February 2005 - California Dental Association

d e p a r t m e n t s The Associate Editor/Fifteen (or so) Things We Love About Dentistry

Impressions/Report Finds Claims Against Amalgam Lack Scientific Evidence

Dr. Bob/Waiting Room Blues

features

Musculoskeletal Pain and the de nta l he a lthca r e coMMu ni ty

An introduction to the issue.

Allan C. Jones, DDS

Work doesn’t have to Be Pa i nf u l

An additional introduction to the issue.

Timothy J. Caruso, MBA, MS

Prevalence of uPPer extre Mi ty sy M PtoM s a nd di sor de r s a Mong de nta l a nd de ntal hygiene students

Robert A. Werner, MD; Alfred Franzblau, MD; Nancy Gell, PT; Curt Hamann, MD; Pamela A. Rodgers, P.D; Timothy Caruso, PT; Frank Perry, DDS, MEd; Courtney Lamb, DDS; Shirley Beaver, RDH, PhD; David Hinkamp, MD; Kathy Eklund, RDH, MPH; and Christine P. Klausner, RDH, MS

Working Postures of denti sts a nd de nta l hygi e ni sts

Richard W. Marklin, PhD, and Kevin Cherney, BS

functional training for denti stry: a n e xe r ci se Pr e scr i Pti on f or de nta l he a lth care Personnel

Allan C. Jones, DDS, NSCA-CPT, and Shad Forsythe, MS, ATC, CSCS

getting your Back Back to W or k: Pa i n r e l i e f - W he r e to sta rt

Timothy J. Caruso PT, MBA, MS, Cert. MDT, and David J. Pleva, PT, MA, Dip. MDT

CDA JournalVolume 33, Number 2f e b r u a ry 2 0 0 5 Journal

FEBRUARY.2005.VOL.33.NO.2.CDA.JOURNAL 93

If it weren’t forlab techniciansadvancing theircraft, we wouldstill be cementing crowns that look like Chiclets.

n a recent issue of Back-packer,there was a list of 50 things welove about camping and the out-doors. In fact, it was more than alist; it was actually the entireissue. If there are 50 things we

love about the outdoors, surely there mustbe an equal number of things we loveabout our profession. Due to space con-straints, however, we had to pare down ourlist. With that, we offer 15 (or so) things welove about dentistry.

Cast gold. What could be better than in-specting a highly polished MOD inlay onlaywith perfect occlusal anatomy, and findingthe margins imperceptible to the sharpest ex-plorer? Then finding out it was placed 35years ago by your predecessor. Forget porce-lain and composite, that is esthetic dentistry.

Oral pathologists. Let’s face it. Oralpathology was one of those courses in den-tal school you could only cram for. As ourtraining turned from the academic to theclinical, oral pathology was that last re-maining purely scientific hurdle we had tojump in order to graduate. So the night be-fore an exam, we got together in our studygroups, ordered Domino’s Pizza, loaded upon caffeine, projected our oral path slidesonto a wall and tried to tell the differencebetween benign keratosis and cellular atyp-ia. Most of us don’t understand why any-one would make a career out of oral pathol-ogy; perhaps they find H and E stain intox-icating or simply enjoy playing with micro-scopes. Whatever the reason, we’re gladthey like taking the hunks of soft tissue wesend them, slicing them up, and seeingwhat they’re made of. And we’re glad theycan tell the difference between benign ker-

atosis and cellular atypia so wecan call Mrs. Jones and tell herwith confidence that she doesn’thave oral cancer.

Eugene Sekiguchi, ADA im-mediate past president. Spendtwo minutes talking with himand you’ll understand.

Porcelain. This is a materialthat has climbed many rungs onthe prestige ladder. What oncewas relegated to use in bathtubsand toilets now adorns the smilesof the majority of the adult popu-lation. It has a remarkable abilityto be transformed from a ratheruseless and unattractive powderinto those beautiful little nuggets that looklike teeth, and keep our patients happy,their smiles healthy and attractive, and ourschedules full.

Lab technicians. The men and womenresponsible for creating the aforemen-tioned nuggets of porcelain, as well asthose made of gold, composite and what-ever the material du jour happens to be. Inthe art and science of dentistry, they arethe Van Goghs and the Renoirs. Like mostgood artists, they can be temperamental.However, they make it up to us by servingas our default scapegoat when there is apoorly fitting restoration or a mix-up inthe due date, even when it is not theirfault. Thus, our relationship flourishes.Besides, if it weren’t for lab technicians ad-vancing their craft, we would still be ce-menting crowns that look like Chiclets.

Bob Horseman. Those other journalsmay have their erudite wordsmiths, distin-guished scientific researchers, and academ-

The Associate Editor

Fifteen (or so) Things We LoveAbout Dentistry

Steven A. Gold, DDS

94 CDA.JOURNAL.VOL.33.NO.2.FEBRUARY.2005

ic giants on their editorial boards. Butdamn it, WE HAVE HORSEMAN!

