Pain and hand problems are caused by moving improperly. Ergonomic equipment, in theory, is designed to force your body into proper positions. They CAN work but it would be better for you to learn how to move ergonomically without the equipment.
The reason is, let’s say you have an improper ulnar deviation when you type (wrist twists to the left on your left and right on your right), you can still execute that improper motion with an ergonomic keyboard and, what good is fixing your typing deviation when you open doors, brush your teeth, write, use your phone or drive your car with the same deviation?
You can’t spot fix ergonomic problems. It is all or nothing. That is why people don’t heal because they try to fix isolated symptoms and not everything that is part of the problem. You may have pain in your wrist but that is only the location of the symptom. The problem is most likely how you are using your whole arm.
Often it is not a single movement that is a problem but a cavalcade of movement issues. You may type with flat fingers, curled fingers, too much pressure, equalized fingers, not enough “up,” radial deviation, you may abduct too much, you might isolate a finger, dorsiflexion, have an isolated elbow or shoulder . . . there are a lot of motions we should not do but we do them because many of us are lazy and unaware.
In the old days, manual typewriters forced us to type with the weight of the arm or, gravity. Today's effortless keyboards have insidiously encouraged us not to use gravity and the fulcrum of the elbow to type and thus, we isolate smaller parts which strain our tendons. There is no such thing as "repetitive stress." There is only improper movement and if you move improperly, all movement is then "repetitive stress."
Imagine casting a fishing pole with just your fingers, you'd probably hurt yourself. Now imagine that only with the wrist. That is better but still not optimal. Now with your elbow. Better. Add the shoulder. Notice how you are now using all the parts of the arm for one movement. No single part is isolated but they all share in the casting, including but not exclusively the fingers. Now as you cast, notice how your feet are planted, how your weight or center of gravity is distributed, your back and abs, notice also the equal and opposite motion required to cast. In order to cast forward you must first cast backward. Typing, too. In order to type down you must first have an up motion. Without it, you will strain your flexor tendons. That is also the most dangerous part of using a mouse. We rest our index finger and long flexor tendon flat on the button and click with no "up" or equal and opposite motion. There is nothing wrong with the mouse, only how we use it.
The laws of physics must be obeyed. Break them and there is a price to pay.
Showing posts with label carpal tunnel. Show all posts
Showing posts with label carpal tunnel. Show all posts
Monday, January 20, 2020
Monday, April 30, 2018
Point Of Sound
One of the causes for strain, stress, injury and
other maladies pianists, organists and typists experience is simply that
they press too hard into the keybed of their device or instrument.
Let's first take a look at sports and then physics (that HS subject you
think you don't use in real life).
As a baseball player stands at home plate and the ball is hurtling toward him, he back-swings, forward swings, hits the ball, then all the energy left over from the swing dissipates into the follow through. The same action occurs when an athlete swings a tennis racquet, kicks a ball, swings a golf club, punches someone, throws a ball, etcetera. That is Newton's third law of physics that every action has an equal and opposite action. In order to forward swing, one must first back swing. Even when we walk forward, as one leg is extending up and forward, the other leg is pushing backward. So according to the laws of physics, in order to type or play the piano down, one must first lift up. Many of us were trained or taught to play or type from a resting and relaxed position which actually creates tension because holding a position requires effort. So we know that everything requires an opposite motion and a follow through. I bet all you smart kids out there know exactly where I'm going with this.
Now imagine that our baseball, tennis, soccer, golf, football players or boxers are standing before a concrete wall and they backswing then forward swing but instead of hitting an object and following through, they strike the immovable wall. All the energy of the swing, instead of following through and dissipating, ricochets back into the athlete. That can hurt.
A piano is much the same. Many pianists press into the keybed of a piano and not only does that fail to produce any more of a tone but, all the energy of pressing down is being transferred back up into their finger joints and tendons. We often don't notice this until after an hour or so of practice or the next morning when we wake up with stiff fingers. We are taught by bad teachers "no pain, no gain." In this case, it is very much a lie. No pain, no gain is fine when building muscle but not for bones, joints, tendons, ligaments and certainly not for our technique. Often poor technique, strain or missed notes are a result of what we are not doing rather than what we are doing and often we are using the wrong muscles.
Sit at any acoustic piano and very slowly, depress a key so you don't play a sound. At some point you will hit a little bump in the action, then press through it and you will hit the keybed. That little bump is the point of sound once you actually play.
As a pianist drops the controlled weight of their arm onto a key, they must use Newton's third law. As they hit the point of sound, much like an athlete striking a ball, they must then follow through without hitting the keybed. When they press into the keybed, not only is their energy backfiring but, they are pressing down and according to Newton, we can't set up for the up motion if we are pressing down. This hinders technique. You can't play down if you don't play up and you can't play up if you are pressing down.
So, the key and cure to playing without tension or pain is learning to play to the point of sound and simply following through and not pressing into the keybed. Unbeknownst to most teachers, their students press into the keybed. It is a motion that is often invisible. When a student experiences problems with technique or pain, the teacher often says practice more or run exercises to build strength and endurance and the teacher is often oblivious that the way the student practices is what needs to be addressed, not a clock.
Danger Will Robinson. Before anyone tries to learn to play to the point of sound, there are other components of technique which must first be in place. This includes controlling arm weight, controlling up/down, controlling in/out from the shoulder and elbow, using the fulcrum of the elbow, controlling rotation of the forearm through the use of the pronator and supinator muscles. Likewise, there are movements to avoid such as abduction, curling the thumb under the palm, isolating a finger, equalizing fingers, radial and ulnar deviation, and trying to play too relaxed, still and quiet.
