Medical context - piano playing injuries

Ageing hands at the piano

I do like to tinkle out a few tunes on the piano, and latest excitement has been with duets.  For this you can buy specialist 2-person sheet music (exploring classical tunes is all the more fun with a beautiful woman to play with).  Alternatively - tough songs are easier with four hands (here's a jazzy one I'm trying).  The charm of a duet is you get good company, and you only have to do half the work!  So, to keep the interest going, I headed to a Joplin ragtime recital out in Nottingham featuring a little Atwell (great) and a Bowie tribute.  Now, chatting with the pianist post-gig, it turned out he was a little anxious about his hand problems, with a wonky thumb and some pain - understandably so.  And the question of medical advice came up.  But, much as we've covered hands in lectures, I had no specific medical context to help out!  So here's an attempt at targeted activity research...
Context of piano playing injuries:
The more you play (and the higher level you play at) the more likely you are to become injured. LINK (2010) - p.61.  Prevalence of ongoing injuries in professional musicians seems to be greater than 50%.

Piano players' common occupational ailments LINK (2010) - p.62
1) Tendinitis - inflammation of tendons
2) Overuse syndrome / RSI (not necessarily an accepted diagnosis) - degeneration of tendons/ligaments/nerves as rate of injury > rate of healing;  LINK
3) Carpal tunnel syndrome - median nerve trapping in the carpal tunnel of the wrist
4) Radial nerve compression syndrome - particularly entrapment of radial nerve at elbow
5) + Osteoarthritis - degenerative changes to hand/wrist joints due to overuse LINK (1984)

Abducted (splayed out) fourth and fifth fingers most likely to be damaged LINK (1989) - p.108
Extended wrist play causes damage, as do fortissimo and octave play LINK (1998) - p.11

Treatments
NB: these are remarkably similar to one another
1) Tendinitis: avoid rapid increase in tendon use; splinting and rest; painkillers; steroid injections.
2) Overuse syndrome: rest and anti-inflammatories; + potential use of ?quack massage therapy (ART) which describes a rather simplistic pathophysiology LINK
3) Carpal tunnel syndrome: splinting and rest; steroids; carpal tunnel release surgery LINK
4) Radial nerve compression: splinting and rest; steroids; surgical release of nerve along its course LINK
5) Osteoarthritis: rest, pain-based treatment and potentially joint replacement LINK

Additional advice

> Most piano-playing hand disorders are due to the mechanical process of learning and playing; non-expert doctors are ill-equipped to be able to offer helpful advice about how to resolve these problems; experienced piano teachers are more likely to be able to do so based on their own experience LINK

> Resting within and between practice sessions enables removal of metabolic waste products and replenishment of phosphocreatine, ATP, acid/base balance, resting membrane potentials ?weak LINK
> Resting during practising also enhances procedural memory retention LINK
> If you're overstretching with your small hands, you can either pick tunes with smaller spans, or there are people out there who'd like to sell you a smaller-size ergonomic piano, sounds sensible enough, if a little inconvenient to transport to performances! LINK

Tendinitis in the hand LINK

Carpal Tunnel Release

Joint changes in osteoarthritis of the hands LINK

'Play Me I'm Yours' street piano duet - Toronto

Health behaviours influence life expectancy much more than quality of medical care

Dahlgreen Whitehead Model of Health (1991)

Our medical course is satisfyingly broad beyond the physical science - they even have us considering the sex lives of the elderly (all part of a healthy lifestyle, but lots of chlamydia & lack of partners tends to hold many of them back though, apparently).  All the talk of public health rang a bell in my head from psychology days about the importance of health-promotion and the limits of medical care to help.  So I wondered, well, since part of the reason we're in this is to have an impact, just what impact does medical care have on health, relatively speaking?

One meta-analysis [LINK] indicates that health-related behaviour accounts for 40% of early deaths in the US, genetics 20%, stressful social circumstances (e.g. income inequality, discrimination, lack of social relationships 20% (LINK1 LINK2 - together approx equivalent to tobacco smoking)), physical environment 10%, while early death is influenced only to a limited extent by the quality of medical care (10% of deaths).  The challenging message for us trainee doctors is 'public health is much more important than your hospital interventions'.  So - I briefly reviewed the research to see if these stats hold up.  They seem to!  

