OVERUSE INJURIES AND PIANO TECHNIQUE: A BIOMECHANICAL APPROACH by BRENDA G. WRISTEN, B.A., M.M. A DISSERTATION IN FINE ARTS Submitted to the Graduate Faculty of Texas Tech University in Partial Fulfillment of the Requirements for the Degn'ee of DOCTOR OF PHILOSOPHY Approved August, 1998 Ac , li^'D /1 ©1998, Brenda G. Wristen ACKNOWLEDGEMENTS I would like to extend my sincerest gratitude to Dr. Lora Deahl: teacher, mentor, and friend. Her constant guidance and encouragement has been truly invaluable, both in the writing of this docimient and throughout the course of my graduate study. I am truly indebted for her personal concern and the sharing of her keen intellect and musicianship. I would also Uke to thank Dr. Roger James for his expert assistance in the area of biomechanics; without it, this dissertation would have been impossible. Deepest appreciation is extended to all members of my dissertation committee-Dr. Lora Deahl, Dr. Roger James, Dr. Paul Cutter, Dr. Donald Tanner, and Dr. Daniel Nathan-for their constant willingness to read and offer suggestions and support. I am especially appreciative of Dr. Jane Ann Wilson for her guidance in teaching class piano, her unwavering encouragement, and her many acts of generosity. I am also sincerely grateful to Dr. Wayne Hobbs for sharing his expertise and insights concerning musicology and for providing valuable career advice. Finally, I would Uke to thank all of the faculty and staff members from the Texas Tech School of Music for their many kind expressions of caring and words of encouragement during the course of my doctoral study. 11 TABLE OF CONTENTS ACKNOWLEDGMENTS ii ABSTRACT vi LISTOFTABLES viii LIST OF FIGURES ix CHAPTERS I. INTRODUCTION 1 Justification 1 Review of Related Literature 5 Biomechanical Models of Fingertip Position 5 Biomechanical Models of the Hand 8 Correlation of Hand Characteristics with Overuse Injuries 12 Wrist Motion 13 Upper Arm and Torso ...16 Control of Horizontal and Vertical Motion at the Piano . 18 Ergonomics of Virtuosity 19 Summary of Literature 21 Methodology 22 n. TWENTIETH CENTURY PEDAGOGICAL VIEWS OF THE PLAYING APPARATUS 24 Historical Survey of Piano Technique 24 LudwigDeppe (1828-1890) 25 Theodore Leschetizky (1830-1915) 26 Josef Lhevinne (1874-1944) 27 Tobias Matthay (1858-1945) 29 Paul Pichier (1873-1955) 35 Abby Whiteside (1881-1956) 41 Otto Ortmann (1889-1979) 43 George Kochevitsky (1903-1993) 47 General Principles of Twentieth Century Piano Pedagogy 49 Views Concerning The Use of Technical Exercises 52 Use of Exercises Versus Isolation of Technical Problems Contained Within Repertoire 52 Finger Independence Exercise 59 111 III. BIOMECHANICAL DESCRffTIONS OF SELECTED SKILLS 67 Constraints Upon Movement 67 Environmental Constraints 67 Biomechanical Constraints 69 Morphological Constraints 69 Interactions of Constraints 71 The Playing Apparatus: A Kinesiological Description 72 Structure of The Shoulder 72 Structure of The Elbow 79 Structxire of The Wrist 84 Structure of The Hand and Fingers 86 Biomechanical Description of Selected Piano Skills 91 Scales 94 Arpeggios 118 TriUs 132 Double Notes 145 Broken Chords and Octaves 166 IV. PREVENTION OF KEYBOARD INJURIES BASED ON MEDICAL, BIOMECHANICAL, AND ERGONOMIC OBSERVATIONS 174 Overuse Injuries in Pianists 174 Overuse Injury Terminology Conflicts 175 Acute Versus Overuse Injuries 176 Force Characteristics 178 Muscle Characteristics 179 Actions of Muscles 180 Muscular Strength 181 Muscular Power 182 Muscular Endurance 182 Tendon Characteristics 184 Elastic Properties of Tendons 185 Viscoelastic Properties of Tendons 187 Summary of Forces Relevant to Tendon Loading 188 Preventing Keyboard Injuries 189 Common Sites and Types of Injuries 189 Risk Factors for Developing Keyboard Injuries 202 Recommendations for Preventing Keyboard Injuries . 227 V. CONCLUSION 230 The Need For Biomechanical Analysis of Piano Technique 230 Instructions for Performing Qualitative Analysis 234 Suggestions for Further Research 251 iv BIBLIOGRAPHY 253 APPENDICES A: GLOSSARYOFTERMS 260 B: ADDITIONAL ANATOMIC FIGURES 266 C: ADDITIONAL FACTORS RELEVANT TO MUSCLE AND TENDON FUNCTION 273 ABSTRACT Of the total number of musicians seeking medical help each year for injury, over half are pianists. Inappropriate playing technique is a contributing factor to the development of an injury. Pedagogues did not begin to concern themselves with the physiological aspects of piano playing until the twentieth century. Even then, recommendations for building technique were primarily based on the playing techniques of famous performing artists and were often idiosyncratic. These observations are opinion-based and are not applicable to all players; furthermore, in many cases they are biomechanically and ergonomically insupportable. This dissertation is the first study to approach the combined motions comprising specific pianistic tasks from a biomechanical perspective, taking into account environmental, anatomic, and biomechanical constraints. Twentieth-century pedagogical views concerning piano technique are surveyed, and the debate concerning the appropriate