A virtuoso technique looks like it is effortless and relaxed. That is true, the fingers are relaxed because the arm does all the work. Observers are often looking at the pianist's hands and fail to notice the elbow and arm is actually doing most of the work. Pianists who attempt to play from the fingers and have fatigue, are told to relax so, they relax the same muscles they are continuing to use and they achieve nothing.
Once all of the proper motions are achieved and the improper ones eradicated, point of sound will just happen. Some "techniques" such as the Russian Technique, surreptitiously imbue the pianist with these movements but personally, I would rather learn the physics and ergonomics of movement rather than being tricked through mindless imitation. Although, it works to some degree. Where it fails is when a pianist encounters a passage they can't execute and if they knew the mechanics of the arm, would be able to figure out what sort of adjustment is required to play that passage.
I once studied with a leading concert pianist in my area who didn't know what he was doing but had a phenomenal natural technique. His instruction to me was to watch him play then imitate his motion. That would have been fine but I already had bad habits hardwired into my brain which were getting in the way. Since he didn't know anything about ergonomics nor physics, he had no idea how to fix me other than prescribing "practice more."
I once gave a lecture on this topic and a pianist disagreed with me about Newtons third law citing that the piano is down, not up. The finger must come straight down onto a key. If the pianist is playing with a "still and quiet hand" and they must also play black keys, note that the black keys are higher than the white keys. This results in the still and quiet pianist to stretch or twist to reach those keys which in turn create vector forces or, two muscles pulling one bone in two directions simultaneously. This creates tremendous imbalance in the arm which controls the hand and fingers and this leads to an incoordinate technique. Keep in mind your fingers have no muscles. They are moved by the flexor muscles in your forearm so that is where the pianist must first play from.
If you were to walk up stairs, your ascending leg would lift HIGHER than the next stair, then come straight down onto it. If you tried to walk upstairs without lifting your foot higher than the step, you'd trip. Playing the piano is the same. We must use the larger muscles of the arm to get the fingers higher than the notes we are desirous to play. Of course as we become more efficient, we minimize the height but make no mistake, although it may appear invisible, it is still there. Hanon knew this and prescribed the pianist to isolate one finger and lift it high but, this isolation engages the flexors and extensors at the same time resulting in strain to the long flexor tendons which leads to median nerve entrapment (AKA carpal tunnel syndrome). Remember the arm, hand and fingers can only move in one direction at a time. By abducting, for instance, the hand gets pulled in two or four directions despite the pianist trying to play a passage in a specific direction.
I have no conclusion to this post other than don't try this at home. Find a teacher who knows what a pronator and abductor is and work from there.
As a baseball player stands at home plate and the ball is hurtling toward him, he back-swings, forward swings, hits the ball, then all the energy left over from the swing dissipates into the follow through. The same action occurs when an athlete swings a tennis racquet, kicks a ball, swings a golf club, punches someone, throws a ball, etcetera. That is Newton's third law of physics that every action has an equal and opposite action. In order to forward swing, one must first back swing. Even when we walk forward, as one leg is extending up and forward, the other leg is pushing backward. So according to the laws of physics, in order to type or play the piano down, one must first lift up. Many of us were trained or taught to play or type from a resting and relaxed position which actually creates tension because holding a position requires effort. So we know that everything requires an opposite motion and a follow through. I bet all you smart kids out there know exactly where I'm going with this.
Now imagine that our baseball, tennis, soccer, golf, football players or boxers are standing before a concrete wall and they backswing then forward swing but instead of hitting an object and following through, they strike the immovable wall. All the energy of the swing, instead of following through and dissipating, ricochets back into the athlete. That can hurt.
A piano is much the same. Many pianists press into the keybed of a piano and not only does that fail to produce any more of a tone but, all the energy of pressing down is being transferred back up into their finger joints and tendons. We often don't notice this until after an hour or so of practice or the next morning when we wake up with stiff fingers. We are taught by bad teachers "no pain, no gain." In this case, it is very much a lie. No pain, no gain is fine when building muscle but not for bones, joints, tendons, ligaments and certainly not for our technique. Often poor technique, strain or missed notes are a result of what we are not doing rather than what we are doing and often we are using the wrong muscles.
Sit at any acoustic piano and very slowly, depress a key so you don't play a sound. At some point you will hit a little bump in the action, then press through it and you will hit the keybed. That little bump is the point of sound once you actually play.
As a pianist drops the controlled weight of their arm onto a key, they must use Newton's third law. As they hit the point of sound, much like an athlete striking a ball, they must then follow through without hitting the keybed. When they press into the keybed, not only is their energy backfiring but, they are pressing down and according to Newton, we can't set up for the up motion if we are pressing down. This hinders technique. You can't play down if you don't play up and you can't play up if you are pressing down.
So, the key and cure to playing without tension or pain is learning to play to the point of sound and simply following through and not pressing into the keybed. Unbeknownst to most teachers, their students press into the keybed. It is a motion that is often invisible. When a student experiences problems with technique or pain, the teacher often says practice more or run exercises to build strength and endurance and the teacher is often oblivious that the way the student practices is what needs to be addressed, not a clock.
Danger Will Robinson. Before anyone tries to learn to play to the point of sound, there are other components of technique which must first be in place. This includes controlling arm weight, controlling up/down, controlling in/out from the shoulder and elbow, using the fulcrum of the elbow, controlling rotation of the forearm through the use of the pronator and supinator muscles. Likewise, there are movements to avoid such as abduction, curling the thumb under the palm, isolating a finger, equalizing fingers, radial and ulnar deviation, and trying to play too relaxed, still and quiet.
A virtuoso technique looks like it is effortless and relaxed. That is true, the fingers are relaxed because the arm does all the work. Observers are often looking at the pianist's hands and fail to notice the elbow and arm is actually doing most of the work. Pianists who attempt to play from the fingers and have fatigue, are told to relax so, they relax the same muscles they are continuing to use and they achieve nothing.
