The Bagpipe, Carpal Tunnel Syndrome, and Dupuytren's Contracture - A Medical Diary

By James Harrington

Recommended Reading

Before I say anything else, I want to point out an extensive discussion of musculoskeletal injuries in musicians (MSI) which I imagine most people looking at this page will be needing to read. One important quote would be "For musicians, risk factors that have the greatest demonstrated association with MSI are lack of warm-up and lack of adequate breaks during practice sessions (Zaza and Farewell, 1997)." There is very informative discussion on what constitutes a good warm-up.

Also, follow this link to a good set of stretches that should be great to help a piper avoid physical problems. There is also some additional information that may be helpful. Finally, practice habits have a huge bearing on physical binds we get ourselves into. We practice harder to get ourselves out of a bind, and wind up making things worse. One of the most important things we have to do is get into the right frame of mind regarding practice and what brings improvement. Here is an incredible page that should give you some strong ideas about how to go about developing your piping abilities, and how not to, and how to start to work yourself out of a physical problem you may have gotten yourself into. It's for the piano, but extrapolote... Fundamentals of Piano Practice - send the guy some bucks if you find that page helpful.

Indroduction

I have played the Scottish bagpipe for a long time, though with a long hiatus in the middle of my career. I achieved success in amateur competitions and reached the open level of competition, but have lately had some difficulties due to medical conditions which significantly impair coordination. I have a mild case of carpal tunnel syndrome, which is quite common. One figure I've seen says there are 250,000 operations performed each year to try to correct severe cases. I also have Dupuytren's Contractures, which is a genetic problem that prevents fingers from being lifted as high as they would normally be. It comes on with increasing age and is progressive, however it is normally at least partially if temporarily correctible with surgery. It is not especially common, yet is common enough that two particularly well-known pipers have also suffered its effects. I was told that "Big Angus" MacDonald, MBE of the Scots Guards, and also a well-known Ontario piobaireachd proponent and judge, both have/had it. There are surely other pipers I am not aware of.

Aside from a few threads on Bob Dunsire's Bagpipe Web site, I have not found any information on these conditions from a piper's standpoint. There is some indication that some people experience similar symptoms, but the reports are not in detail. I have decided to simply report as objectively as I can my own experiences with these two medical problems and with their treatment as it affected my piping. If anyone knows of published information on these topics, whether books, articles, or Web sites, that would be especially relevant to a piper's interest, please send me an e-mail. Also, if you would be willing to share your own experience as a piper with either of these conditions, whether in the same detail as here or much more briefly, please send me the information and I will add it. I would be glad to retain anonymity of the sender of such information if you request it. In addition, if you have information on other medical issues pipers in particular are likely to encounter or which especially affect the activity of playing bagpipes which you would like to share with other people with the same problem, please send it , including a report on the method you used to deal with the problem and how your method seems to have worked out relative to solving the medical problem and enabling or not enabling you to continue playing the pipes.

I am going to mention the various technical problems I've experienced as a piper without knowing precisely which are related to the two medical problems that have been diagnosed. I believe that carpal tunnel syndrome in particular as been a problem since my early days of piping long before it was ever diagnosed and others who experience similar problems might want to consider whether there is any possibility carpal tunnel syndrome is involved. I will report some details of my piping career in order to put the medical information in a context.

Very Basic Hand Anatomy

I'm not going to give a technical medical description of the finger muscles here. Briefly, we have flexor muscles in our forearm which connect to tendons that pass through our wrist and our palm and connect to our fingers. When the flexor muscles are contracted, our fingers make a fist or grip a chanter, or if held over the chanter, move down to cover the holes. Note, the flexor muscles are in the forearm, not the hand. We also have finger extensor muscles in our forearm which run over the top of our wrist and connect to tendons in our fingers. When the extensor muscles are contracted, our hand opens to show our flat palm, we drop something we are holding, or, when gripping a chanter, our fingers lift to uncover a hole. Besides the flexor and extensor muscles, there are abductor and adductor muscles called the interosseals that move our fingers "sideways", spreading them apart to fit the holes on the chanter or pulling them together for a salute. There are some muscles located in the hand that specifically curl the fingers at certain joints, of which the lumbricals are an example. These can be though of as flexor muscles by their character, though they are not technically the "finger flexors" which are located in the forearm.

In addition to the muscles, our hands are made to work through three nerves.

Carpal Tunnel Syndrome

I am not a doctor so nothing I say about carpal tunnel syndrome or anything else should be taken as medical advice. There are lots of Internet sites that describe carpal tunnel syndrome because it is so common. I'll give a brief summary description and give a few links to or quotes from sites that seem to give a good information on the condition.

The carpal tunnel is a passage through the bones of the wrist through which the nine flexor tendons and the median nerve pass. It is surrounded on the top and sides of your wrist by eight small wrist bones called the carpal bones. If you turn your hand palm up, you can locate the portion of the carpal tunnel not surrounded by bone by going to the last crease in your wrist, just below the midway point between your thumb and little finger muscles at the bottom of your palm, just at the base of where the thumb muscles attach to the wrist. Protecting the carpal tunnel and constricting its size just beneath the skin at that spot on your wrist is a strong ligament called the flexor retinaculum, or transverse carpal ligament, which covers the carpal tunnel. This ligament doesn't serve much purpose in humans. It's protective function is relatively unimportant. It also serves as a fulcrum for your muscles to give the grip maximum strength, but people still function normally without it.

The carpal tunnel is surrounded by bone and basically unstretchable tissue. There is only so much room for the tendons and nerves that pass through it. If anything occurs to decrease the amount of room in the carpal tunnel or to increase the cross-sectional volume of the structures that pass through it, the median nerve in the carpal tunnel comes under pressure from the other structures and the symptoms of carpal tunnel result. If the pressure on the nerve is not relieved, eventually the nerve becomes permanently damaged and can no longer function normally even with relieved pressure. A number of treatments for carpal tunnel syndrome are available. (Besides the ones mentioned on that page are B6 and other creams which some say help.) The most extreme treatment is surgery. I've seen a figure that states there are 250,000 surgeries to correct carpal tunnel syndrome each year. The surgery consists of slicing the carpal ligament in the wrist so that it no longer constricts the diameter of the carpal tunnel.

There are two views of the cause of carpal tunnel syndrome. One is that overuse of the flexor muscles in repetitive motions causes the tendons and/or their sheaths or even the tenosynovium through which they pass within the carpal tunnel to become thickened and possibly inflamed. The swelling decreases the amount of room in the carpal tunnel for other structures and the median nerve is impinged. The continued movement of the tendons in the decreased carpal tunnel cross-sectional area causes additional inflammation and swelling, and over time the impingement of the median nerve becomes worse and worse. The impingement, or pressure, on the nerve is what causes the symptoms. The other view is that a proper balance of strength between the flexor and extensor muscles is required in order to prevent the carpal and metacarpal bones and other portions of your hand anatomy from compacting abnormally around the carpal tunnel, reducing the cross-sectional area and causing impingement of the nerve even in absence of abnormal inflammation or swelling. The extensor muscles are always weaker than the flexor muscles, but if the flexor muscles become quite strong and tight over time while the extensor muscles remain relatively weak and flaccid, the imbalance causes reduction of the cross-sectional area of the carpal tunnel and nerve impingement which becomes progressively worse as the imbalance between flexor and extensor muscles becomes greater and greater. At some point inflammation and swelling may kick in here, as well. In both cases, release of pressure on the nerve is the only way to bring relief. The person may stop the activity that is causing the problem in the first place. This may necessitate a career change or dropping a favorite activity such as bicycling or piping. Most physicians recommend this be done as a first step in treatment. In addition or alternatively, elective surgery may be performed, or the extensor muscles may be strengthened, or a number of other treatments may be attempted.

