Assistant Professor of Neurology and Geriatrics
University of Arkansas for Medical Sciences
Interim Clinical Core Leader, UAMS Alzheimer's Disease Center
4301 West Markham Street, #500
Little Rock, Arkansas 72205
As a neurologist, I'm extremely familiar with Carpal Tunnel Syndrome (CTS), a
disorder in which the median nerve is compressed at the wrist. Typical symptoms
are numbness in the first 3 digits of the affected
hand, which may initially come and go, especially at night. The disorder can
categorically be diagnosed as present or absent through the use of NCS, "Nerve
Conduction Studies" (older docs may still call it "NCV" or "Nerve Conduction
Velocity," though a proper study includes much more than just velocities). EMG
("Electromyography") is not necessary to diagnose the condition (this involves
insertion of needles into muscles and recording of impulses from the muscles).
Non-neurologists often use the EMG in diagnosing CTS, however (but it's
not necessary, just the NCS is needed).
There are several myths about CTS, chief among these that you can cause CTS by
using a keyboard. This has been disproved in well-designed
studies (but is still held onto by people like personal injury lawyers, who
stand to gain by trying to link a medical illness to someone who can be sued).
What is likely is that if you use a keyboard a lot and have mild CTS, you're
much more likely to notice it.
It is true that
the median nerve is pulled against the wrist ligaments
by flexion of the wrist--bending the hand forward, like some people do
when holding a fiddle, for example. Extending the wrist (bending the
hand back slightly) relaxes the nerve slightly. So, one of the
conservative treatments involves use of a "cock-up" wrist splint, which
holds the hand in a slightly extended position--the splint can often
just be worn at night and the symptoms relieved (it's hypothesized that
the condition might be aggravated by repeatedly flexing the wrist in
sleep). Some people wear them around all day, however. This is the
least invasive non-surgical therapy.
Acupuncture has not been studied in well-designed studies, partly
because it's hard to do with acupuncture (hard to have a placebo arm of
therapy, for instance). What studies have been done are promising
using traditional acupuncture. So-called "laser acupuncture" has so
far shown no benefit in treating CTS.
adjustment of the
neck or back can have no effect whatsoever on actual CTS, as CTS
involves a nerve problem in the wrist (though I've had chiropractors
argue with me that the problem really, at its "heart," is a problem of
spinal misalignment--these people are, to be charitable, unscientific).
There is a good, evidence-based review of non-surgical treatments for
CTS to be found in the Cochrane Database of Systematic Reviews,
considered the definitive treatment, though it doesn't
always work. Unfortunately, surgery is often done without proper
diagnosis--people often complain of numbness in the fingers, and
surgeons sometimes just operate without getting NCS. Very often, those
people don't have CTS at all, so the surgery doesn't help. When it's
properly diagnosed, surgery is usually (but, again, not always)
with permission from Dr. Mark Pippenger.
CLASSICAL MUSIC And Hearing Loss
Danger: Music zone
Decibel assault on performers' ears isn't relegated to rock shows
the classical ranks deal with it too
By Louise Roug
Tribune Newspapers: Los Angeles Times
September 8, 2004
For violinist Matthew Faust, things finally got so bad that playing in big
orchestral works felt like being in a war zone. Even his "full metal jacket" --
custom-molded earplugs with maximum filters -- wasn't enough to protect him.
"I needed a crash helmet," he says.
To Seth Mausner, a violist with the San Francisco Symphony, the experience can
feel like "being assaulted."
Marcia Dickstein, a harpist who often performs with Los Angeles Opera and the
Long Beach Symphony, likens it to "somebody driving nails through your head."
At symphony concerts, audiences may thrill to a piece played at maximum volume.
But if you're a musician sitting with your back to the brass section, the
sensation can be overwhelming.
An often-cited study by Canadian audiologist Marshall Chasin measured hearing
loss among rock musicians and found that about 30 percent were afflicted in some
way. Among their classical music counterparts, the figure was 43 percent. Yet
while noise-induced hearing impairment is a well-known issue in the rock world,
long highlighted in educational campaigns featuring The Who's Pete Townshend and
rapper Missy Elliott, the discomfort from loudness suffered by classical
musicians is generally kept hush-hush.
"Classical musicians do suffer from hearing loss related to the volume of sound
onstage," says Steven Braunstein, a bassoonist with the San Francisco Symphony.
"It's a real problem for many people," especially if "you have four trumpets and
four trombones right behind your head. It gets very, very loud."
Measured in decibels, in fact, symphonic sound can soar up to 110, equivalent to
the sound of a jackhammer or power saw.