Once all of the proper motions are achieved and the improper ones eradicated, point of sound will just happen. Some "techniques" such as the Russian Technique, surreptitiously imbue the pianist with these movements but personally, I would rather learn the physics and ergonomics of movement rather than being tricked through mindless imitation. Although, it works to some degree. Where it fails is when a pianist encounters a passage they can't execute and if they knew the mechanics of the arm, would be able to figure out what sort of adjustment is required to play that passage.
I once studied with a leading concert pianist in my area who didn't know what he was doing but had a phenomenal natural technique. His instruction to me was to watch him play then imitate his motion. That would have been fine but I already had bad habits hardwired into my brain which were getting in the way. Since he didn't know anything about ergonomics nor physics, he had no idea how to fix me other than prescribing "practice more."
I once gave a lecture on this topic and a pianist disagreed with me about Newtons third law citing that the piano is down, not up. The finger must come straight down onto a key. If the pianist is playing with a "still and quiet hand" and they must also play black keys, note that the black keys are higher than the white keys. This results in the still and quiet pianist to stretch or twist to reach those keys which in turn create vector forces or, two muscles pulling one bone in two directions simultaneously. This creates tremendous imbalance in the arm which controls the hand and fingers and this leads to an incoordinate technique. Keep in mind your fingers have no muscles. They are moved by the flexor muscles in your forearm so that is where the pianist must first play from.
If you were to walk up stairs, your ascending leg would lift HIGHER than the next stair, then come straight down onto it. If you tried to walk upstairs without lifting your foot higher than the step, you'd trip. Playing the piano is the same. We must use the larger muscles of the arm to get the fingers higher than the notes we are desirous to play. Of course as we become more efficient, we minimize the height but make no mistake, although it may appear invisible, it is still there. Hanon knew this and prescribed the pianist to isolate one finger and lift it high but, this isolation engages the flexors and extensors at the same time resulting in strain to the long flexor tendons which leads to median nerve entrapment (AKA carpal tunnel syndrome). Remember the arm, hand and fingers can only move in one direction at a time. By abducting, for instance, the hand gets pulled in two or four directions despite the pianist trying to play a passage in a specific direction.
I have no conclusion to this post other than don't try this at home. Find a teacher who knows what a pronator and abductor is and work from there.
Thursday, June 16, 2016
Playing With Fire Workshop
I recently presented a workshop called "Playing With Fire" which was designed to teach people how to move ergonomically whether they are musicians, computer users or stay at home moms who make arts and crafts with the kids during the day. There is an epidemic of repetitive strain injuries and the current treatment options presented by the medical community are flawed, destructive and unnecessary.
The first thing everyone needs to know is what causes the most common of repetitive strains: Carpal Tunnel Syndrome. It's medical name is Median Nerve Entrapment. If someone misuses their hands to the point that they inflame the long flexor tendons in the forearm and wrist, the inflamed tendons which now takes up more space, has no place to go. There are bones on one side of the wrist and the traverse carpal ligament on the other. So when the tendon inflames it presses on the only other tissue in the tunnel - the median nerve. Much like sitting between two overweight people on an airplane. The symptoms of a crushed nerve are pain, numbness and tingling. The reasons for the inflammation are quite easy to understand. The most common is a break in the wrist while performing repetitive tasks. The other is dual muscular pulls. Obviously we can only move one body part in one direction at a time but we often move our fingers in two directions at a time. We may flex one and either abduct or extend another. Even though we can do this, the extender and flexor muscles are still interconnected and we are using both at the same time. This act of tension usually puts all the strain on the tendons. In the piano world, our teachers either tell us to practice more, build up the muscles or relax. That is all bad advice. Practicing more bad movement, building up the wrong muscles and relaxing the wrong muscles will only create more problems.
When someone develops symptoms of median nerve entrapment they go to see their doctor who then begins to treat the symptom. They may ask what you think caused the strain and may suggest that you stop doing it for a while. This logic is greatly flawed. If you are moving incorrectly and rest for a while, the inflammation may indeed dissipate however, the erroneous movement is still part of you and when you take up the practice again, the problem will still be there and the symptom will come back. Symptoms are actually good. They tell us that something is wrong. Fix what is wrong, not the symptom.
Other treatment options may include anti inflammatory drugs, cortisone injections (which do a lovely job at dissolving tissue), splints which goes against everything we know about movement or, surgery, which is often totally unnecessary.
The actual solution and "cure" is simply movement re-education. The patient needs only to learn how to move properly. This could include not bending or twisting the wrist, not moving the fingers while bending the wrist, learning to not use tiny muscles to do some movements but instead use the larger muscles which are naturally designed to do that movement, learn the proper alignment of the arm and how it is the arm that must support the hand and not the hand moving independent of it, avoiding dual muscular pulls which can be crippling to the hand.
Not everyone has the capacity, patience, intellect or determination to heal. We've come to beleive that a doctor can fix our problems and we all want a quick fix. Who wants to spend months or even years learning to undo bad habits when a doctor can make a slice with a scalpel and like magic, the issue seemingly disappears. As I said, doctors tend to treat symptoms and not the problems. If the problem is we are moving incorrectly, we shouldn't be seeing a doctor. My favorite analogy to use is if your wheels are out of alignment and wearing down your tires, you don't just get new tires, you have to fix the alignment. If your body is out of alignment and wearing down the soft tissue in your wrists, you don't just make room for the inflammation by having surgery, you need to fix the alignment.