Although my own case is not quite typical in the universe of carpal tunnel sufferers, it is important to understand that loss of coordination is a prime symptom of carpal tunnel syndrome (CTS). The CDC provides this description of the symptoms of carpal tunnel syndrome: "The symptoms of CTS often first appear as painful tingling in one or both hands during the night, frequently painful enough to disturb sleep. Accompanying this is a feeling of uselessness in the fingers, which are sometimes described as swollen, even though little or no swelling is apparent. As symptoms increase, tingling may develop during the day, commonly in the thumb, index, and ring fingers. A decreased ability and power to squeeze things may follow. In advanced cases, the thenar muscle at the base of the thumb atrophies, and strength is lost. Many patients with CTS are unable to distinguish hot from cold by touch, and experience an apparent loss of strength in their fingers. They appear clumsy in that they have trouble performing simple tasks such as tying their shoes or picking up simple objects." BUPA (ex-British United Provident Association) states "The severity of the symptoms can vary. The symptoms may be mild or only occur from time to time. As the condition worsens, symptoms may become constant. The hand muscles may become weakened, making it difficult to grip objects, and there may be permanent loss of feeling. Fine finger movements, such as writing, may become more difficult." The Gordon Hand Clinic provides information that "movement of the thumb away from the palm may become weak. Loss of sensation or feeling in the affected fingers also occurs. The combination of weakness and a loss of feeling results in the problem of dropping objects and poor dexterity... Sustained activities such as holding an object for long periods, or driving, may reproduce the symptoms."

In case you are wondering whether bagpipes are actually likely to bring on carpal tunnel syndrome, take a quick trip to the Carpal Tunnel Onset Accelerator page. Don't perform the activity precisely as recommended there; instead, limit your exposure to about 30 seconds of the activity. See if you can visualize an analogy between the recommended activity and making gracenotes with your index finger. You may be surprised.

My own case of carpal tunnel is relatively mild. There are only two activities which cause pain. One is driving long distances, when I rest the weight of my arms from my fingers and the carpal ligament area is pressed against the steering wheel. The flexors are tensed due to the hanging weight. After a half-hour or so I experience the pain from driving as a very mild nerve-like pain, more like a slight tenderness, at the base of my thumb and little finger and through the area between them, in other words across the transverse carpal ligament, and as a very slight burning sensation in the same area, barely noticeable. Not a serious problem in itself.

The other painful activity for me is playing the chanter or pipes. The pain I experience from the carpal tunnel while playing pipes or practice chanter is a very strong, painful burning sensation - burning in the sense that over-tired, exhausted muscles "burn" - that seems to come from the fleshy area of the thumb muscles of my right hand, about one inch up from my wrist. This is not precisely over the carpal tunnel area, but is still due to carpal tunnel syndrome. The pain does not start immediately when I play. If I hold the chanter loosely, it will take a long time for it to come on. If I play normally, it will start anywhere from three to twenty minutes after I begin to play, depending on exactly what I am doing. I've also noticed that moving my thumb down further causes the pain to come more quickly, and moving it up relieves it somewhat. If I do not stop playing when the pain starts, within a minute or two it becomes very painful and I am forced to stop. In addition, with the pain comes numbness and severe loss of coordination. If you have ever played in a St. Patrick's Day Parade or other event where the temperature is around 35 degrees for an extended period of time and your hands became frozen, you are familiar with the degree of loss of coordination numbness of the hand brings with it. Though the cause in this case is not related to cold, the numbness otherwise feels basically the same and playing simple gracenotes becomes similarly impossible. After I stop playing the pain and numbness go away quickly and I can play again after thirty seconds or so.

The extreme numbness that makes gracenotes impossible only comes with the burning pain. However, I usually will feel a slight tingling sensation in my hand and a very slight numbness before I feel any pain. Often I might play for ten minutes and then begin to notice a little tingling or numbness, and then some minutes later the burning sensation will come, slight at first but quickly increasing, followed soon by severe numbness and total loss of coordination.

My practice regimen has accommodated the carpal tunnel symptoms so that I never experience the burning sensation and extreme numbness any more. Though I might practice for as long as two or three hours on occasion, I stop and rest frequently, as soon as I notice the burning is coming on. I've never been sure exactly what it is that brings on the pain, whether it's the odd angle of the right wrist when playing the chanter or pipe, holding the thumb across the palm and squeezing, or the steady contraction of the finger muscles (flexors) when gripping the chanter. I believe it's a combination of all three, though some people experience numbness or tingling in their left hand from playing pipes, so the bend in the wrist is not a critical component.

Though I have accommodated the carpal tunnel syndrome to avoid pain, I have not avoided problems related to coordination, and these would be of interest to pipers in general. I will say more of that in a minute.

There are certain tests that are performed to diagnose carpal tunnel syndrome. One is a clinical diagnosis - you press your hands together in a certain way that compresses the carpal tunnel and count how many seconds it takes before you feel numbness in your hands. If they feel numb in less than a certain amount of time, you officially have carpal tunnel syndrome. Another is an electronic test called an EMG that measures nerve conductance for certain muscles of your hand. For each muscle, there is a range of values for conductance that are considered "normal". If you have any muscles which exhibit substandard conductance, you have a definitive diagnosis of carpal tunnel syndrome.

There are some problems with the diagnostic tests. Mainly they stem from the fact that the condition is experienced through perception of pain, while the diagnostic tests measure something other than pain level and do so in conditions other than those in which pain is experienced, and then the diagnosis is made based on whether some arbitrary, univerally- applied threshold is passed. This is similar to many medical tests, but unfortunately it isn't uncommon for people with carpal tunnel syndrome not to be diagnosed with it because the tests don't support the diagnosis. Then the condition goes untreated until it gets much worse and at some point is officially diagnosed.

I was clinically diagnosed with mild carpal tunnel syndrome by the hand position and timing test, but the EMG test for conductance did not diagnose it. All my muscles - or their innervating nerves, rather - had conductance values within the normal range. One had a value exactly at the border of normal, so one more gradation lower and it would have supported the carpal tunnel syndrome diagnosis. My doctor agreed I did have mild carpal tunnel syndrome and was not averse to doing the surgery at some point. However, I did not schedule surgery at that time due to other problems with my hands (Dupuytren's Contractures) which I needed to deal with first.

At the time of the diagnosis, about two years ago in summer of 2003, I was experiencing some difficulties with coordination in my right hand, for playing the pipes. However, if I would practice hard for a few days - say, for two hours a day at least - my coordination would come to a pretty good level and I could play well by the end of the session. When I began playing the next day coordination would have greatly dropped again, but it would return to "normal" by the end of another long practice. This was more than what we expect to get from "warming up". I couldn't play very well at all at the start of the workout, but after two hours I could play the way I thought I should be able to. Warming up is a ten-minute or so process and only results in a moderate increase in abilities, not a great increase. I was having some difficulties from Dupuytren's Contractures and hoped that once they were taken care of, some of the coordination problems would go away and after a while I would be in good shape again. I did have a surgery for Dupuytren's Contractures, and as far as I can tell there should have no longer been an impediment to good playing. However, over the last two years the coordination problems have gradually become much worse. Now (July 2005) no number of hours or sequential days of practice brings me to a point where I am playing decently, for my right hand is always in bad shape. At the same time as the lack of coordination increased, the recognized symptoms of carpal tunnel have also increased. Now I often feel a very slight ache in my palm where it hurts when I play, except I won't have played for a few days, or driven the car. I rarely felt that ache two years ago. Two years ago there was no pain from driving the car a long ways, now there is. Two years ago, when I quit practicing all the pain would go away. Now practicing makes the nerve act up so that there is a very slight ache for as much as several hours after I stop playing. I have noticed in the last two months that my handwriting (the hand that is not the one with definite carpal tunnel symptoms) has become a little messier, and I have some problems with coordination in writing that I don't believe I used to have. I am pretty sure the lack of coordination I am experiencing all the time when I play now is due to the carpal tunnel syndrome. There are some very interesting points to this, which may be of interest to many pipers.

Musicians are among the groups of people prone to suffer from carpal tunnel due to the ways they perform actions repetitively and perform static (no movement) finger flexion. However, my experience of carpal tunnel isn't typical compared to a common description of the symptoms.