1) Research papers about common diseases, their causes, and historic changes in life expectancy 

(give qualitative support to the statistic)

The diseases which cause the greatest number of deaths - UK

Ischaemic heart disease (12%), Dementia & Alzheimers (~10%), Stroke (~6%), Lung cancer (~6%), Chronic lower respiratory infections (~5%) (together account for 41% of deaths)

http://www.ons.gov.uk/ons/rel/vsob1/mortality-statistics--deaths-registered-in-england-and-wales--series-dr-/2014/sty-what-do-we-die-from.html

The risk factors which cause the greatest number of early deaths - Europe

Tobacco smoking - 15% of all deaths; Other cardiovascular risk factors: hypertension, obesity, low physical activity/obesity, high blood glucose, high cholesterol, low fruit & veg intake - 25% of all deaths (together smoking and cardiovascular risk therefore account for 40% of deaths)

http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf

The diseases which cause the greatest number of years lived with disability (DALYs) - UK

Cancer (14%), Ischaemic heart disease (10%), Depression (8%), Stroke, (6%), Road Traffic accidents (4%), Direct effects of alcohol use (4%) - together account for 46% of years lived with disability

http://apps.who.int/quantifying_ehimpacts/methods/en/smith.pdf

Contributing non-medical factors to disease/death pre-20th century (life expectancy has increased by 25 years across the 20th century):

- people weren't aware that tobacco smoking was bad for your health

- people weren't aware that a balanced diet was required for health

- people weren't aware that exercise was good for your health (idleness)

- widespread slum housing (squalor)

- deaths at work

    

Contributing medical factors pre-20th century:

- infant and maternal mortality perinatally (which can now be resolved by obstetric care and vaccination)

- hypertension (which can now be modified by exercise, smoking cessation and diet, as well as being assessed and controlled medically)

- infection (which can now be controlled by antibiotics)

http://www.cdc.gov/about/history/tengpha.htm

2) Back-of-envelope calculations on Quality of Life and behaviour:

(give quantitative support to the statistic)

NHS - £110bn budget, NICE guidelines indicate acceptable spends vary between £0-30k per QALY (Quality-adjusted-life-year), therefore 11m QALYs saved per year if £10k per QALY is assumed.

https://www.nice.org.uk/advice/lgb10/chapter/judging-the-cost-effectiveness-of-public-health-activities

AND

Sedentary lifestyle, i.e. lack of exercise: 7 QALYs lost per sedentary patient -> 60% prevalence -> 252m QALYs

Smoking: 10.5 QALYs lost per heavy smoker -> 20% prevalence -> 120m QALYs

Obesity: 5 QALYs lost per obese patient -> 25% prevalence -> 75m QALYs

High alcohol consumption: 4 QALYs lost per heavy drinker -> 15% prevalence -> 34m QALYs

Total on these factors - 470m QALYs (may be some double counting, but this is 40x the amount of QALYs seemingly accounted for by NHS interventions)

Prevalence stats 1) http://www.hscic.gov.uk/catalogue/PUB05131/obes-phys-acti-diet-eng-2012-rep.pdf

Prevalence stats 2) http://www.hscic.gov.uk/catalogue/PUB17712/alc-eng-2015-rep.pdf

QALYs cost (from a Scandinavian study) http://www.ncbi.nlm.nih.gov/pubmed/17852988

3) Conclusion:

Based on these data, health behaviours in the UK have a far greater impact on life expectancy and quality of life than does the quality of medical care.  Challenging!  A good incentive to encourage our patients to get active, stop smoking, and lose weight.

Causes of death in the UK (2014) - ONS

Risk factors for death with high income Europe highlighted - WHO (2009):
Smoking - 15% of the 3.8m total deaths
The other cardiovascular factors are combined elsewhere in the research paper to give the 25% figure