The first thing everyone needs to know is what causes the most common of repetitive strains: Carpal Tunnel Syndrome. It's medical name is Median Nerve Entrapment. If someone misuses their hands to the point that they inflame the long flexor tendons in the forearm and wrist, the inflamed tendons which now takes up more space, has no place to go. There are bones on one side of the wrist and the traverse carpal ligament on the other. So when the tendon inflames it presses on the only other tissue in the tunnel - the median nerve. Much like sitting between two overweight people on an airplane. The symptoms of a crushed nerve are pain, numbness and tingling. The reasons for the inflammation are quite easy to understand. The most common is a break in the wrist while performing repetitive tasks. The other is dual muscular pulls. Obviously we can only move one body part in one direction at a time but we often move our fingers in two directions at a time. We may flex one and either abduct or extend another. Even though we can do this, the extender and flexor muscles are still interconnected and we are using both at the same time. This act of tension usually puts all the strain on the tendons. In the piano world, our teachers either tell us to practice more, build up the muscles or relax. That is all bad advice. Practicing more bad movement, building up the wrong muscles and relaxing the wrong muscles will only create more problems.
When someone develops symptoms of median nerve entrapment they go to see their doctor who then begins to treat the symptom. They may ask what you think caused the strain and may suggest that you stop doing it for a while. This logic is greatly flawed. If you are moving incorrectly and rest for a while, the inflammation may indeed dissipate however, the erroneous movement is still part of you and when you take up the practice again, the problem will still be there and the symptom will come back. Symptoms are actually good. They tell us that something is wrong. Fix what is wrong, not the symptom.
Other treatment options may include anti inflammatory drugs, cortisone injections (which do a lovely job at dissolving tissue), splints which goes against everything we know about movement or, surgery, which is often totally unnecessary.
The actual solution and "cure" is simply movement re-education. The patient needs only to learn how to move properly. This could include not bending or twisting the wrist, not moving the fingers while bending the wrist, learning to not use tiny muscles to do some movements but instead use the larger muscles which are naturally designed to do that movement, learn the proper alignment of the arm and how it is the arm that must support the hand and not the hand moving independent of it, avoiding dual muscular pulls which can be crippling to the hand.
Not everyone has the capacity, patience, intellect or determination to heal. We've come to beleive that a doctor can fix our problems and we all want a quick fix. Who wants to spend months or even years learning to undo bad habits when a doctor can make a slice with a scalpel and like magic, the issue seemingly disappears. As I said, doctors tend to treat symptoms and not the problems. If the problem is we are moving incorrectly, we shouldn't be seeing a doctor. My favorite analogy to use is if your wheels are out of alignment and wearing down your tires, you don't just get new tires, you have to fix the alignment. If your body is out of alignment and wearing down the soft tissue in your wrists, you don't just make room for the inflammation by having surgery, you need to fix the alignment.
Thursday, December 24, 2015
Healing from Repetitive Stress Injuries Naturally
Healing from Repetitive Stress Injuries Naturally
The original video was an hour long so I made copious cuts to shorten it. Unfortunately, the many cuts caused an audio sync issue. Deal with it. Close your eyes, don't watch my lips.
Thursday, October 22, 2015
Friday, December 20, 2013
Ligaments, Tendons and Bumps, Oh My!
A 20 year old piano major approached me about two months ago because she
was experiencing some disturbing symptoms and was wondering if I could
help her. Amy wasn't having any discernible problem playing but her
plaint was when she woke up in the morning or in the middle of the
night, her three middle fingers were stiff, almost locked and painful.
After she slowly flexed them a few times they were fine and they didn't
give her any problems until the next morning. Her teacher was assigning
several difficult works for her to study and forcing her to play with
flat fingers so I took about ten minutes to feel her hands and fingers
and immediately knew what her problem was.
Our tendons are made up of thousands of fibers all neatly bundled together, those bundles are bundled, then those bundles are bundled several times over and finally the entire massed bundle makes up a tendon about the size of a linguini and the tendon as a whole is protected in a lubricated sheath where it can glide back and forth effortlessly.
Think of the tendon as a plastic, polypropylene, polyester or nylon braided rope. The single rope as a whole is actually made up of thousands of smaller fibers making the whole greater than the individual parts. Every hiker, camper or construction worker knows that when you cut one of these ropes you need to finish off the ends by melting or burning it. This creates a little knot of melted materiel and prevents the rope from fraying. Likewise, as the rope is used, stretched, dragged over edges and exposed to friction, along the path of the rope there will be fraying. Shakespeare said it nicely, "Take but degree away, untune that string, And, hark, what discord follows!" Conversely, allow a rope to constantly fray, And hark, what discord follows.
The body repairs frayed tendons much the same, by putting little knots of scar tissue where damage has occurred. Doctors often refer to these knots as nodules. They can be quite painful and can eventually cause the finger to lock up. Laymen will refer this symptom as "trigger finger." Picture a sweater with a hole in it. If you were to sew up the hole, there would be a little knot there. Although the hole is now healed, the sweater won't wear as effortless as it used to. Every thread in a sweater is connected to every other thread and every movement will pull on that knot. That is why diagnosing hand issues is so difficult. The pain may be in the forearm but that is where the tissue is giving way because there is a knot in the palm.
When you flex your flexor muscles in your forearm, your muscles pull your long flexor tendon which is attached all the way to the tip of your finger and your finger bends. If there is a little knot or nodule anywhere in the sheath, usually near a joint or in the palm, the nodule can get snagged in the sheath and lock the finger. Forcing it open can cause more tearing and the build up of even more scar tissue. A downward spiral begins; Hark, what discord follows. As I felt Amy's hand, I could feel the little nodule bumps of scar tissue gliding back and forth.
Have you ever heard about the legend of the Gordian Knot? It was a knot so complicated that it was impossible to solve or unravel. Thousands tried but none were successful until Alexander the Great attempted to untie the knot. When he could not find the end to the knot to unbind it, he sliced it in half with a stroke of his sword. This technique of problem solving was called the "Alexandrian solution." A technique many doctors use today.