You will see from my symptom diary that I first experienced some of the coordination problems many years ago after I'd been piping for only three years. Also, I first experienced the painful burning sensation from carpal tunnel syndrome after I'd been piping about the same amount of time. At that time, the carpal tunnel symptom of pain would go away after a few days of practice and not return until after I had taken a break of several weeks from practice. However, the coordination problems persisted for years. Even with those specific coordination problems I was able to reach the open level of competition in Ontario, but they were quite significant problems for me at the time, problems with specific movements we all have to perform. At that time I would not have considered it a remote possibility that I had carpal tunnel problems, but now I am thinking I was suffering effects of carpal tunnel syndrome for years with tremendous frustration and didn't realize it. (Or who knows, maybe some muscles weren't strong enough to do their job, and that's what led to problems. It's so hard to tell...)

Bagpipes require a much greater degree of coordination than nearly any other activity. The EMG test has a range of conductance values that is "normal". It actually measures the amount of time it takes for electrical impulses to travel along the median and ulnar nerves. If one measured EMGs for ten technically excellent pipers, how would the conductance values look? It seems doubtful to me that one can train one's nerves by practicing to increase the conductance values - though I could be wrong about that, I'm not up on the physiology - but could it be that the people who can eventually become technically excellent players are those who have naturally high EMG measurements? High compared to the average piper who is not able to play well, that is. And if you take those players and subject them to some physical stress that lowers their EMG conductance values to values just barely "normal" according to the definition of normal, what would happen to their coordination and ability to play the pipes? Carpal tunnel syndrome is a stress that affects EMG measurements.

We all know there are people who can play pipes well and people who can't. Of those who can't, in many cases it is not due to lack of trying, it's because their fingers just won't do what they're supposed to. Those who have taught many adult students have certainly run across students whose fingers will move well enough for some easy tunes, but not well enough for more advanced music, and no amount of practice seems to help. Due, I believe, to carpal tunnel syndrome in my right hand, my own playing has slid from open level to a point where my fingers will move well enough for some things but not well enough for difficult music, basically grade IV level technically, and no amount of practice will help. This, combined with the idea that I think I played for years with virtually no pain-related symptoms of carpal tunnel yet suffered from lack of coordination as a result of it, has me wondering just how many bagpipers really are suffering from a symptom of undiagnosed carpal tunnel syndrome which is preventing them from playing as well as they should be able to.

For most of these people who might be suffering from carpal tunnel problems, there is no chance that going to the doctor would result in diagnosis with carpal tunnel syndrome because the symptoms are relatively mild. Yet, carpal tunnel syndrome is so common that there are 250,000 surgeries for serious cases each year, and it is already believed that far more cases of carpal tunnel go unreported than are reported. Loss of coordination is not what gets most people to see the doctor about carpal tunnel syndrome, and it isn't even a well-recognized symptom except in conjunction with significant pain and numbness, while the coordination problems I'm experiencing constantly are without the pain and numbness and are only a noticeable problem because I play the bagpipes. For everyday life I never noticed any problem at all until pretty recently with the driving and maybe writing, and those symptoms are not at all obvious. Also, for most people, carpal tunnel syndrome develops slowly. Mild cases are barely noticeable. They may get worse, they may not. If someone already has a mild case of carpal tunnel syndrome when they start taking piping lessons and doesn't know it, they will not realize that their lack of coordination on the pipes is partially due to carpal tunnel syndrome. They will continue, struggle, and reach a ceiling past which they cannot go because of carpal tunnel syndrome, and never know the cause of their limitation. Some people will tell them they "started too late." Of course, many do start too late, but possibly that isn't the main problem for some older students.

People who suffer from serious carpal tunnel problems would laugh at the symptoms I'm describing, for at more advanced stages it's a very serious medical problem that affects many aspects of life, not just one's esoteric hobby. I'm not saying pipers are very likely to suffer serious problems from carpal tunnel syndrome. Anybody who does get a bad case is going to go to the doctor for sure, prompted by significant and lasting pain, and it will get diagnosed and treated. If it was a major problem for pipers' lives in general, I'm sure we'd have all heard about it by now. What I'm saying is, because piping is an activity that is naturally going to strengthen and tighten the flexor muscles of the fingers but not the extensor muscles, it is highly likely that pipers will work themselves towards a narrowed carpal tunnel due to muscle strength imbalance against the extensors, and the effect on the median nerve may be to reduce their coordination. In addition, because carpal tunnel is such a common condition in working adults, many people will develop mild carpal tunnel syndrome from work, which piping will exacerbate. For many of these people, I believe the symptoms will be unnoticeable except for their lack of finger coordination for piping. Because carpal tunnel develops slowly and the symptoms don't match most people's idea of what carpal tunnel syndrome is, nearly all of those people will probably say "I'm getting old and the fingers just don't work so well any more," or "Gosh, this is a darn hard instrument. I just can't play very well."

The immediately preceding paragraphs are conjecture on my part. If any reader is an expert in hand physiology, I'd love to get feedback on those ideas. What I know for sure is that I have a very mild case of carpal tunnel syndrome in my right hand, and I also have pretty major coordination problems, for a piper, in my right hand, which have developed in parallel with other carpal tunnel symptoms.

Dupuytren's Contracture

I have said a few words about this condition above. Here is a Web page on Dupuytren's Contractures with good information. Besides surgery, there is a non-surgical treatment practiced primarily in France by rheumatologists, which is called needle aponevrotomy. The advantage is less chance of nerve damage. U.S. doctors typically don't know about this treatment or mention it. If you want more information, here is a Web page on aponevrotomy by Dr. Batois. Here is a page with a number of links about Dupuytren's Contractures.

The condition definitely interferes with piping. Even if it doesn't prevent you from lifting your finger off the chanter, muscular adaptations are necessary in order to compensate for restricted range of motion of the fingers, and those adaptations may introduce unwanted sympathetic tensions in other fingers. After the symptoms are relieved and range of motion are restored, it can be difficult to undo the muscular adaptations. If you are a piper suffering from the condition, after the range of motion of your finger begins to be restricted, don't wait long before you get treatment. As soon as you feel your fingers moving differently than they used to so you have to make some kind of adjustment, it's time to take action immediately in order to avoid the possibility of problems due to muscular adaptations.

At the time I had the surgery, September 2003, the doctor told me about a new treatment that is being developed and is in clinical trials. The treatment involves injection of an enzyme into the abnormal tissue. The enzyme "digests" the abnormal tissue but does not digest normal tissue. The date this treatment will be available to the public is unknown, but the doctor suggested it could possibly be as early as 2005-2006.

In my own experience, there was some nerve damage associated with surgery, and that was quite negative for my piping, though I still hope to overcome it. Nerve damage of one kind or another is apparently fairly common. Since needle aponevrotomy is supposed to rarely damage nerves, I think I'd take the trouble to fly to France for that treatment if I had it to do over again. With luck, the enzyme treatment will come through clinical trials well and will be a treatment that very rarely results in any sort of nerve damage.

Carpal Tunnel Treatment Experiment

I could and would get surgery for the carpal tunnel syndrome, but I recently found a treatment for carpal tunnel which may work extremely well and appears to be a better option than the surgical option because:

The treatment is an orthopedic glove device which exercises the extensor muscles and stretches the flexor muscles. Called FLEXTEND, it was created and is sold as a treatment for carpal tunnel syndrome. They report a better than 80% success rate in total cure of symptoms. I have heard of another orthopedic glove product called Handeze or something like that, which is completely different. I am going to try FLEXTEND and report progress in the diary. I have communicated with one of the employees who says they have hundreds of customers who are musicians who use it, not to treat any distinct medical problem like carpal tunnel syndrome, but simply to increase their dexterity and flexibility in order to play their instrument better. They say among these musicians are some of the best professionals (note: including drummers), though many will not let their names be made public lest prospective employers get the idea they are having problems. That's understandable. Luckily, in piping we don't have that problem. :-) I'll see how it works out for me. If I can report improvement in the diary, then I'd have to recommend the device to just about every piper, because there are very few who wouldn't be better players with increased coordination in their hands, and at the cost one could hardly go wrong. But we'll see what happens here. I should be able to start the program by August 1, 2005, and I hope to start seeing results before Labor Day.

