Over the past 10 years of being involved in the management of patients with chronic pain I have treated a large number of professional and amateur musicians with pain problems related to their musical pursuits.

Many of the problems musicians have are also found in anyone whose job involves repetitive action and static loading of muscle groups — some of the most potent of causes of the current soft tissue injury explosion.

Posture and ergonomics The entry of ergonomic concepts into the field of industry was hastened by the ‘RSI Epidemic’ of the early 1980’s in Australia. Many of the solutions to the problems of ov-erusage in industry have application for teachers of music and voice.

Bernardino Ramazzini, a 17th Century Italian physician, was the first doctor to try and link the type of work performed with a range of illnesses in workers ranging from those who worked in mines, scribes, leather workers and those who worked in metals. In his 1700 work ‘Diseases of Workers’ Ramazzini wrote:

‘Various and manifold is the harvest of diseases reaped by certain workers from the crafts and trades that they pursue; all the profit that they get is fatal injury to their health. That crop germinates mostly, I think, from two causes. The first and most potent is the harmful character of the materials that they handle, for these emit noxious vapours and very fine particles inimical to human beings and induce particular diseases; the second cause I ascribe to certain violent and irregular motions and unnatural postures of the body, by reason of which the natural structure of the vital machine is so impaired that serious diseases develop therefrom.’

Although the first part of Ramazzini’s statement may not have relevance to repetitive action, the second certainly does.

If one cannot alter the basic position of wrist and fingers or the limbs in general, then it is likely the person performing the action will do so with undue muscular exertion and they may be statically loading their muscles more than they need to. In the case of music students, correction or prevention of these faults should be the responsibility of the teacher.

Static loading or isometric contraction of the muscles of the shoulder girdles and the upper back is one of the major contributing factors in the development of overusage symptoms of pain, stiffness, weakness and exhaustion in these areas.

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85% of headaches seen by CP’s are of the tension-type. These may not always occur in the same part of the head. Nor do they occur for the same reason.

Many headaches are caused probably by muscle tension which is secondary to tension, anger, and other repressed feelings which lead to muscle spasm.

They are usually felt in the back of the head but they may also occur in the temples. They are sometimes associated with eyestrain and pain around the eye sockets.

When the opinion of the eye specialist is that the eyes are perfectly normal, then the headaches are almost certainly due to tension.

Tension headaches are commonly described as being ‘like a tight band’ or ‘like someone is drilling a needle into my temple’. Such headaches are often in evidence for prolonged periods — literally from hours to days or even weeks. Some complain that they awaken with the headache and go to sleep with it.

They are often triggered by whiplash type injuries following motor car accidents. Recently, patients with repetitive strain injury have also complained of similar headaches as well as their other soft tissue pain.

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One of the greatest challenges facing medicine today is not how to practise acupuncture or cure cancer or osteoarthritis. Rather, it is a careful and objective evaluation of Western medicine. How is the Hippocratic requirement satisfied that treatment must, first of all, cause no harm?

Pain is the most common symptom confronting the doctor. Yet, curiously, it has no standard definition. Why do some respond well while others repeatedly return to haunt their doctor because their pain shows little improvement?

Pain can occur without injury — and injury without pain. Pain is not just a function of the amount of bodily damage alone. The amount, and quality, of the pain we feel is also determined by our previous experiences and how well we remember them. Our ability to understand the causes of pain and to grasp its consequences, as well as our cultural values, all play an important role in the way we perceive and respond to pain.

Pain cannot be measured. The doctor must rely entirely on the patient’s description in trying to understand what the patient experiences. There are several thresholds related to pain. Typically, thresholds are measured by applying a stimulus such as electric shock or radiant heat in the small area of skin and actually increasing the intensity.

Complex assessment

A reason for the hitherto lack of accurate assessment of the causes of chronic pain is that the condition involves complex combinations of sensory, perceptual, psychological, psycho-social and environmental factors.

Thus often a concerted effort has to be made by a closely knit team of interested practitioners to make the correct diagnosis and develop the most effective treatments. This team approach which is the basis of pain clinics is now gaining popularity. Chronic pain sufferers can only rejoice.

But let’s have a burst of refreshing honesty here. Doctors aren’t gods. They don’t know everything about everything! There is still much to be learned. And while many patients can be helped, it is impossible to help everyone.There are no magic cures. No magic wands. What has to be stressed is more effective pain management. That simply means the patient must be helped to cope with pain which is likely to persist for indefinite periods even if its severity cannot be totally relieved.

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There are still many gaps in our knowledge of the physiology of pain. In many areas medical science is still on the low end of the learning curve, particularly with non-malignant painful conditions.

However research into pain has been on the increase since the 1970s largely because of:

1. the ‘gate theory’ of pain by Melzack and Wall in 1965

2. the unprecedented curiosity about acupuncture anaesthesia

3. the rapid development of pain therapy programs

4. the awareness of the need to understand pain more clearly to more effectively treat it

5. the formation of the I ASP (International Association for the Study of Pain) and the publication of its journal Pain.

Improvements in patient care have been partly due to the interest of professionals in learning how to manage acute and chronic pain more effectively.

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