If Amy were to go see a doctor, the first thing he may suggest is to stop playing the piano for weeks or months, rest and wear a brace. Rest in these situations is not going to help. The body's defense against this kind of damage is to create scar tissue which is not flexible and will lock the tissue in place much like a spider web can entomb and insect. Scar tissue is what caused her problem in the first place. If you were to take an unraveled rope and just throw it in a pile, it would be in a tangled mess of a knot. Letting it sit there for six months will not untangle it. You need to slowly and patiently unravel it and straighten it out and then roll it back up neatly. That is what our bodies want us to do. When it comes to scar tissue, proper movement promotes healing, not rest.
A second treatment a doctor may prescribe Amy is physical therapy. This is close to the solution because as I said, proper movement promotes healing but PT most likely will not solve her problem. She will receive massage therapy, contrast baths, working with weights and pulleys, molding clay, wax and other muscle building techniques, but, when Amy goes home to her piano, all the physical therapy in the world won't be able to counteract the damage she will do in the privacy of her own home or practice room. Like the Battle of Thermopylae, it doesn't matter how many Persians march through the pass, the Greeks had the upper hand.
A third treatment option will most likely be a cortisone shot. Cortisone melts tissue. If the doctor can inject the cortisone directly into the nodule he can melt it away, along with anything else which comes in contact with the cortisone. No thank you.
A final treatment will be surgery where they will cut the sheath or scrape the nodule off the tendon and of course, the body will respond to the surgery by creating - say it with me - "scar tissue." The good news is during the several months it takes to fully heal, with PT, you will have full control over your fingers again. This may be a solution for the average person, however, for a concert pianist, the result could be devastating.
So what was Amy's problem causing her symptoms? It was simply her flat finger technique. Now, I'm not a university piano professor so I don't want to comment on his desire for Amy to play with flat fingers. What I do know is that the finger is made up of several bones which neatly line up and are held together by ligaments, pulled by tendons and controlled by muscle. If I were to poke you in the eye, I would align my fingers so all the bones were in a straight line for maximum eye poking jabs. A curved finger would not do the job as effectively. When playing the piano, the opposite is true.
There are two ways I teach my students to find their optimal finger alignment or kinetic chain. The first is to lay on the floor, flat on their backs with bended knee. With their arm to their side, gently isolate one finger and lightly press it to the floor while lifting the whole arm off the floor. Then gently rotate, swivel and explore a circle with the finger touching one spot on the floor. Not to get all Zen here, but as in everything in life, it is in the imbalance where we can find the balance. If you shift too far forward you will feel the tension in the front joint of the finger, too far back you will feel the tension in the tendon beneath. If you hyper-extend the finger, you will experience that discomfort, too. Do this will all five fingers and upon discovering the perfect effortless alignment, look at the finger and palm and take note of the perfect curve much like the dome of a cathedral ceiling. That is the finger at its optimal strength where the load bearing bones are properly aligned by the tendons. A second method of finding this alignment is to stand with your arms to your side. Shake your hands until they are loose then let them hang to your side. Without moving a single finger, raise your hand and look at your fingers and palm. They should be in perfect alignment for optimal piano playing power.
It is the bones that depress a key and it is the tendon which puts the bone in place to play it. Amy's flat finger technique was forcing the tendons to play the key and as a result was fraying her tendons and ligaments like a nylon rope. I'll repeat, it is the tendon which aligns the bone and the bone which presses the key down through the use of gravity and the weight of the arm. Tendons are for alignment, ligaments hold the bones together, bones do the load bearing work. Deviate from nature's design and you're going to have problems. These ligament, bone, muscle and tendon duties are not interchangeable. Can we do it? Sure. Should we? I can rob banks and make a lot of money but eventually I'll get caught and arrested.
After only two months of study with me, Amy's symptoms have pretty much disappeared and she stopped taking lessons. That is really unfortunate for her as she has several other problems her university piano professor has not addressed. She also has a pretty bad ulnar deviation of the wrist and she has adduction and abduction issues with her thumb. The combination of these two movements will eventually strain the tendon in her thumb creating a leakage of synovium fluid, the lubricant within the tendon sheath, and create a ganglion cyst or, "Bible Bump." Guess how Dr. Alexander will treat this?
-Malcolm Kogut (not a doctor, either).
Our tendons are made up of thousands of fibers all neatly bundled together, those bundles are bundled, then those bundles are bundled several times over and finally the entire massed bundle makes up a tendon about the size of a linguini and the tendon as a whole is protected in a lubricated sheath where it can glide back and forth effortlessly.
Think of the tendon as a plastic, polypropylene, polyester or nylon braided rope. The single rope as a whole is actually made up of thousands of smaller fibers making the whole greater than the individual parts. Every hiker, camper or construction worker knows that when you cut one of these ropes you need to finish off the ends by melting or burning it. This creates a little knot of melted materiel and prevents the rope from fraying. Likewise, as the rope is used, stretched, dragged over edges and exposed to friction, along the path of the rope there will be fraying. Shakespeare said it nicely, "Take but degree away, untune that string, And, hark, what discord follows!" Conversely, allow a rope to constantly fray, And hark, what discord follows.
The body repairs frayed tendons much the same, by putting little knots of scar tissue where damage has occurred. Doctors often refer to these knots as nodules. They can be quite painful and can eventually cause the finger to lock up. Laymen will refer this symptom as "trigger finger." Picture a sweater with a hole in it. If you were to sew up the hole, there would be a little knot there. Although the hole is now healed, the sweater won't wear as effortless as it used to. Every thread in a sweater is connected to every other thread and every movement will pull on that knot. That is why diagnosing hand issues is so difficult. The pain may be in the forearm but that is where the tissue is giving way because there is a knot in the palm.