Here are two Web sites that give a lot of information about carpal tunnel syndrome and other similar conditions and go into the flexor/extensor balance issue, and about the FLEXTEND device:

Note, the idea that strengthening the extensor muscles to enlarge the carpal tunnel can be important in treatment of carpal tunnel syndrome is not widely known in medical descriptions of treatments. The monograph linked above does seem to say that only 10% of cases of carpal tunnel syndrome actually involve swollen tendons or sheaths, and the other 90% are due to some unknown cause of nerve compression. It also says that a lessening in the size of the carpal tunnel may cause compression. The high success rate claimed by FLEXTEND in reducing carpal tunnel symptoms supports the product's premise.

If carpal tunnel can be a problem with bagpipes, then bagpipers who spend a lot of time at the computer at work, another major risk factor for developing carpal tunnel, may well be in serious trouble. I found a product or system called Fingerweights which is advertised as good preventative therapy for musicians and computer users to avoid problems in the hands and fingers, to increase fine motor coordination, and even to reverse early signs of serious problems. They are bands of velcro or some other material you put around your fingers, and attach small weights to while you're working at the computer. For some instruments you also play while you're wearing them, but I don't think that would be so helpful with bagpipes because of the angle we hold our hands at while playing - the force of gravity doesn't act in a helpful direction. They'd be helpful while playing practice chanter at the table, however. Interestingly, they also seem to work mainly by exercising the extensor muscles. The FLEXTEND is almost certainly a better tool for intentional exercise and stretching as treatment for hand problems, but the Fingerweights should also be extremely helpful to people who spend a lot of time at the keyboard and can use them during that activity. A search of the Internet for Fingerweights should bring up places to purchase the product. Here's one: Guitar Musician

Alternative to Carpal Tunnel Diagnosis

I find the information in the following link very interesting, and there are people with carpal-tunnel-like symptoms who should take a look: Thoracic Outlet Syndrome

Dangerous Advice

The last thing I'll say about carpal tunnel syndrome is to point out a piece of seriously bad advice I saw in print, given by a prominent piper. This statement was that our muscles do most of their learning when they are tired, so when we practice, if our hands begin to feel tired, even to hurt a little, that's the most beneficial time to continue practicing. The recommendation was specifically to ignore soreness in the hands from fatigue. This is a terribly dangerous bit of advice. Adequate rest during practice sessions is very important to avoid physical injuries to our muscles and tendons. When we begin to feel pain, our bodies are telling us we're doing something that is hurting ourselves. Continuing activities that cause us to experience pain may be appropriate in some rare emergency situations, but continuing to play bagpipes or any instrument when we feel pain is definitely a big mistake. Someone could read the advice given by this person and wind up with a very serious physical problem that could even end their piping career permanently. If you are wondering about how to maximize your musical progress in practice sessions without injuring yourself, first of all you have to "practice smart." I'm sure there are many aspects to practicing smart, but you should definitely follow the various pieces of advice given in this document about musculoskeletal injuries in musicians.

Symptom Diary

Jan 1972: began learning the practice chanter at age 17. I had no one to tell me where gracenotes were to be placed relative to the beat, but learned to finger without crossing noises and to finger movements correctly as far as I can tell. I incorrectly decided that doublings were to be played before the beat, i.e. in double C, high g gracenote goes before the beat, d gracenote on the beat. Caused a problem with double Fs because my high G finger did not move quickly enough at that time to play the two high g gracenotes very close together in order to put the first high g gracenote before the beat and still have the rhythm of the tune sound OK. For the next thirteen years I could not play double Fs because I got off on the wrong foot.

March 1974 (?) - after a 2-3 week layoff with no practice, I picked up the pipes and started out trying to play a jig with some quick movements. For the first time I ran into the burning sensation at the base of my thumb that I now recognize as carpal tunnel. Hit it a few times that day when I tried difficult music, but with easier music it was OK. Same thing next day, not quite so bad, then the third day all was fine.

1974 - 1982: I would rarely run into the burning sensation. When I did, it was always after not practicing for several weeks. More often than the burning, my right hand in particular would feel tired if I was out of shape, and sometimes my right wrist would hurt a little when I was done playing, on rare occasion even so much that it might almost feel like I'd sprained it. Sometimes I'd overwork the index finger and it would be sore for a few days, but otherwise but nothing would last long beyond when I was done practicing. Typical practice sessions were 2-3 hours.

Winter 1976 (grade III solo) - I began to play my first strathspey with a new (for me) band. We were playing John Roy Stewart. I had a lot of trouble coordinating the double Bs, probably more than was called for. Mostly problems lifting the right ring finger and then making a D gracenote immediately in the same hand. It improved greatly, but was long a weakness.

Spring 1977 (?) - I had begun to learn piobaireachd the year before. I was working on toarluaths for that variation. My toarluaths were almost fine, just a little too quick and too light. I slowed it way down to get control over the D and E gracenotes. For three days I practiced really slow toarluaths about one hour a day. When I tried to do them at a more normal speed, my brain was confused about when it should close the chanter to the low G - was it early as for a really slow toarluath, or quite late as for a really fast toarluath, or somewhere in the middle for a toarluath at the speed I wanted to play? The subconscious mental confusion translated to my fingers, and for years my brain wanted my fingers to do something before it was time to go to the low G. I would hold them still, but sometimes my right ring finger would slip off the low A hole just before the low G, or for a B toarluath, the B finger would stiffen up and slide off the hole just before closing to the low G. If you have problems with toarluaths, don't do what I did. Take some other approach to correcting the problem, if nothing more than mixing slow with fast. Don't let your brain wind up with two or more totally "programmed" mathods to play the same movement because your brain may not be able to clearly separate them in the music. I've seen it advocated to foster control by playing movements at all different speeds. That's a good idea - but don't do what I did, that was a real pity how it worked out. One thing I did was play at different speeds in the same piece of music which really got the brain messed up. It's one thing to play different speeds in an exercise, and another to play different speeds in a tune. Another possible reason for the problem may have been that I was thinking both low Gs before the pulse. Now I believe the D gracenote in the toarluath ends on the pulse with the E gracenote after. Playing toarluaths that way, there's less chance for mental confusion about when to start - it's pretty much just immediately before the pulse whether you play the low Gs short or longer.

I played The Man From Glengarry for my reel. Too hard for grade III, but I didn't know better. Mostly technically OK, but had a terrible time with the birl off B, followed by C-A tachum followed by birl with high G gracenote. Sometimes I could do it, but most often it wasn't clear. Problems covering the holes coming down the scale into the first birl. Recovering from the first birl to do a C-A tachum was tough. If I managed it I was often unable to get the second birl in. I was still playing doublings and birls before the beat, which in retrospect really didn't help.

Summer 1977 (?) - I began to have a problem with D gracenotes on birls, the piobaireachd movement that substitutes D gracenotes for the high G gracenotes one sees prepended to birls in light music. It had never been a problem before, but all of a sudden it was. The right ring finger would want to pop up and blur the birl movement. There was no problem at all with birls led with a high G, just when a D was in front. Now I was having trouble with the ring finger in both toarluaths and D gracenote birls.

Fall 1977: Worked on a jig called The Fox-hunt (Donald MacLeod 2). Lots of bottom-hand work. Each part ended D-B-D-double E-low A-birl. My fingers would often not come down on the holes in the long E in the last measure of each part, then the low A and birl would be messed up. The middle and ring fingers of the right hand were tense in anticipation of the birl, long before it was time for the birl.

Around 1977 - 1978: I began having problems in the last measure of 2/4 marches that end each part with double C - E gracenote to low A - birl. That's just about every competition march. My ring finger wanted to pull off the hole in front of the birl. Caused a nasty sound! Many practices off and on for a few years were pure torture because of this.

