of the muscles which move the phalanges, I could analyze better than heretofore the mechanism of finger movement in other usages of the hand as for instance in the in- strunentalist.. In spite of the attraction which such studies present, I am compelled to renounce then for the time being to avoid overextension of this investiga- tion." [Such studies have been postponed by others also; their time is surely come. (44) Gray's Anatomy (5 p591) Analogies between this arched form [of the carpal struc- ture] and that of the foot have been indicated; but the hand jonally weight-bearing, and this com paris. e pursued here." {only occasionally in everyday life, but vitally in piano playing. (444) Landomeer (14 7394) ‘we are far from understanding the particular structure of each interosseous and ite functional relationship to the finger. [The present paper perhaps indicates the significance such knowledge would have.) (4) Kapandji (9 202-3): “when the hand assumes the shape of a hammer (Fig. 93) FDS and FDP flex the PIP and DIP joints. This is the initial position of the pianist's) fingers [ine playing method assuned has not been precisely described; the position shown in the figure is one tending to OUS rather than to highly skilled playing. ] (v) Kapandji (9 p24s) "the movement of inimal opposition (Fig 200) [of the thumb] is associated with almost linear displacement of Mi-[the first metacarpal] so that its head comes pro- gressively to lie anterior to M2. This movement, oc- curring in the plane of the palm, ie seldom used and of Tittle functional value [xt te a vital movement in piano playing in scalar passages when the hand moves over the thumb. ] 216(v4) Hochberg (6) p1871-1872: "Our experience demonstrates that tendinitie, usually of finger extensors, is a most common ailment of musicians. Symptoms of extensor forearm or doreal hand pain, loss of facility, and fatigue on repetitive movement reflect overusage during angular movements such as octaves (loud, fast simultaneous playing of the thumb and fourth or fifth finger of one hand held rigidly...). In add~ ition, these difficulties may result from shearing move- ments during the forceful rotation required to perform broken octaves (thumb and fifth finger alternate rather than play simultaneously ...). [Evidently the method of performance in these cases is of fhe "naive" type. Correct! instruction and training ie need- ed. (vii) Lorda (18 pi7i-2): “the theory that distal skill emerges out of and depends on proximal control is not confirmed by the findings of this study. ... 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