use of exercises is explored. The kinesiology of the playing apparatus is detailed. A theoretical biomechanical norm is offered for seven different pianistic tasks: scales, arpeggios, trills, double-third scales, octave scales, broken chords, and broken octaves. Mechanical factors of muscles and tendons and their responses to force application are described. Common sites and types of injuries suffered by pianists are also discussed. Advice for the prevention of keyboard injuries is offered based upon both empirical and quantified data from the medical, biomechanical, and ergononuc sciences. Certain practice habits and movements are identified as having the potential to cause injury. vi The dissertation culminates with instructions for performing a qualitative biomechanical analysis of a given pianistic task on an individual pianist using checkHsts developed for that purpose. Vll LIST OF TABLES 3.1 Extrinsic Muscles of the Hand 92 3.2 Intrinsic Muscles of the Hand 93 5.1 Checklist for Scales 241 5.2 Checklist for Arpeggios 243 5.3 Checklist for Trills 244 5.4 Checklist for Double-Third Scales 245 5.5 Checklist for Octave Scales 246 5.6 Checklist for Broken Chords 247 5.7 Checklist for Broken Octaves 249 Vlll LIST OF FIGURES 2.1 Finger Independence Exercise around One Sustained Note .... 60 2.2 Finger Independence Exercise around a Sustained Chord 60 2.3 Finger Flexors 63 2.4 Finger Extensors 65 3.1 Glenohumeral Joint 74 3.2 Possible Movements of the Shoulder 76 3.3 Pronation and Supination 81 3.4 Pronator Quadratus 82 3.5 Supinator 83 3.6 Possible Movements of the Wrist '. 85 3.7 Joints of the Fingers 88 3.8 Possible Movements of the Thumb 89 3.9 Possible Movements of the Fingers 90 3.10 Arcs Described in the Frontal Plane by the Upper Arms and Torso in the Playing of a Scale 115 3.11 Flattened Circle Described in the Frontal Plane by the Right Elbow in Playing a Scale 117 3.12 Flattened Circle Described in the Frontal Plane by the Left Elbow in Playing a Scale 117 4.1 Stress-Strain Curve for Tendons 186 4.2 The First Dorsal Extensor Compartment 193 4.3 'Trigger" Finger 194 4.4 The Carpal Tunnel 196 4.5 Cubital Tunnel Syndrome 198 ix 4.6 Thoracic Outlet Syndrome 199 4.7 Optimum Position for Reduction of DIP Joint Force 211 4.8 Optimimi Position for Reduction of MCP Joint Force 211 4.9 Optimum Position for Reduction of FDP Tendon Force 213 5.1 General Reconunendations for Prevention of Piano-Related Overuse Injuries 233 5.2 Worksheet for Conducting Subjective Qualitative Analysis of a Skill 239 B.l Insertions of Long Flexor and Extensor Tendons in the Fingers 267 B.2 Posterior View of the Forearm 268 B.3 Anterior View of the Forearm 269 B.4 Major Flexor Muscles of the Shoulder 270 B.5 Major Extensor Muscles of the Shoulder 270 B.6 Major Abductor and Adductor Muscles of the Shoulder 271 B.7 Major Horizontal Adductor and Abductor Muscles of the Shoulder 272 CFLAPTER I INTRODUCTION lustification In the last decade, interest in injuries caused by music-making activities has dramatically increased. Performing Arts Medicine has evolved into a distinct medical specialty in response to these concerns. Books, articles, and videotape series concerning overuse injuries and other medical problems of musicians are appearing at an exponentially increasing rate. Unfortunately, while writings and research concerning music-related injuries have prohferated in the medical community, the professional music world has only just begun to focus attention upon this problem. The focus of the majority of articles that have been written on music- related injuries is upon treatment of these problems. Fewer are the articles that discuss prevention of injuries, and fewer still, those which discuss the correlation between injury and piano technique. Among piano teachers, a debate has arisen in the midst of the rising tide of injured players as to the appropriateness of using technical exercises. Technical exercises and etudes have been emphasized by performers and teachers as the best way to build a strong technique for the past two himdred years. Piano pedagogy experts are beginning to challenge that view, in the belief that misuse of these exercises is all too common and leads to injury. This divergence of opinion is epitomized in a series of discussions between Fernando Laires and Dorothy Taubman which appeared in Piano Quarterly in 1987 concerning Isidor Philipp's "Exercises for the Independence of the Fingers."! Laires, a student of PhiUpp, claims that these exercises are not in and of themselves hazardous. Taubman, who has experience in helping rehabilitate injured pianists through modification of technique, disagrees. She points out that there are certain notated features in the exercises which can be physically damaging. This debate over the appropriateness of using exercises in the development of piano technique is but one facet of a larger issue: How can the risk of sustaining a piano-related injury be minimized? Much of the advice given by well-known piano pedagogy experts is not built upon a correct understanding of anatomical fimction and is therefore suspect.