When you flex your flexor muscles in your forearm, your muscles pull your long flexor tendon which is attached all the way to the tip of your finger and your finger bends. If there is a little knot or nodule anywhere in the sheath, usually near a joint or in the palm, the nodule can get snagged in the sheath and lock the finger. Forcing it open can cause more tearing and the build up of even more scar tissue. A downward spiral begins; Hark, what discord follows. As I felt Amy's hand, I could feel the little nodule bumps of scar tissue gliding back and forth.
Have you ever heard about the legend of the Gordian Knot? It was a knot so complicated that it was impossible to solve or unravel. Thousands tried but none were successful until Alexander the Great attempted to untie the knot. When he could not find the end to the knot to unbind it, he sliced it in half with a stroke of his sword. This technique of problem solving was called the "Alexandrian solution." A technique many doctors use today.
If Amy were to go see a doctor, the first thing he may suggest is to stop playing the piano for weeks or months, rest and wear a brace. Rest in these situations is not going to help. The body's defense against this kind of damage is to create scar tissue which is not flexible and will lock the tissue in place much like a spider web can entomb and insect. Scar tissue is what caused her problem in the first place. If you were to take an unraveled rope and just throw it in a pile, it would be in a tangled mess of a knot. Letting it sit there for six months will not untangle it. You need to slowly and patiently unravel it and straighten it out and then roll it back up neatly. That is what our bodies want us to do. When it comes to scar tissue, proper movement promotes healing, not rest.
A second treatment a doctor may prescribe Amy is physical therapy. This is close to the solution because as I said, proper movement promotes healing but PT most likely will not solve her problem. She will receive massage therapy, contrast baths, working with weights and pulleys, molding clay, wax and other muscle building techniques, but, when Amy goes home to her piano, all the physical therapy in the world won't be able to counteract the damage she will do in the privacy of her own home or practice room. Like the Battle of Thermopylae, it doesn't matter how many Persians march through the pass, the Greeks had the upper hand.
A third treatment option will most likely be a cortisone shot. Cortisone melts tissue. If the doctor can inject the cortisone directly into the nodule he can melt it away, along with anything else which comes in contact with the cortisone. No thank you.
A final treatment will be surgery where they will cut the sheath or scrape the nodule off the tendon and of course, the body will respond to the surgery by creating - say it with me - "scar tissue." The good news is during the several months it takes to fully heal, with PT, you will have full control over your fingers again. This may be a solution for the average person, however, for a concert pianist, the result could be devastating.
So what was Amy's problem causing her symptoms? It was simply her flat finger technique. Now, I'm not a university piano professor so I don't want to comment on his desire for Amy to play with flat fingers. What I do know is that the finger is made up of several bones which neatly line up and are held together by ligaments, pulled by tendons and controlled by muscle. If I were to poke you in the eye, I would align my fingers so all the bones were in a straight line for maximum eye poking jabs. A curved finger would not do the job as effectively. When playing the piano, the opposite is true.
There are two ways I teach my students to find their optimal finger alignment or kinetic chain. The first is to lay on the floor, flat on their backs with bended knee. With their arm to their side, gently isolate one finger and lightly press it to the floor while lifting the whole arm off the floor. Then gently rotate, swivel and explore a circle with the finger touching one spot on the floor. Not to get all Zen here, but as in everything in life, it is in the imbalance where we can find the balance. If you shift too far forward you will feel the tension in the front joint of the finger, too far back you will feel the tension in the tendon beneath. If you hyper-extend the finger, you will experience that discomfort, too. Do this will all five fingers and upon discovering the perfect effortless alignment, look at the finger and palm and take note of the perfect curve much like the dome of a cathedral ceiling. That is the finger at its optimal strength where the load bearing bones are properly aligned by the tendons. A second method of finding this alignment is to stand with your arms to your side. Shake your hands until they are loose then let them hang to your side. Without moving a single finger, raise your hand and look at your fingers and palm. They should be in perfect alignment for optimal piano playing power.
It is the bones that depress a key and it is the tendon which puts the bone in place to play it. Amy's flat finger technique was forcing the tendons to play the key and as a result was fraying her tendons and ligaments like a nylon rope. I'll repeat, it is the tendon which aligns the bone and the bone which presses the key down through the use of gravity and the weight of the arm. Tendons are for alignment, ligaments hold the bones together, bones do the load bearing work. Deviate from nature's design and you're going to have problems. These ligament, bone, muscle and tendon duties are not interchangeable. Can we do it? Sure. Should we? I can rob banks and make a lot of money but eventually I'll get caught and arrested.
After only two months of study with me, Amy's symptoms have pretty much disappeared and she stopped taking lessons. That is really unfortunate for her as she has several other problems her university piano professor has not addressed. She also has a pretty bad ulnar deviation of the wrist and she has adduction and abduction issues with her thumb. The combination of these two movements will eventually strain the tendon in her thumb creating a leakage of synovium fluid, the lubricant within the tendon sheath, and create a ganglion cyst or, "Bible Bump." Guess how Dr. Alexander will treat this?
-Malcolm Kogut (not a doctor, either).
Thursday, January 31, 2013
Heal Thyself: Part Three
In Part One I touched briefly upon disorders, treatments and an
admonition to find another way to heal oneself other than traditional
treatment. In part two I talked a bit about movement of the wrists
(dorsiflexion, ulnar deviation, radial deviation, etcetera) and the body
in whole. Here I'd like to talk briefly about why some people will
never heal.
If an injury is the result of improper movement or from extensive stretching of the tendons, to the point that they have micro tears and consequent layers of scar tissue, the only way to heal is to cease creating micro tears and break up the existing scar tissue. Imagine if you cut a three inch circular hole in your favorite sweater then without replacing the missing swatch, simply sew up the hole. The knot that ensues and the stretching and pulling of the fabric is sort of what happens to your muscles when they are hog-tied by scar tissue.
