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C L I N I C A L P R A C T I C E ABSTRACT
Background. The authors reviewed
studies to identify methods for
dental operators to use to A D A
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N
CON
or MSDs.
musculoskeletal
IO
Types of Studies
T
T
A
N
I
C
Reviewed. The authors U U
A ING ED 3
disorders in clinical reviewed studies that
related to the prevention of
RT
ICLE
bony structures of the vertebrae resting on top of tures are common among dentists, due to years of
one another. When these curves become either poor posture involving holding the neck and head
exaggerated or flattened, the spine increasingly in an unbalanced forward position to gain better
depends on muscles, ligaments and soft tissue to visibility during treatment (Figure 2). In this pos-
maintain erect. ture, the vertebrae no longer can support the
When sitting unsupported—a frequent posture spine properly, and the muscles of the cervical
in dentistry—the lumbar lordosis flattens (Figure and upper thoracic spine must contract con-
2). The bony infrastructure provides little support stantly to support the weight of the head in the
to the spine, which now is hanging on the mus- forward posture.4 This can result in a pain pat-
cles, ligaments and connective tissue at the back tern, which often is referred to as tension neck
of the spine, causing tension in these structures. syndrome. This syndrome can cause headaches
Ischemia can ensue, leading to low back strain and chronic pain in the neck, shoulders and inter-
and trigger points. This flattening of the lumbar scapular muscles, and it occasionally can radiate
curve also causes the nucleus in the spinal disk to pain into the arms. Sustained contraction of cer-
migrate posteriorly toward the spinal cord. Over vical muscles also causes weakening of the spinal
time, the posterior wall of the disk becomes weak, disks, with possible disk degeneration or hernia-
and disk herniation can occur. Therefore, opera- tion.5 Therefore, frequent relaxing and stretching
tors need to know about strategies they can use to of the neck muscles, strengthening of the deep
maintain the essential lumbar lordosis whenever postural cervical muscles and preservation of the
possible. cervical lordosis in proper posture (ear over the
Maintaining the cervical lordosis in the proper shoulder) with all activities, including sleeping
position is equally important. Forward-head pos- and driving, is essential for optimal muscu-
susceptibility to injury due to the mechanisms we instead of twisting the torso. Operators should try
discussed in a previous article.1 Increasingly, the to retrieve items with the closest hand, especially
literature supports the idea that workers should with rear delivery systems, to avoid twisting or
vary their work positions as often as possible to reaching across the body. Repeated unilateral
shift the workload from one group of muscles to twisting in one direction may result in muscle
another.6,9,10,14,15 imbalances or structural tissue damage, leading
Alternate between standing and sitting. to low back pain.17,18
Standing uses different muscle groups than does
sitting; therefore, alternating between the two PERIODIC BREAKS AND STRETCHING
positions lets one group of muscles rest, while the Chairside directional stretching. Studies
workload is shifted to another group of muscles. suggest that the increase in operator pain since
Alternating between standing and sitting also can the 1960s may be due to longer work periods
be an effective tool in preventing injuries.15 One without breaks, due in part to the use of four-
study revealed that dentists who worked solely in handed dentistry techniques.14,19 Having opera-
a seated position had more severe low back pain tors take frequent breaks20 and reverse their
than did those who alternated between standing positions is integral in an effective injury preven-
and sitting.16 tion program.
A B C D
Figure 4. Examples of chairside directional stretches. A. Neck and shoulder combination. With the elbow at shoulder
height and at a 90-degree angle, gently pull the arm across the front of body with opposite arm. Look over the
shoulder being stretched and hold for two to four breathing cycles. Repeat. B. The untwister. With the knees wider
dcreates a relaxation response in the central sues, the operator should allow for rest periods to
nervous system; replenish and nourish the stressed structures. If
dwarms up the muscle before beginning to these breaks are too far apart, the rate of damage
work; will exceed the rate of repair, ultimately resulting
didentifies tight structures that may be predis- in breakdown of tissue. According to Karwowski
posed to injury. and Marras,6 resting for more than 50 seconds
How to stretch safely. To avoid injury does not result in an increased force-generation
during stretching, keep the following tips in capacity, or strength, of the muscles. This indi-
mind: cates that to optimize the strength capacity of the
dassume the starting position for the stretch; worker and minimize the risk of experiencing
dbreathe in deeply; muscle strain, following a schedule of brief, yet
dexhale as you slowly increase the intensity of frequent, rest periods would be more beneficial to
the stretch up to a point of mild tension or workers than would lengthy infrequent rest
discomfort; periods.