Last year, the European Union set a maximum limit of 85 decibels for the
workplace, including concert halls, in a directive that generated derision but
In the United States, where symphony halls are regulated by the Occupational
Safety and Health Administration (allowing a 90-decibel level over an eight-hour
day in any workplace), nobody is suggesting scrapping Mahler. But to guard
against debilitating decibels, an increasing number of orchestras are
experimenting with unorthodox seating arrangements, motorcycle windshields and
As music moved from 18th Century private salons to 20th Century concert halls,
small chamber ensembles -- often a group of string and woodwind players -- grew
into symphony orchestras with large brass and percussion sections.
"Composers want more people onstage, more sound, and the instruments become
super-charged," says UCLA musicologist Robert Fink, describing this evolution.
"What happens between Mozart and Mahler is the industrialization of the
orchestra. Orchestras become analogous to factories where sound is produced. You
punch in; you punch out. And at the same time, the instruments are getting more
Loud is in.
As brass instruments, in particular, became bigger, the orchestra's sound
increased. At the same time, so did audience expectations.
The result is that music "has gotten more exclamation points," says Florence
Nelson, a piccolo player and secretary-treasurer of the American Federation of
Musicians. "People want that today. They want that loud sound."
Onstage, though, rapture sometimes gives way to misery.
"There's a kind of loud where everything starts vibrating, and it's thrilling,
right on the edge of being painful," says harpist Dickstein. "Then there are the
times when I'm right in front of the timpani, and I start to cry, my eyes start
to water, and I have to put my head between my knees to plug in the earplugs."
In a survey of more than 400 musicians, Allison Wright Reid, a British health
and safety expert, found that close to 80 percent had experienced pain because
of loud noise, and about a third complained that their hearing had become
"You don't go stone deaf," says Reid, who wrote "A Sound Ear," a report
sponsored by the Association of British Orchestras. Rather, musicians may lose
their perfect pitch, or experience increasingly inaccurate and unreliable
hearing with "all sorts of extra noise thrown in," she says. "It's like driving
a very old car: You don't know if it's going to get you there, and it constantly
worries you because [of the] noise."
In practical terms, loud noise can destroy the tiny hairs in the inner ear that
translate sound waves into nerve impulses for the brain.
Blunt trauma -- an explosion or other high-impact sound -- can cause immediate
and permanent hearing loss. But hearing can also be damaged gradually by
constant exposure to an above-normal decibel range, with the damage manifest as
a limited ability to pick up certain frequencies -- a sort of muffled sensation
-- or as tinnitus, a constant buzzing or ringing tone.
The risk faced by musicians depends on what section of the orchestra they are
seated in, what instrument they play, how often they perform and rehearse,
acoustics and repertory.
And noise damage doesn't stop at the ear.
Among brass players, for example, the force needed to play at very high levels
can also result in torn lip muscles and damage to the control of the soft
According to several studies, musicians may also experience an accelerated heart
rate, increased blood pressure, muscle contractions, tension, irritability and
"Initially I didn't tell anyone about it," violinist Faust, 43, says about the
hearing problems he began having in 1990. In orchestras, "there's a little
machismo. It's something you don't share. It's seen as sort of a weakness."
At first, Faust's doctor said he was suffering from sensorineural hearing loss
caused by noise. Eventually, Faust developed tinnitus. Having hoped since high
school "to win a chair in a full-time orchestra," he tried earplugs, acupuncture
and herbs, as well as moving to quieter sections of the orchestra.
The management of the Oregon Symphony, his employer, was helpful and
sympathetic, but its concern wasn't sufficient. Faust acquired "a phobia," he
says. "You develop a fear of loud sounds."
During concerts, he was trapped.
Finally, Faust, who fell in love with the violin at age 5, went on disability
While some British orchestra "noise teams" have considered changes to the
standard repertory, American orchestras have preferred less drastic measures to
avoid damage and discord.
Backstage at Walt Disney Concert Hall, free foam earplugs are available for
players. In San Francisco, plexiglass shields have been attached to orchestra
chairs -- a common, if imperfect, sound barrier.
Some players spend hundreds of dollars themselves on custom-made earplugs. As a
result, a cottage industry has grown up around musicians' ears.
Whereas foam earplugs reduce the sound in high frequencies, making everything
sound muffled, these high-tech plugs offer better fidelity by reducing volume
across the spectrum.
Audiologist Lisa Tannenbaum used to sell hearing aids but decided she preferred
"the preventive side of things." These days, she makes earplug molds for as many
as 40 ears in a day.
Copyright © 2004, Chicago Tribune