In order to cease creating micro tears one needs to stop moving and bending incorrectly and stop stretching the tendons to the point where the body needs to create scar tissue. Coaches and physical therapists prescribe stretching to warm up muscles when really, all they are doing is creating micro tears in the muscles and tendons. The body's response to this minor damage is to rush blood to the damaged site which makes the body feel warm. The body is not technically warming up, it is rushing blood to the site to immobilize the tissue: Nature's cast. If coaches really want to warm up the body of their athletes they would make them sit in a sauna and give them a massage. Just ask Olympic trainers.
In order to break up the scar tissue created by over stretching, you need to, well, stretch. The solution to this conundrum is actually very easy; allow the body to move naturally in its mid-range of motion. That is why I am a strong opponent to the use of braces because they inhibit the body from moving in its mid range of motion and also forces the wearer to overcompensate by using other unnatural movements on areas of the body which will only strain new joints and new tissue. This new misuse and overuse will facilitate a downward spiral of repetitive motion disorders. I have heard many stories where the inital pain started as a twang in the forearm, then a sharp pain, then numbness of the hand, followed by constant pain in the wrist, then elbow and shoulder pain, back pain follows then it become bilateral. Revisit that old song, "The hip bone's connected to the knee bone."
Most injuries occur because the athlete (or musician) had something not in proper alignment in the first place and over or under compensated with another part of the body which wasn't intended to move that way. Proper movement promotes healing, plain and simple. Once the body is trained to move properly, scar tissue will begin to break up, inflammation will go down and symptoms will disappear. The body will begin to work as efficiently as it was designed while it is slowly freed from the tether of scar and pain.
Have you ever been buried in snow or sand to the point where you couldn't move? Brute force will not free you from the mass piled upon you. However, if you gently move up and down, left and right, forward and backward, you will create little air pockets. As the pockets increase in all directions, not just one, you will eventually obtain enough space where you can use more and employ larger muscles to displace greater mass and eventually break free (unless you are in a ten foot deep avalanche). The person with over and misused tendons must start out the same way; free to move effortlessly in every direction and expand from there. After meeting with my practitioner for the first time, during the following week I experienced painless snapping sensations in my forearms. That was the scar tissue breaking and releasing my tendons as they began to move as nature intended. I was no longer overstretching but moving just enough to entice the scar to release its hold on my muscles. Much like the Chinese finger torture we all experimented with as kids. The harder you try, the harder it is to get free.
Unfortunately, when there is a glimmer of hope, that is where many people give up on their training and begin moving "normally" again. At that point, the ailment comes back with a vengeance because they are no longer creating micro tears but tearing the whole mass of scar tissue. Those are the type of people who never heal, much like a yo-yo dieter. Many people won't even get that far. Musicians are the worse. I had one student who dutifully practiced the exercises that I prescribed to him then he practiced other music he was interested in but, without employing the new movements I was unconditionally demanding of him. He was using his motor memory which was flawed and ingrained in his muscles and brain from the first day he touched a piano, causing his problems of today. He was in a downward going from one step forward to two steps back. There was no hope for him to heal and I dropped him as a student after three lessons. Another woman wanted to heal NOW! I told her it would be six months of moving ONLY as I instructed her but that prospect was too difficult. She opted for the quick fix of surgery. Two years later, her carpal tunnel syndrome reasserted itself and she had a second surgical procedure. This time following her surgery her fingers no longer responded the same and she no longer plays the organ in church and still has pain. A third student with the discipline much like I had did nothing but the exercises I prescribed to him and after a few weeks he was pain free. He continued working with me and very soon he was playing much better than he did before his injury. His symptoms were gone and he was able to transpose his new found discipline to other parts of his body where he told me his walking, driving, hiking and skiing drastically improved.
A friend of mine complained most of his life of knee pain. His physical therapists dutifully treated his knee pain symptoms. After over twenty years of icing, exercising and resting his knees he saw a new doctor who told him that his knee problems was in his hips. Because he had a hip problem he unnaturally over compensated each step which put unnatural and misaligned strain on his knees. With very simple sleuthing, the doctor discovered that his hip problem was caused by an old shoulder injury. The shoulders and hips work together when we walk. His right shoulder was frozen in tandem with his right hip which caused stress problems in both knees. The bulk of the damage was in the hip so he had a hip replacement and the knee pain practically disappeared.
The difficulty in trying to help someone to help themselves is that they need to give 100% of their effort and dedication toward the healing process. Anything less is unacceptable and doomed for failure. There can be no deviation from the course. With the insidious disorder of tendonitis, in the words of Yoda, "There is no try, only do." There is no option for cheating, no break from dedicated effort, no shortcuts and no going back. The only way to heal is the hard way - by making movement easy and effortless as the body was designed. It is really simple. But, we flawed humans want it now.
Buddha said "Before enlightenment there is chopping wood and carrying water. After enlightenment, there is chopping wood and carrying water. The differences are tremendous but not visible."
-Malcolm Kogut.
If an injury is the result of improper movement or from extensive stretching of the tendons, to the point that they have micro tears and consequent layers of scar tissue, the only way to heal is to cease creating micro tears and break up the existing scar tissue. Imagine if you cut a three inch circular hole in your favorite sweater then without replacing the missing swatch, simply sew up the hole. The knot that ensues and the stretching and pulling of the fabric is sort of what happens to your muscles when they are hog-tied by scar tissue.
In order to cease creating micro tears one needs to stop moving and bending incorrectly and stop stretching the tendons to the point where the body needs to create scar tissue. Coaches and physical therapists prescribe stretching to warm up muscles when really, all they are doing is creating micro tears in the muscles and tendons. The body's response to this minor damage is to rush blood to the damaged site which makes the body feel warm. The body is not technically warming up, it is rushing blood to the site to immobilize the tissue: Nature's cast. If coaches really want to warm up the body of their athletes they would make them sit in a sauna and give them a massage. Just ask Olympic trainers.