1977 was not a good year. Nothing but frustration.

1978: I had a job for about a year in a factory that bent metal tubes for use as gas and brake lines in vehicles. I'd often bang my knuckles on the equipment, and they'd be sore. I developed little bumps on the top of the knuckle of the middle joint of both middle fingers. These always hurt a little, and they tended not to want to curl up all the way because the extensor had to be stretched over the bumps, so I forced them into the curled position regularly. I thought the bumps were perhaps arthritis brought on by bruising on the equipment, but in 2003 I found out that the tender bumps were a symptom of Dupuytren's Contractures. They grew to a certain size and stopped. Not overly obvious, but they're still there now. The one on the middle finger of my right hand is larger than the left and is more sore when pressure is applied.

Around 1980: the problem with D gracenotes on birls in piobaireachd mostly cleared up. It still took focus, but I could keep the right ring finger down and didn't have to worry about what would happen each time I played the movement. However, the ring finger pulling up before toarluaths and crunluaths, especially from low As and Bs, remained a big headache. That lost several competitions for me in 1981 and 1982.

Around 1981: Playing any jig that ended C-A-A-birl - the D gracenote on the first low A would often be blurry. Related to the up-coming birl because replacing the birl with a high G gracenote resulted in the D gracenote being clean.

Spring 1982: was competing in grade I for the second year. An instructor recommended I should move into open the next season. I had problems with two tunes in particular. One of the marches was The Argyllshire Gathering. I had to watch the opening B-A tachum followed by the birl to avoid fingers stiffening and messing up the birl. Also an instructor had finally told me doublings had to be played on the beat, and it was difficult to get the descending double D - double B - double low G pattern timed correctly in the endings. But I could manage it. One of the reels was The Smith of Chilliechassie, Capt. John MacLellan's setting. The fifth part would give me fits at times with a D gracenote on a short B off a low A, followed by a birl. Again, troubles getting things on the beat there, too, but the middle finger and ring finger would stiffen on the B before the birl. Much of the time it was fine, but there were periods it really would not come out.

Summer 1982: noticed a slight odd pit in my palm, an indentation of the skin in the main crease of my right hand even with my ring finger. I learned years later that this was the beginning of development of Dupuytren's Contractures.

August 1982: won first in Amateur Piobaireachd at Maxville. A great prize despite all kinds of problems I'd deal with that never quite went completely away.

All these preceding problems collectively added up to a lot of frustration, as you can imagine. Yet, except for the double F problem, they all came and went, returned, went away again, etc. By 1982 there were weeks where, when playing the pipes, I practically felt in Nirvana. The instrument was part of me and I felt I had to do no more than think something in order to have it come out about as perfectly as one could want. I could sight-read just about anything at tempo and make few mistakes, and I was finally just beginning to actually understand the light music idiom. 1982 was a great year, but then again I was practicing the pipes about 15 - 25 hours a week, two to eight hours a day (mostly 3-4).

One can analyze the preceding problems in an interesting way. Ignore the double F problem here, it's a different cause. Every one of the others was a bottom hand problem. Every one of them involved the right little finger. Every one of them involved D gracenotes somewhere. Most problems involved stiffening of a finger before a movement, a finger that in fact did not participate in the movement. And most interestingly, for the first four years I played, I had no problems whatsoever with involuntary movements or finger slippage in anticipation of other movements. The problems began to accumulate over the years. They would tend never to go away; it was mostly just accumulation. They mostly all seemed to have to do with moving some bottom hand fingers to the chanter while at the same time raising or preparing to raise the little finger to prepare for a birl. The index, middle, and ring fingers of my right hand did not naturally move independently from the little finger.

The index and middle fingers and to some extent the ring finger are moved by the median nerve. The little finger and much of the ring finger is moved by the ulnar nerve. The ring finger wants to move with the little finger before birls because they are pretty much controlled by the same nerve. However, I don't see the relationship between the index finger or middle finger and the little finger, why there would be a problem coordinating what those fingers are doing with a birl.

I don't understand why the problems come and go, and then come back. They never go away permanently. A problem may fade into the background for two or three months, but then suddenly up it will pop again and I'll fight with the same lack of coordination I thought I'd conquered many moons ago.

I am left-handed, not right-handed, so it isn't surprising to me that the coordination problems were nearly all right-hand problems. But it is surprising to me, certainly not intuitive, that someone who practiced as much as I did couldn't simply vanquish coordination problems that were severe enough to pull fingers off the chanter, and would get up into grade I and even open and still have issues of these sorts. And it's suspicious that I am now finding that carpal tunnel syndrome has a great effect on my coordination, and that I did experience some problems with carpal tunnel syndrome at that time, though I didn't connect it with anything in particular except bothersome but short-lived pain at times. For the most part my coordination was excellent, but what was the neurological source of those right-hand problems I could never quite overcome regardless of effort?

Sept 1982: moved to Wisconsin, began grad school

Sept 1982 - Jan 1987: didn't play much, busy with grad school. There weren't any pipe bands in the area, besides a Shrine Band which I wasn't involved with. I'd work on playing double Fs on the beat sometimes and the problem I had would get a lot better, i.e. my left index finger wouldn't be tied up in knots trying to go up-down-up-down faster than it could, but it was very difficult to keep it relaxed for the movement because of the years of trepidation before every instance of a double F. And if your finger isn't relaxed for a double F, it's not going to come out.

Jan 1987 - May 1987: worked for competition in Alma. Played Neil Sutherland of Lairg as one of the strathspeys. Trouble with the double strikes in the third part, especially the Bs. Eventually they came in, but I was always nervous about whether I'd get them or not. In 1982 they had been there pretty much without trying. Showed the effect of extended practice layoff, the first since I'd begun playing in 1972. The biggest problem was the very first measure. C-B-A triplet - dotted eighth low A/sixteenth B - g gracenote on low A - low A toarluath on the fourth beat. I spent huge amounts of time playing that measure trying to train my right ring finger to stay relaxed before the toarluath. If I left out the D gracenote on the short B in the second beat it was a lot less problematic - odd, having problems with the toarluath because of an innocuous little gracenote before it that really caused the problem. I've noticed that many more times with more recent problems. That was the only time I competed in open. In retrospect it was a bad choice for a tune for me - who needs a worry in the first measure they play before a judge? But I didn't realize that first measure would be a constant headache from an involuntary stiffness reflex. I loved the tune, but I don't think I'd compete with it now even if my hands were up to it.

1987 - 1989 or so: played with a band in Milwaukee, but no serious playing after May 1987. The little pit in my right palm became more obvious. A doctor noted it, but didn't know just what it was.

1989: Began a career as a computer programmer.

1989 - 2001: No piping at all. Picked up a practice chanter maybe three times in all those years. Over these years the pit in my right palm became surrounded with thicker tissue and a "band" of tissue formed between it and the base of my left ring finger. This was maybe eight years after I'd first noticed any symptoms. It tightened up a little and slowly I lost the ability to flatten my ring finger out parallel with the rest of my fingers. Also, my father suffered from the same problems during the earlier years of this time, and his doctor diagnosed it as Dupuytren's Contractures. Knowing what it was and what the options were from him, I didn't consult a doctor because it really didn't bother me except once when I tripped and fell, and my inability to flatten my hand caused a minor injury when some of the abnormal tissue tore a little. (Luckily I didn't break my fourth finger bending it backwards when I landed on my right hand palm down.) Also, I developed a pit in the crease of my left hand between the ring and little fingers, and around 2000 or 2001 a band started to form to my left little finger, beginning to pull it down.

July 2001: I started piping again, now at age 47. After twelve years I found the fingers rather rusty, but if I'd play regularly for at least an hour a day for two or three weeks, my coordination would come right along and I could play most of the tunes I used to play reasonably well. I was convinced that if I put sufficient time in, I could get back to where I had been years earlier. There were, however, two significant medical problems that stood in the way.