dhold the stretch for two to four breathing In a study on the efficacy of microbreaks during
cycles; the workday, McLean and colleagues22 found that
dslowly release the stretch and return to neu- by complying with regularly scheduled micro-
tral position; breaks, the subjects had less discomfort and that
drepeat the stretch if time allows; the addition of 30-second microbreaks showed no
davoid stretching in a painful range and discon- detrimental effect on worker productivity. Other
tinue stretching if it increases pain. authors have pointed to the efficacy of using
dperform stretches in both directions to detect micropauses and stretching during dental proce-
unilateral tightness (Figures 4A-4C illustrate dures.23-25 Stretches can be modified so that dental
stretching in one direction only); operators can perform the stretches easily at
dperform directional stretches primarily toward chairside, while wearing their gloves (Figure 5).
the tightest side throughout the workday and Operators should perform directional stretches
perform the stretches in both directions at home. regularly throughout the day, both in and out of
Stretching during microbreaks. To prevent the operatory setting. They also can benefit by
injury from occurring to muscles and other tis- walking or performing other activities involving
working posture, optimize the function of the both variety and the benefits of cross-training.
arms and hands and prevent injuries. The results of a study assessing the muscu-
Areas to strengthen include the trunk stabi- loskeletal symptoms of dentists found that phys-
lization muscles, primarily the transverse and ical exercise can be a buffer against musculo-
oblique abdominal muscles and multifidus mus- skeletal ill health and stress for dentists over a
cles; the stabilizing muscles of the shoulder wide range of ages.13
girdle, mainly the middle and lower trapezius Stress management. It generally is accepted
muscles; and the downward gliding muscles of the that dentistry can be a stressful occupation.
rotator cuff, the infraspinous, subscapular and Stress can elicit muscular contraction and pain,
teres minor muscles. Dentists should avoid over- especially in the trapezius muscle.29 Operators
strengthening the chest and anterior neck muscu- may use various stress-reduction techniques to
lature, deltoid muscles and upper trapezius mus- decrease stress-related muscular tension. They
cles, as this may exacerbate muscle imbalances to include breathing techniques, progressive relax-
which they are prone. Areas to ation, visualization, massage, aer-
stretch include the chest muscula- obic exercise, meditation or yoga.
ture, hamstring muscles, low back Aerobic exercise
muscles, buttock (piriform) muscles EDUCATION
should be performed
atory techniques Boca Raton, Fla.: CRC Press; 1999:256, 835, 925.
7. Hagberg M. ABC of work related disorders: neck and arm disor-
has made ders. BMJ 1996;313(7054):419-22.
delivery of dental 8. Hedman T, Fernie G. Mechanical response of the lumbar spine to
seated postural loads. Spine 1997;22:734-43.
care more effi- 9. Harrison D, Harrison S, Croft A, et al. Sitting biomechanics, part
cient and pro- 1: review of the literature. J Manipulative Physiol Ther 1999;22(9):
594-609.
ductive; however, 10. Chaffin D, Andersson G, Martin B. Occupational biomechanics.
it also has con- Ms. Valachi is a phys- Dr. Valachi is in private 3rd ed. New York: Wiley-Interscience; 1999:364, 366, 386.
ical therapist, a certi- family practice, St. 11. Chang BJ. Ergonomic benefits of surgical telescope systems:
tributed to an fied ergonomic assess- Helens, Ore., and is co- selection guidelines. J Calif Dent Assoc 2002;30(2):161-9.
increase in PSPs ment specialist, and founder of Posturedon- 12. Ariens G, Bongers P, Douwes M, et al. Are neck flexion, neck
co-founder of Posture- tics, Portland, Ore. rotation, and sitting at work risk factors for neck pain? Results of a
among operators. dontics, Portland, Ore. Address reprint prospective cohort study. Occup Environ Med 2001;58(3):200-7.
Because this requests to Dr. Valachi 13. Lehto T, Helenius H, Alaranta H. Musculoskeletal symptoms of
at 2225 S.W. Scenic dentists assessed by a multidisciplinary approach. Community Dent
problem is multi- Drive, Portland, Ore. Oral Epidemiol 1991;19:38-44.
factorial, any possible solution 97225, e-mail 14. Finsen L, Christensen H, Bakke M. Musculoskeletal disorders
“stretchit@ among dentists and variation in dental work. Appl Ergon
should be multifactorial as well. posturedontics.com”. 1997;29(2):119-25.
Available research supports 15. Callaghan J, McGill S. Low back joint loading and kinematics
during standing and unsupported sitting. Ergonomics 2001;44:280-94.
the idea that this problem can be managed or 16. Ratzon N, Yaros M, Mizlik A, Kanner T. Musculoskeletal symp-
alleviated effectively using a multifaceted toms among dentists in relation to work posture. Work 2000;15:153-8.