In order to break up the scar tissue created by over stretching, you need to, well, stretch. The solution to this conundrum is actually very easy; allow the body to move naturally in its mid-range of motion. That is why I am a strong opponent to the use of braces because they inhibit the body from moving in its mid range of motion and also forces the wearer to overcompensate by using other unnatural movements on areas of the body which will only strain new joints and new tissue. This new misuse and overuse will facilitate a downward spiral of repetitive motion disorders. I have heard many stories where the inital pain started as a twang in the forearm, then a sharp pain, then numbness of the hand, followed by constant pain in the wrist, then elbow and shoulder pain, back pain follows then it become bilateral. Revisit that old song, "The hip bone's connected to the knee bone."
Most injuries occur because the athlete (or musician) had something not in proper alignment in the first place and over or under compensated with another part of the body which wasn't intended to move that way. Proper movement promotes healing, plain and simple. Once the body is trained to move properly, scar tissue will begin to break up, inflammation will go down and symptoms will disappear. The body will begin to work as efficiently as it was designed while it is slowly freed from the tether of scar and pain.
Have you ever been buried in snow or sand to the point where you couldn't move? Brute force will not free you from the mass piled upon you. However, if you gently move up and down, left and right, forward and backward, you will create little air pockets. As the pockets increase in all directions, not just one, you will eventually obtain enough space where you can use more and employ larger muscles to displace greater mass and eventually break free (unless you are in a ten foot deep avalanche). The person with over and misused tendons must start out the same way; free to move effortlessly in every direction and expand from there. After meeting with my practitioner for the first time, during the following week I experienced painless snapping sensations in my forearms. That was the scar tissue breaking and releasing my tendons as they began to move as nature intended. I was no longer overstretching but moving just enough to entice the scar to release its hold on my muscles. Much like the Chinese finger torture we all experimented with as kids. The harder you try, the harder it is to get free.
Unfortunately, when there is a glimmer of hope, that is where many people give up on their training and begin moving "normally" again. At that point, the ailment comes back with a vengeance because they are no longer creating micro tears but tearing the whole mass of scar tissue. Those are the type of people who never heal, much like a yo-yo dieter. Many people won't even get that far. Musicians are the worse. I had one student who dutifully practiced the exercises that I prescribed to him then he practiced other music he was interested in but, without employing the new movements I was unconditionally demanding of him. He was using his motor memory which was flawed and ingrained in his muscles and brain from the first day he touched a piano, causing his problems of today. He was in a downward going from one step forward to two steps back. There was no hope for him to heal and I dropped him as a student after three lessons. Another woman wanted to heal NOW! I told her it would be six months of moving ONLY as I instructed her but that prospect was too difficult. She opted for the quick fix of surgery. Two years later, her carpal tunnel syndrome reasserted itself and she had a second surgical procedure. This time following her surgery her fingers no longer responded the same and she no longer plays the organ in church and still has pain. A third student with the discipline much like I had did nothing but the exercises I prescribed to him and after a few weeks he was pain free. He continued working with me and very soon he was playing much better than he did before his injury. His symptoms were gone and he was able to transpose his new found discipline to other parts of his body where he told me his walking, driving, hiking and skiing drastically improved.
A friend of mine complained most of his life of knee pain. His physical therapists dutifully treated his knee pain symptoms. After over twenty years of icing, exercising and resting his knees he saw a new doctor who told him that his knee problems was in his hips. Because he had a hip problem he unnaturally over compensated each step which put unnatural and misaligned strain on his knees. With very simple sleuthing, the doctor discovered that his hip problem was caused by an old shoulder injury. The shoulders and hips work together when we walk. His right shoulder was frozen in tandem with his right hip which caused stress problems in both knees. The bulk of the damage was in the hip so he had a hip replacement and the knee pain practically disappeared.
The difficulty in trying to help someone to help themselves is that they need to give 100% of their effort and dedication toward the healing process. Anything less is unacceptable and doomed for failure. There can be no deviation from the course. With the insidious disorder of tendonitis, in the words of Yoda, "There is no try, only do." There is no option for cheating, no break from dedicated effort, no shortcuts and no going back. The only way to heal is the hard way - by making movement easy and effortless as the body was designed. It is really simple. But, we flawed humans want it now.
Buddha said "Before enlightenment there is chopping wood and carrying water. After enlightenment, there is chopping wood and carrying water. The differences are tremendous but not visible."
-Malcolm Kogut.
Wednesday, January 2, 2013
Contrast Bath
Fill one side of your kitchen sink with HOT water. Make it as hot as you can tolerate because it will cool down fast. Usually the temperature out of the hot tap is fine depending on the temperature settings you have on your hot water boiler. Then fill the other side with ice cold water. Dumping a bowl of ice cubes in the cold side will work nicely.
Soak your arms for one minute in one side, then plunge your arms into the other side for one minute. Do this going back and forth about seven times in each basin. Initially the hot or cold may seem unbearable but you will get used to it quickly.
The hot water will promote circulation in your arms and the cold will reduce inflammation. This is not a cure but may help in the recovery process or at least alleviate some of the discomfort you may have.
Circulation is important for healing because the increased blood flow helps to rebuild damaged tissue and will also carry away toxins and damaged cells.
Remember, inflammation is nature's cast. It is your body's way of warning you not to use the injured body part until it can heal. Eliminating the discomfort doesn't resolve the problem. Don't fix symptoms.
I also suggest that you consider washing dishes by hand rather than using a dish washer. The warm soapy water is beneficial and can be a relaxing therapy session for sore hands.
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