First, I would get a burning sensation in my right hand after I'd played for about five minutes. The time varied depending on what I'd do. At first I wasn't that worried about it because in the past it had gone away after a few days, but after it continued on for weeks, beginning to hurt really fiercely after a few minutes of playing and bringing with it complete if temporary loss of coordination until I rested, I realized it wasn't going to go away. I had no idea what it was, but it was definitely a bad thing, interfering significantly with my practice.

The other issue was the contracted ring finger on my right hand. Though the tendon itself wasn't affected, it was the same effect as if the flexor tendon to that finger had become too short. It didn't cause any kind of pain whatsoever, but the sensation was that it wasn't lifted high (because it wasn't), and it didn't feel right at all. I could never get used to the feeling of it being significantly lower than the right middle finger, which would be lifted to the normal height. Several consequences almost immediately developed from the problem with the right ring finger.

Besides those medical problems, there was one other unexpected problem to contend with in getting started again. In the years since I'd been absent from the piping scene, the pitches of D and G went down relative to low A. They used to be intentionally a bit sharp to the low A, and chanter manufacturers accordingly placed the D and high G holes a bit higher on the chanter. Now the holes are a bit lower, and since the overall pitch is higher as well there is no option of using old chanters with the spacing I am used to and just taping the pitch down. I have found it amazingly difficult to adjust my hands to the lower hole positions on the newer chanters, especially my bottom hand. I have seen advertisements for custom-made chanters with holes placed as the player desires, and I might get one of these if the other problems go away so the hole placement is the only thing I have left to contend with - otherwise it's expensive and the result would still be frustrating and poor playing, so no point.

One very interesting piece of good news, though. After thirteen years of not playing, the bad finger pattern I had developed for double Fs disappeared pretty much completely, and I was immediately able to successfully replace it with the correct pattern. The correct pattern hasn't had a lot of ingrained work, but I would no longer be afraid to play a tune with double Fs in it in public. I'd be fairly confident nothing disastrously unmusical would happen. I might still not choose to compete with Atholl Cummers or The Ewe Wi' the Crooked Horn with their double F-happy parts, but I wouldn't be nervous with them as a band tune.

April 2001 - July 2003: I played fairly regularly through this time, mostly on practice chanter but some pipes as a band member. The ring finger of my right hand slowly came closer to the chanter at its maximum extension, so it took more force to hold it up and make sure it didn't come down on the B hole when it shouldn't. Although the right little finger wasn't much involved (thank goodness, or birls would have been impossible), it still wound up being pulled in a little, to the point where I had to stretch the little finger down almost as far as it could go to cover the bottom hole, and there was really no extra play at the bottom to slide the little finger across the hole downward to do the figure 7-type birls. Sometimes the little finger would miss the hole on low G, just not being stretched down as far as it could go and so landing above the hole. I was able to address that temporarily by using my other hand to stretch the little finger away from the other fingers. After the passive stretch the little finger would cover the hole with enough room to move down a bit.

At home, I didn't spend much time playing tunes. I was mostly working on repetitive exercises for a half hour to three hours blowing while the TV was on, constantly trying to train the muscles of my right middle finger and index finger not to tense up when I lifted my ring finger. This problem seemed only to get worse with time, probably because of the increased force needed to get the ring finger up. I could still usually get to a point where things were pretty coordinated after a long practice, especially after several days practice in a row, but towards the end it would take so much practice to get there that those times were getting much fewer and farther between. I also found that when I was most successful, and all the fingers would fingally seem to be moving just right (I could even get out The Hen's March or The Piper's Bonnet), the very next day would be an absolute disaster, and I'd be back to square negative-one with extra finger tension and bad coordination. It happened every time. Very discouraging. Sometimes I'd just quit the practice chanter for two or three weeks out of frustration, and in so doing work my way back up to square one. Then I'd give it another go.

Near the beginning of this time, I decided to try to train myself to do two things. First, play the tap and draw birl rather than the figure 7. Second, to move my right thumb a little lower on the chanter, about even with or barely below my middle finger, in order to apply a little force against my ring finger. I hoped that these two things together would help with the recurring problems I'd had in the past with the ring finger and middle finger often not behaving well before birls and toarluaths. I wanted to eliminate the sliding movement of the little finger and keep the middle finger in place. Since I did this, now four years ago, I have had little trouble with those specific problems, but then I haven't been playing tunes much, mostly just exercises. I do know they don't totally solve the problem, because some of the problems before were due to stiffening and sliding before toarluaths, and there is no sliding movement of the little finger in toarluaths anyway. However, I do believe it has helped a little. However, I've had some problems with the thumb. Bringing the thumb down does aggravate the carpal tunnel symptoms, bringing on pain. When the body does something that causes pain, we tend to "favor" that muscle, to relieve the pain, unconsciously. I find myself constantly moving the thumb back up, and I think it's either to relieve the pain or, possibly, because the thenar muscle, one of those which helps the thumb perform a pincer movement, has become weak due to carpal tunnel syndrome. The latter is a known symptom, but where I read about it I see it in the context of "in severe cases," and I'm not so sure it would be going on in my hand as I don't have a severe case. I would say my right hand thumb muscles are signficantly weaker than on my left hand, but that could just be the difference between dominant and (? - non-dominant?) hands. Or, it could be due to carpal tunnel syndrome, I don't know.

During this period of time, the carpal tunnel pain did not disappear, but it did seem to come on after a little more delay. Also, I didn't often experience it severely because as soon as my hand started to hurt much I'd quit for a minute. I still didn't really know what the problem was, but I was sure it had something to do with the nerves in my hand. I thought maybe my thumb muscles were somehow pinching a nerve since it hurt more when I pulled my right thumb lower on the chanter. I'm not sure just how the thumb position affects carpal tunnel. Possibly moving the thumb across your hand squeezes the carpal ligament downwards, creating extra pressure on the median nerve? I don't know. In any case, the pain and numbness symptoms of carpal tunnel didn't seem to change much during this 2.25-year period.

The whole business of sensation in the hands and coordination playing the chanter is subjective, but my distinct impression during this period was that things were steadily getting worse.

July 2003: I decided to see the doctor about the pain in my hand and to pursue getting surgery for the Dupuytren's Contracture in my right hand. My main concern with the Dupuytren's was that, through the muscle adaptations I was making for Dupuytren's, I was training my muscles to do things that I would have to undo after the surgery, and I didn't know how well that would work. The longer I went, I reasoned, the harder it would be to get back to "normal" after the surgery. Getting my ring finger functioning well again seemed the highest priority, so I wanted a diagnosis for the pain but really wanted to get the Dupuytren's surgery done first.

The doctor scheduled Dupuytren's surgery for September, and an EMG test for carpal tunnel syndrom in August. The EMG test didn't show carpal tunnel syndrome, but the clinical test (Phalen's test) did. The doctor agreed it would make sense to get the Dupuytren's surgery taken care of, see how everything settled out after that, and then pursue the carpal tunnel surgery if I wanted to.

September 2003: I had the Dupuytren's surgery for my right hand. Recuperation was quick and relatively painless. My hand straightens out completely normally now, and the little finger stretches down perfectly well. One major disappointment, though. The doctor said there had been more involvement at the base of my ring finger than he had expected once he got in there, and some nerves had been locally affected by the cutting needed to remove the tissue. In fact, there was a significant effect on the ulnar nerve. The ring finger is innervated on the side next to the little finger by a branch of the ulnar nerve that runs up the side of the finger to provide sensation and some muscle control. After the surgery, the joint of my ring finger next to my palm was pretty numb in the area next to my little finger. Not totally numb, but maybe 95% sensation loss. The numbness extended up into the next joint of my ring finger, but was maybe 50% numb there. The end joint is innervated by a different nerve and was unaffected. Now, almost two years later, the numbness is less, maybe 30% sensation loss in the worst spot, with tingling when I rub over the crease at the base of the ring finger. Nerves do regenerate - I was told they grow back at the rate of about one quarter inch per year. Possibly someday the feeling will return to normal.

