บรรยายในการประชุมวิชาการประจำปีของชมรมศัลยแพทย์ทางมือแห่งประเทศไทย ครั้งที่ 35 "Hand Surgery in Disruptive Society" ณ คณะแพทยศาสตร์ มหาวิทยาลัยธรรมศาสตร์ วันที่ 21-22 มีนาคม 2562

1. Nerve Entrapment in Musicians
Nattakul Yamprasert, MD
Department of Orthopaedics
Maharat Nakhon Ratchasima Hospital

2. Musician
A person who plays a musical instrument as their job or hobby. (Collins Eng. Dict.)
A person who plays a musical instrument, especially as a profession, or is musically
talented. (Oxford Dict.)
Someone who is skilled in playing music, usually as a job (Cambridge Eng. Dict.)
“INSTRUMENTALIST”

3. Physician’s Perpective

4. Musician’s Perpective

5. Incidence of Nerve Entrapment in Musicians
Hochberg (JAMA,1983) 15%
Lederman (Med Prob Perform Art, 1989) 13%
Lederman (Med Prob Perform Art, 1993) 22%
Lederman (Med Prob Perform Art, 2006) 20%
(Based on 1,353 musician patients)

6. Nerve Entrapment in Musicians
Thoracic Outlet Syndrome (22%)
Cubital Tunnel Syndrome (21%)
Carpal Tunnel Syndrome (18%)
Cervical Spondylosis (9%)

7. Other Diagnosed Nerve Entrapment
● Focal dystonia
● Digital Neuropathy (flutists’ neuropathy)
● Pronator syndrome
● Guyon’s canal syndrome
● Posterior interosseous neuropathy
● Long thoracic neuropathy

8. “What’s different between
musicians and nonmusicians?”

9. ● High functional demand
● Seeking prompt treatment
● Musical instrument is
primary source of income
● Desire aggressive
treatment in mild
symptom due to
noticeable performance
impairment

10. How Physicians Deal?

11. Patient Evaluation

12. Patient Evaluation
● The instrument played
● Level of skill
● Practice habits
● Technique applied

13. Physical Examination
● Inspection
● Palpation
● Provocative Tests
● Bring the musical instrument to medical
office visit

14. Physical Examination
● Evaluate with and without instrument
● Musician - instrument mismatch
● Static and dynamic stress during playing

15. Violinist
Left Elbow:
● Flexion
Left Wrist:
● Flexion
Left Forearm:
● Supination
Right Shoulder, Elbow & Wrist:
● Repetitive motion

16. Left Elbow:
● Flexion
Left Forearm:
● Neutral
Cellist

17. Forearms:
● Pronation
Pianist
Wrists:
● Neutral-palmar flexion

18. Left Wrist:
● Flexion
Guitarist

19. Left Shoulder:
● Internal Rotation
● Adduction
Right Shoulder:
● External Rotation
● Abduction
Left Wrist:
● Extension
● Radial deviationRight Wrist:
● Extension
● Radial deviation

20. Extension + radial
deviation

21. Predisposing Factors
Compression by hypertrophied forearm muscles
Anoxia due to venous congestion caused by
playing posture
Friction trauma from repetitive motion

23. Nonoperative
Treatment
● Pharmacological
treatment
● Ergonomic of
instrument
● Decrease duration
of position at riskActivity modification

24. Ergonomic Design

25. Operative
Treatment
Same indication as in
nonmusicians but...
● Avoid operations
those may impair
sensation
● Postoperative
immobilization
before return to
play is mandatory
for some
instruments

26. Left Wrist:
● Flexion
Guitarist

27. Thai Musician Survey (2019)

28. Online Survey
Survey period: 1st - 20th March, 2019
Electronic-based (Google Form)
Distribution via
● LINE
● Twitter
● Facebook

29. 61 Participants
23 full-time musicians
13 part-time musicians
25 non-professional musicians

31. 1. Guitar (Acoustic,
Electric)
2. Piano, Flute

32. Wrist & Finger

33. Pain

35. 1 Medication
2 Physical Therapy

36. Take Home Messages
Management of nerve entrapment in the
musician requires thorough understanding
of extraordinary demands to return to
pre-illness level of function.
Most of these patients responded to
nonoperative treatment.
In case of surgery, avoid disturbing critical
tactile sensation..