Professional Documents
Culture Documents
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or MSDs.
musculoskeletal
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Types of Studies
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Reviewed. The authors U U
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disorders in clinical reviewed studies that
related to the prevention of
RT
ICLE
musculoskeletal disorders trunk can lead to low back pain, while yet
other studies examined the detrimental
effects of working in one position for pro-
BETHANY VALACHI, M.S., P.T., C.E.A.S.; longed periods. Additional studies con-
KEITH VALACHI, D.D.S. firmed the roles that operators flexibility
and core strength can play in balanced
Second in a two-part series on the musculoskeletal health and the need for
musculoskeletal health of dental operators to know how to properly adjust
professionals ergonomic equipment.
Results. This review indicates that
ental operators often cannot avoid prolonged strategies to prevent the multifactorial
Figure 1. The four primary curves of the spine: cervical lordosis, thoracic kyphosis, lumbar lordosis and sacral
kyphosis. Adapted with permission of the publisher from Saunders and Saunders.2
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 unsupporteda frequent posture spine properly, and the muscles of the cervical
in dentistrythe 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.
Reposition the feet. Subtle It is difficult for most dental
changes in foot position can shift operators to avoid PSPs. In optimal
the workload from one group of low A common mistake PSPs, muscle ischemia and joint
back muscles to another, allowing among dentists hypomobility can occur due to pro-
the overworked tissues to be replen- is positioning longed muscle contractions. When
ished with nutrients. patients too high. assuming awkward PSPs, dental
Position patients at the professionals are predisposed to
proper height. A common mistake developing muscle imbalances
among dentists is positioning caused by repeatedly flexing for-
patients too high. This causes elevation of the ward, bending to the side and rotating in one
shoulders and abduction of the arms, leading to direction. In general, dentists tend to lose flexi-
prolonged static muscular tension in the neck and bility in the direction opposite to that in which
shoulders. Magnification enables operators to they are postured statically during the day.21
maintain a greater working distance and position Stretches performed in the reverse direction of
patients at the proper height, with the shoulders awkward PSPs may prevent muscle imbalances
relaxed and the forearms approximately parallel that can lead to pain and MSDs. Directional
with the floor. stretches can be performed in or out of the opera-
Operators should take the time to position tory and can be incorporated into a daily routine
their patients properly for mandibular and maxil- that facilitates balanced musculoskeletal health.
lary procedures. Generally, patients should be Directional stretching involves a rotation,
placed in a semisupine position for mandibular sidebending or extension component that gener-
procedures and a supine position for maxillary ally is in the opposite direction of that in which
procedures. the operator frequently works (Figures 4A-4D).
Avoid twisting. Operatory design plays an This strategy addresses the muscle imbalances
important part in how often dentists perform that tend to develop.
detrimental twisting movements during the Frequent stretching breaks address the detri-
workday. Rear delivery systems encourage exten- mental physiological changes that can develop
sive trunk twisting and shift of vision to retrieve while working in optimal or awkward PSPs:
instruments, and side delivery systems require ischemia, trigger points, muscle imbalances, joint
moderate twisting. Transthorax (or over-the- hypomobility, nerve compression and disk degen-
patient) delivery systems minimize twisting and eration. Furthermore, stretching
shift of vision. When possible, dentists should dincreases blood flow to muscles;
position instruments within easy reach. If the dincreases production of joint synovial fluid;
operatory design requires the dentist to turn to dreduces formation of trigger points;
retrieve instruments or handpieces, the dentist dmaintains normal joint range of motion;
should swivel the chair to face the area squarely dincreases nutrient supply to vertebral disks;
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
than shoulder width, bend to the left side, resting the full body weight through the left elbow on the left knee. Stretch
the right arm overhead and look toward the ceiling. Hold for two to four breathing cycles. Repeat. C. Upper trapezius
stretch. Anchor the right hand behind the seat of the chair. Gently bring the left ear toward the left armpit. Hold for
two to four breathing cycles. Repeat. D. Downward squeeze. Assume a neutral head posture (ears over the shoulders)
and do not let the head move forward throughout the exercise. Lift the chest upward, position the arms at the sides
with fingers pointing upward and palms facing forward. Roll the shoulders back and down, squeezing the shoulder
blades downward and together. Hold for one long breath cycle. Repeat five times.
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
Figure 5. Chairside stretching can be performed during breaks such as while waiting for anesthetic to take effect in the
patient.
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
and hip flexor (iliopsoas) muscles. As professionals, dentists under-
three to four times
This combination of strengthening stand the concept of being lifelong
and stretching addresses a unique a week for at least students so they can maintain their
pattern of muscle imbalances 20 minutes. proficiency in clinical techniques
that can develop among dental that benefit their patients. To pro-
professionals. tect their own health, dentists
Guidelines for exercise. Certain guidelines should seek out and receive education about mus-
should be observed when beginning any exercise culoskeletal health, injury prevention and dental
program: ergonomics. Ideally, this education should begin
dconsult a physician before beginning any exer- during dental school and continue through the
cise program; dentists professional life.
ddo not perform strengthening exercises for One dentist, however, has found that injury
painful or fatigued muscles; prevention and dental ergonomics education still
dbegin exercise gradually, starting with the is in its infancy.25 Most dental practitioners have
minimum number of repetitions; not been trained in these areas, and they have
dstop exercise immediately if numbness, tin- not developed the skills and knowledge necessary
gling, dizziness or shortness of breath occurs; to practice in a manner that is ergonomically cor-
dperform strengthening exercises three to four rect. This lack of training is due in part to the
times per week and stretching exercises daily; need for more research and for better teaching
dalways exercise in a pain-free range. tools and better-informed and -trained teachers.
Aerobic exercise. Aerobic exercise should be Part of the blame for the lack of training can be
performed three to four times a week for at least attributed to the magnitude of the task.
20 minutes. One major contributing factor to Dental operators can be taught to manage and
MSDs is decreased flow of nutrients and oxygen prevent injuries effectively. They can educate
to muscles.1 Aerobic exercise increases blood flow themselves and their staff members using a mul-
to all of the tissues in the body and improves tifactorial approach that includes preventive edu-
their ability to use oxygen. In addition, aerobic cation, postural and positioning strategies, proper
exercise improves cardiovascular and cardiorespi- selection and use of ergonomic equipment, and
ratory function, lowers heart rate and blood pres- frequent breaks with stretching and strength-
sure, increases high-density lipoprotein (good) ening techniques before painful episodes occur.
cholesterol, decreases blood triglycerides, reduces Prevention strategies should be easy to use to
body fat, improves stress tolerance, increases ensure long-term compliance.
mental acuity, improves sleep quality and may
increase longevity.28 Operators should choose aer- CONCLUSIONS
obic exercises that they enjoy. It is advisable to do Work-related pain is common among dental pro-
at least two types of aerobic exercise regularly, for fessionals. The development of four-handed oper-
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.
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seated postural loads. Spine 1997;22:734-43.
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cient and pro- 1: review of the literature. J Manipulative Physiol Ther 1999;22(9):
594-609.
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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.
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at 2225 S.W. Scenic dentists assessed by a multidisciplinary approach. Community Dent
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during standing and unsupported sitting. Ergonomics 2001;44:280-94.
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