The doctor said this was no big deal, that the surgery had gone extremely well. His goal for a functional outcome was to get my hand flat again and "functional." My goal, though, was to play my pipes well again, and I was kind of disappointed with the numbness. I do believe he did a great job, but the surgery didn't go as well as I'd hoped.

It's uncertain exactly how the nerve damage affects my playing. I don't really have any trouble feeling the hole with that finger, and I think I can move my finger up and down like before. But I think there has been a big effect, nevertheless. First of all, when I played chanter or pipes after the surgery, the sensation in my hand was that the part served by the median and radial nerve felt and operated one way, normally, while the part served by the ulnar nerve felt and operated completely differently, as though they were on somebody else's hand. The ring and little fingers felt somewhat like sausages though they weren't at all swollen, and though they seemed to move OK, the movements felt inexact and the sensations of interaction with the chanter were vague compared with the other fingers. Birls worked fine, but everything felt totally weird.

As I played, sure enough, I had to undo the adaptations of the last two years.

Despite the welcome correction of the ring finger contraction, my playing actually took a big turn for the worse after the surgery. A month after the surgery I would attempt to play the second part of The Piper's Bonnet, with all the strathspey double C - E gracenote - low As, and the sensation I felt was of my right hand totally collapsing on the tune. I don't know whether it's strictly a matter of strength or impaired sensation. I could do one or two of the movements, but the third would simply fail in a very uncoordinated fashion and it would go downhill from there. This lack of coordination was definitely worse than before the surgery.

October 2003 - October 2004: Spent a lot of time with practice chanter exercises to rehabilitate my hands. Some things got better, others got worse. The sense of collapse of my hand on The Piper's Bonnet improved by August 2004 but I still could not play the tune decently. I spent a long time with tachum exercises, a tune called "Tachum Tune" written by Ken Eller. There was significant lack of coordination. Tachums seemed to get good to a point, and then fall apart again overnight. There was no long-term improvement. At some point I developed a repetetive strain injury on my right index finger doing too darn many D gracenotes in all these exercises - a stabbing pain in the top of my hand when I lifted my index finger. I still have to be careful about that. Somewhere along the way things went seriously wrong with my right index finger, too, maybe related to that, maybe not. Lifting my fingers to a C began to stiffen my D finger. Double C's became extraordinarily un-coordinated, and doing too many caused pain in the finger. Doing g-d-e gracenotes on C revealed a big coordination problem - I could hardly do them. This seemed to come on fairly suddenly - one week they were fine, the next week they were completely gone and they really did not want to come back. On other notes, g-d-es were basically OK.

With the D finger, one thing I realized was that I had begun to make D gracenotes lifting the finger on the beat instead of bringing it down on the beat. I could do g-d-e gracenotes on low As rapidly, but if I slowed them down they became uneven because the D gracenote was delayed. I could hear it was off, but the fingers felt like they were doing the right thing when they weren't. I have no idea when that began. However, it set up an incorrect pattern in my brain I had to correct. It may have contributed to some of the other problems I'm having today.

October 2004: I was laid off from my job as a computer programmer. Whatever contribution computer programming made to my carpal tunnel syndrome was completely absent from Oct 2004 to at least July 2005. I still use computer for e-mail and things like this document, but my typing time has been quite limited compared to before. There has been no improvement of coordination or lessing of pain, in fact those things have gotten worse.

November 2004 - January 2005: Increase in coordination problems. Continued problems with double Cs. Continued tension in the wrong fingers. Began to notice big problems making double Bs from C - changing from C to B with a high G gracenote would thoroughly stiffen my right index finger, and then I couldn't make the D gracenote in the doubling. With lots of work I could get the index finger to stay relaxed and double Bs would come back, but the problem doesn't just go away, it comes back another day. Repeatedly. These last few things seem to demonstrate problems with index and middle finger coordination, which are the fingers (besides the thumb) controlled by the median nerve that runs through the carpal tunnel.

January 2005: While driving one night I suddenly had the sense that something had instantaneously gone wrong with my right hand. After you play the pipes for a while, you get a "feel" for how the chanter feels in your hand. If you lay your hand on the chanter in a certain way, it just feels right and any other position feels wrong. You can get the same feeling from a car steering wheel. Suddenly the steering wheel felt foreign, and moving my hand around I could not feel any position that felt "right." When I got home I tried the practice chanter, and there too, nothing felt "right." This has literally happened overnight. Since then through today (July 2005), the chanter has never felt right. Sometimes less foreign than other times, but it's never been comfortable since that day. What happened?

January 2005 - March 2005: very little practice at all, but when I did practice, it's the same old garbage.

April 2005 - July 2005: Intermittent practice. Several days on, then some off, but mostly on. Slowly achieving progress with D gracenotes on C and double Cs, but most other things involving the right hand seriously going downhill. The right hand is lately beginning to feel a little weaker than the left. Not extremely, just slightly. I feel it in holding the chanter. Also, in picking up heavy books, the grasp is firm in the left hand, somewhat weaker on the right and the book just feels significantly heavier. This is consistent with carpal tunnel syndrome. The pain in the hand from playing seems about the same, but there is much more often a low ache in the area across the transverse carpal ligament. I notice that, at this time, I can make repeated high G gracenotes perfectly rhythmically in succession, but when I attempt to do the same thing with D gracenotes they are irregular. If I am warmed up I can make a few regularly, then the evenness and regularity in length dissipates. If I am not warmed up the sequential D gracenotes are very uncoordinated. Simply going from B to low A and then quickly making a D gracenote is a big problem - the index finger tenses and the gracenote comes out sometime, any old time. My right index finger also feels stiff, increasingly so, a little sore the last couple of days, and it's feeling less friendly towards full flexion. Weirdly, some tunes still come out very well, especially if I'm warmed up. However, most tunes encounter some roadblock that requires a long time to work out that day, and I know the next day things will be just as bad again. Mostly my right hand has little coordination. I can make the fingers move, but the wrong fingers are constantly getting tensed up and hurting, and gracenotes are timed very poorly unless I take that little section and work it. A few days ago I played through about twenty reels on practice chanter, working on uncoordinated spots, and succeeded in straightening everything out, except for the general sense of weakness in my right hand. Felt good. The next day was bad, and the day after that was terrible, coordinationwise. Frankly, it's hardly worth continuing with piping at this point. It hurts and it doesn't sound very good, and it's a lot of time spent with no good results. It's not fun this way, either. Being out of work with no health insurance right now, I can't schedule the carpal tunnel surgery.

July 2005: Searching the Internet for information on Carpal Tunnel Syndrome I came across a Web site for the FLEXTEND glove. I decided to purchase it. The logic of how it works seems sound, they say they have a great success rate, they have many testimonials on the site. Their representative told me they have hundreds of customers who are musicians who use the glove just to improved dexterity and coordination apart from any benefits of carpal tunnel. It hardly seems it can hurt. They said they are positive it will help me with coordination. I decided to create a diary of my symptoms and treatment progress and share it with other pipers on this Web site. I should be receiving it around July 25th.

July 16, 2005: A new symptom, probably not related to carpal tunnel syndrome, but probably to overuse of the index finger for gracenotes. There is tenderness at the second joint from the end of my index finger, approximately where my thumb presses against the index finger. The pain is not precisely at the joint, but slightly more in the fleshy part of the finger close to the joint. This is in both fingers, more in the right hand than the left. I was trying a new exercise for a few days just previous to this which had me doing a lot of G and D gracenotes trying to make them identically. Apparently I should have taken more breaks while doing this.

July 20, 2005: Though I have been careful about the practicing, the pain in my index fingers at the joint has increased. After I play for a little while, it really hurts, kind of a sharp, jabbing pain at the same location. It sometimes hurts when I'm not playing. It feels like nerve pain. If I massage the fleshy area of my index finger, or squeeze it between two fingers of my other hand, I can feel there is something specific in there that hurts. I have seen pictures that show a branch of the median nerve running up along the side of the finger.

