Hypermobility in Middle School Band Students

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Another Indicator for Future Success

One of the most important days for a middle school band director is the day incoming fifth graders are assigned their instrument. This is the day that the recruiting process comes to fruition and next year’s numbers start to come together. Most often taking place in the band hall, cafeteria or gym, confident fifth graders try out each band instrument one at a time, until they find their fit. The band directors take notes on the students’ physical characteristics, interest level, internal rhythm, ear, natural ability to buzz or make a sound, and other factors. The student leaves with a newfound identity – flute or saxophone or trombone.

The typical screening tests for instrument placement leave out one important factor however: joint laxity, or hypermobility.

Joint hypermobility occurs when joints can bend or stretch further than is considered within the normal range of motion ¹. This is often related to joint laxity in the ligaments due perhaps to the continuing stabilization of collagen ². Hypermobility is more common in children and adolescents than adults due to their continued growth and development ². The Beighton Test (shown right) has been validated to accurately measure joint hypermobility in children ³.

Band directors could also ask students directly if they are known to be double-jointed or hypermobile.

Hypermobility has been linked to musculoskeletal pain both in musicians and children ⁴. Therefore, it stands to reason that young children who are learning a musical instrument may be negatively impacted by their natural joint instability and flexibility.

As a band director, I have seen beginning band students who exhibited signs of hypermobility when they held their instrument. In particular, I noticed that certain instruments presented unique challenges when hypermobility was present in the hands and fingers.

As a clarinetist myself, I first noticed hypermobility in my sixth grade clarinet class. Students who are particularly double jointed often hyperextend their left thumb in an effort to cover the tone hole on the back of the instrument. This is noticeable because the rest of the hand collapses around the instrument, as opposed to the natural “C” shape of the hand. This will also present itself in the right hand, especially if there is no neck strap being used. In addition, the tips of the fingers will often hyperextend in an effort to seal the tone holes completely with the pads of the fingers. Lastly, the fingers may also hyperextend to reach keys that are further away; this is seen particularly in the pinkies of both hands.

Similar issues can be seen to a lesser extent in the other woodwinds. Saxophonists, oboists and bassoonists often have issues when they have hypermobility in their thumbs.

Low brass instruments such as the euphonium and tuba have valves that are more difficult to press down than other high brass instruments. Students with joint laxity may find particular trouble in pressing down these firmer valves. They will often hyperextend the joints in the fingers when pressing down the valves on this instrument.

High brass instruments such as the trumpet and French horn have the same issue, although to a lesser degree. However, proper hand technique (where the fingers are curved to where the tip of the finger underneath the fingernail presses down on the valve cap, as opposed to the pad or fingerprint) can help to prevent this.

When placing incoming beginning band students, consider avoiding those instruments that are more likely to aggravate hypermobility symptoms. For example, a student who displays hypermobility in their pinky fingers may not succeed on clarinet, where multiple keys are depressed with those fingers. Another example might be a student who displays hypermobility in their thumbs. Again, this could make clarinet a more challenging option for that student. In this instance, you might instead suggest saxophone where joint instability in the thumbs may not be such an issue. Similarly, a student who is leaning towards low brass but exhibits high hypermobility should avoid the tuba due to the difficulty of pressing down the valves. Instead, trombone may be a better fit.

As with any other physical indicator for placing students on instruments, the results from either the Beighton test or any hypermobility screening question are meant to be only another consideration, not a hard and fast rule.

In the end, there is no way to completely predict the future success of a musician when they pick their first instrument. However, the band director can perhaps ease the beginning band student’s path by taking their joint hypermobility into consideration.

The Beighton Test

The Beighton Test is widely-used in the medical community to identify symptoms of hypermobility. The score is calculated by testing five actions. Each affirmative response is worth one point.

• Bend the pinky finger back towards the top of the hand until a 90-degree angle is achieved.
• Bend the thumb backwards towards your forearm until it touches.
• Extend arm straight until the elbow bends backwards.
• Extend leg straight and lift hell until the knee bends backwards
• Stand with feet and legs together and bend over. Keeping the legs straight, place the palms on the ground in front of you.

Note: Scoring high on the Beighton Test does not necessarily indicated that an individual has hypermobility or a hypermobility disorder.

In addition, teachers, should be cautious and avoid diagnosing their students with hypermobility or such a syndrome, as there are potential legal repercussions.

Modified Beighton Test

I suggest a modified version of the Beighton test to screen your incoming fifth graders for hypermobility symptoms. This test version focuses solely on the upper extremities and joints used for holding and playing a musical instrument. As with the original test, give a student one point for each action completed positively.

Bend your thumb backwards until it touches your forearm. Start with the left and repeat with the right if completed positively.

Make a “thumbs up” shape. Lightly press on the back joint of the thumb until it hyper extends. Alternative test includes simply asking the student if they are double jointed in their thumbs.

Make an “okay” shape with your thumb and index finger and press gently. Watch to see if the first joint hyper extends by bending backwards past neutral. Repeat with other fingers.

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Bend the pinky finger back towards the top of the hand until a 90-degree angle is achieved.

Note: The results from this test are NOT a diagnosis of hypermobility. Instead, they are meant to simply be another consideration when placing students on instruments.

Sources

Kirk, J.A., Ansell, B.M., and Bywaters, E.G.L. (1967). The Hypermobility Syndrome: Musculoskeletal Complaints Associated with Generalized Joint Hypermobility. Retrieved from http://ard.bmj.com/content/26/5/419.full.pdf

Joint Hypermobility in Children [Editorial]. (2005). Joint Hypermobility in Children. Retrieved from http://rheumatology.oxfordjournals.org/ content/44/6/703.short

Smits-Engelsman, B., Klerks, M., and Kirby, A. (2010). Beighton Score: A Valid Measure for Generalized Hypermobility in Children. Retrieved from http://www.jpeds.com/article/S0022-3476(10)00599-8/fulltext

Brandfonbrener, A.G. (1990). Joint laxity in instrumental musicians. Retrieved from http://www.sciandmed.com/mppa/journalviewer.aspx?issue=1135&article =1364&action=3&search=true#abstract

Van Horebeek, E. Beighton score [electronic image]. Retrieved from http://www.physio-pedia.com/images/8/82/Beighton_Score.png

Double-jointed (hypermobility) [electronic image]. Retrieved from https://qw88nb88.files.wordpress.com/2008/05/thumb-to-forearm.jpg

Is hypermobility connected? [electronic image]. Retrieved from https://crpssupport.files.wordpress.com/2012/06/hypermobility1.jpg

The Hand in Diagnosis [electronic image]. Retrieved from http://stanfordmedicine25.stanford.edu/the25/images/HandInDx/medianNervePalsy.jpg

Ehlers-Danlos Syndrome 101 [electronic image]. Retrieved from https://mastcellblog.files.wordpress.com/2013/04/hypermobile-pinky-finger1.jpg