Very interestingly, I have noticed something else I do that could be related to this symptom. I sit a lot at the computer and my shoulders get pretty tight. When I drive, sometimes I put my right arm back behind the passenger seat to try to stretch the shoulder muscles a bit. I noticed recently that if I extend my fingers at the same time I'm stretching those muscles, I'll feel pain in my fingers, especially that very same spot next to the joint on my index finger from something that's being stretched and affecting the median nerve. I have tried it several times, and observed the pain doesn't completely go away when I relax my hand then, so apparently I'm doing something that hurts the nerve. I don't know whether it's hurting the nerve at that point in my hand because it's somehow being over-stretched along with other tissues, or whether it's being hurt somewhere else and the pain is being transferred to a point in my fingers. I looked at the link to Thoracic Outlet Syndrome and began to wonder if this could be related to the pain in my hands at all, because it's interesting that when I stretch in the car I'm doing something that should only affect my shoulder and chest, yet it does affect my hand. On the other hand, it hurts when I simply press on that part of my index finger, so probably it's not quite the same thing as is described on the thoracic outlet syndrome page.

July 23, 2005: My right index finger is hurting less now, but I'm still trying to be careful of it. Also, I found the page on Fundamentals of Piano Practice. Reading it over carefully, I see some principles I need to apply in my own practice (and so should all pipers, I think).

July 24, 2005: I tried something completely different, after reading the piano practice article yesterday. I set my hands on the chanter about as lightly as I could and tried playing without applying any pressure to make quick gracenotes, with the goal of eliminating all the tension that interferes with various movements. Basically, I was just wiggling my fingers over the chanter, making sure I covered the holes but not really pressing down on them. The gracenotes come out a little blurrier, but I find one thing very interesting - when I was focusing on staying completely relaxed, indeed some of the problems of my fingers fighting each other did go away, and I could play things decently that I have not been able to play for some time! Also, it was very easy to tell when even a little bit of unwanted tension would appear because there was no "desirable" tension in the other fingers, and so I could get rid of the unwanted tension easier. The carpal tunnel pain at the base of my thumb did not appear at all while I was playing this way. However, the nerve in my right index finger did hurt.

I'm wondering if this would be a good way to practice for a while, to help get rid of the "bad" tensions, and also to stay away from carpal tunnel problems better. I can begin to apply a little more pressure later to tighten up the gracenotes, after the other problems are cleared up. Maybe worth trying.

I'm still waiting for arrival of the FLEXTEND glove.

Aug 2, 2005: I was out of town for four days. Basically didn't practice since July 25. Index finger still hurts at a very low level - can't say as the break really helped it get better at all. Wonder if it could be tendonitis? No idea. Definitely have to keep that finger relaxed when I play in order to avoid twinges of pain. Similar idea to an electric shock when I do something wrong, interesting way of getting feedback! Still waiting on the gloves - they're out of the small size and are waiting for a shipment from the contract manufacturer.

Aug 8, 2005: Made some interesting observations. The light-fingered approach is very important to keeping tension out of the index finger. However, for me, it contributes to imprecise playing. Without unwanted tension co-ordination definitely improves, but fingers have a hard time staying on the holes when no pressure is applied. After several days of the light-fingered playing my hands felt very floppy, like I was moving them only "approximately" and not feeling anything, not sensing the chanter in my fingers, and the playing really wasn't that good.

I began playing with a little more pressure but still trying very hard not to let the index finger get tight. For a while last night my hands felt quite good, quite well-coordinated, and except for occasional "catches" of momentary tension and uncoordination, I was able to play pretty decently without problems. I felt two things clearly in my right hand. First, my extensors were relaxed, maybe a little tired out. The relaxation would go hand in hand with lack of feeling that my fingers were fighting each other. Somehow my fingers normally have a tendency to get stiff, fighting each other. Probably the light-fingered approach helps break out of the stiffening cycle and so is extremely helpful for a short time for that reason. The other clear sensation was that I was gripping the chanter more firmly than usual with my middle and ring fingers of my right hand, and I wasn't gripping much at all with the index finger. I was striving to keep the index finger relaxed, and succeeding, but was allowing the other fingers to grip, but not too tightly. The sensation coupled with success in playing decently makes me realize that typically I grip harder with the index finger than my middle and ring fingers, and this is what has caused the index finger to get very stiff, strong over time, and not to relax quickly when it is lifted. Also, while I was playing there were times when the playing was muddy. I found that if I focused on maintaining a grip with my middle and ring fingers, especially with the middle finger on Bs, the whole way things feel when I'm playing is totally different, and significantly the muddiness usually goes away!

Also yesterday and today I tried something I don't ever do - making C gracenotes in coordination with D gracenotes, like double Es but with the right hand. For one thing making gracenotes with that finger felt awkward, but I kept after it and it got a lot better. Not surprisingly, bubbly notes were at least momentarily a lot better after this, too. But I did this at the start of practice yesterday, and I think it had a strong positive effect on getting myself to apply more pressure on the chanter with my middle finger and the positive effects I experienced from that. I should practice C and B gracenotes on B, low A and low G regularly. Hopefully I will remember to do so!

This is interesting when I think about the problem I have with my right thumb wanting to slide upwards. We apply a little pressure with our thumb to balance the force being applied by the fingers over the holes. If we are applying pressure with only one of our other fingers, our thumb tends to want to move opposite that finger. For a while, apparently I've been applying way too much pressure with my index finger. My thumb has been sliding upwards. Is it sliding upwards to go opposite the index finger where more pressure was being applied? It's a somewhat murky area - does the thumb move to be opposite the finger applying more pressure, or does my thumb move for a different reason (pain avoidance, for example) and then the finger that is opposite the thumb begins to apply more pressure? I definitely don't know. However, I was able to effect the most improvement on muddiness of technique by not only applying a little more force with my middle and ring fingers, but by also keeping my thumb opposite the middle finger where more pressure seems to be needed. That both helped increase pressure in those center two fingers and helped decrease unwanted pressure (contributory to tension and I think lack of responsiveness in D gracenotes) in my right index finger. It's worth mentioning that I used to play with my right thumb higher all the time, almost opposite my index finger, and back then my index finger didn't stiffen up like that, so the thumb position isn't truly a "deterimining factor" in having this kind of finger tension problem. I think it's a contributory factor, though.

While I was playing like this, with more pressure from my middle and ring fingers but my right index finger with little pressure, I definitely didn't feel like my hand was "floppy." The pressure on the chanter felt "right," firm but light, and that's a good thing! Often it doesn't feel that way. I don't know if the good sensation was from the way I was using my muscles or an effect of having practiced for quite a long time. Even though the pressure of the fingers felt right, the actual feeling of holding the chanter did *not* feel right, so even when I was just fingering low A, I felt like I was holding my fingers in an unfamiliar position. This is a carry-through from several months ago when all of a sudden the chanter felt like a foreign instrument. I'm sure something significant happened over a short period of time there to my hand nerves or something having to do with my brain. I think somehow I have to get used to the feeling so that it becomes "normal." Hope it won't take years. On the other hand, the important thing is just to be able to play whatever I want without unexpected problems. Maybe the sensation of "rightness" or normality is not a critical issue.

It was interesting that I didn't notice my hand hurting at all while I was doing this. I played through at least a couple of dozen tunes, some two or three times, and the carpal tunnel pain never came in a couple of hours of practice. Perhaps I was taking so many breaks between tunes that it didn't have a chance to occur. Now after practice I can feel a very slight burning that I really don't even notice any more because I have it so often and it's such a low level. I don't know if it was there before practice or not.

I would like to think these are important insights into the causes and pieces of the remedy for the lack of uncoordination I've been having. I've felt I've had insights before, and then the uncoordination returns and I'm not able to get the "right" feeling back by applying the things I thought I'd learned, though, so I'm not that confident I'm on the road to success. I'll keep after this for a while, though.

Still waiting for the FLEXTEND glove. The company is also frustrated with the delay, they say they have no control over this.