Computers. OK, so they crash in themiddle of Monday morning, your softwarecompany gets bought out — four times —and they become obsolete within weeks ofinstallation. But with the integration of dig-ital radiographic and photographic technol-ogy, we can do things today we could noteven conceive of 30 years ago. Besides,would you rather go back to a schedule in athree-ring binder, a pegboard system andyour old Smith Corona typewriter?

Nitrous oxide. A gas composed of threesimple atoms, yet it has allowed countlessnumbers of patients with high anxietyabout dental treatment to safely and com-fortably receive the care that they need.Note: Our research uncovered possibleother uses by our colleagues who wereyoung adults between the years 1967 and1971. Such uses purportedly involved bal-loons and Jimi Hendrix records. Use of ni-trous oxide in such a manner, if it ever oc-curred, cannot be recognized nor con-doned in a professional scientific journal.

Arthur Dugoni. (See Sekiguchi entry.)Oral surgeons. Sure, they may not be

known for giving the most atraumatic in-jections, but we will forever be amazed atthe ease with which they can flick out alower third molar with a dilacerated rootthat is halfway imbedded into the ramus.

Fridays. We love our profession, but ajob is still a job and the weekend is still theweekend.

Dental society and association staff.Although they are (with few exceptions)not dentists and never see the inside of ouroffices, these men and women are our ex-tended staff and work as hard at dentistryon our behalf as we do.

CDA Scientific Sessions. Take yourpick, San Francisco or Anaheim. Cabernetsauvignon, foie gras and the symphony, orbeer, burgers and the House of Blues.Culture elegance and sophistication orMickey, Donald and Goofy. Whichever city

you attend in, you can obtain world-classcontinuing education, shop for any and allitems related to dentistry, get together withcolleagues; and it’s all a tax deduction.

Dental school deans. They’re flamboy-ant, opinionated, and stubborn. They neverdo what we tell them. They’re a slave tothose alumni with bottomless checking ac-counts, but they are also a slave to excel-lence in the profession. They are visionariesand seemingly tireless leaders. They manageto orchestrate students, staff, faculty, andalumni in a grand symphony that advancesthe profession by preparing tomorrow’s den-tists and adding to the body of knowledge.While we are grateful for what they do, mostof us would not dare wish for their job.

Bill Emmerson and Sam Aanestad.Giving up your dental practice to run forstatewide public office? Are you kidding?That alone gets them on the list even ifthey hadn’t won.

Endodontists. It’s 3:30 p.m. Friday.You’re getting ready to go fishing for theweekend in the High Sierras. Your patientwalks in with an abscessed upper secondmolar. The roots are thin, the canals areconjoined and the patient can barely openwide enough for the X-ray due to the pain.Are you going to pick up the handpiece orthe telephone?

Optimism. While complaints and nega-tive comments about the profession some-times garner more attention than they de-serve, there is an overwhelming preponder-ance of optimism in dentistry. We seem tolove our profession and it shows.

We would like to know what otherthings our members love about the pro-fession. If you would like to add to thelist, address your comments to the associ-ate editor.

CDA has recently reorganized its e-mailsystem. All comments, letters or questionsshould now be addressed to the editor atalan.felsenfeld@cda.org. The previous ad-dress is no longer valid.

We love ourprofession, but

a job is still a job and the

weekend is stillthe weekend.

The Associate Editor

The Life Sciences Research Office con-ducted the independent scientific review ofdental amalgam at the request of a workgroup made up of representatives from theNational Institutes of Health, Centers forDisease Control and Prevention, Food andDrug Administration, and the U.S. PublicHealth Service. Established in 1962, the LifeSciences Research Office is a nonprofit, in-

There is

insufficient

evidence “of a link

between dental

mercury and health

problems, except

in rare instances

of allergic

reactions.”

review of seven years’ worth ofscientific studies concludes thereis insufficient evidence “of alink between dental mercuryand health problems, except inrare instances of allergic reac-

tions,” according to a report released lastDecember by the Life Sciences ResearchOffice, Inc., in Bethesda, Md.

Impressions

aReport Finds Claims

Against Amalgam LackScientific Evidence

icology, allergy, pediatrics, epidemiology,and pathology.

Based on a weight of evidence evalua-tion of the literature published between Jan.1, 1996, and Dec. 31, 2003, the expert paneland the Life Sciences Research Office cameto the following conclusions:

■ There is insufficient evidence to sup-port a correlation between dental amalgamexposure and kidney or cognitive dysfunc-tion; neurodegenerative disease, specificallyAlzheimer’s disease and Parkinson’s dis-ease; or autoimmune disease, includingmultiple sclerosis.

■ Various nonspecific complaints at-tributed to dental amalgam have notbeen shown to be due to increased mer-cury release and absorption from dentalamalgam.

■ Mercury exposure from dental amal-gam in the general U. S. population is low,but increases with the number of dentalamalgam restorations.

■ Long-term use of nicotine chewinggum combined with intense chewing habitsand greater than 20 dental amalgam sur-faces have been shown to have more im-pact on exposure to mercury vapor thanbruxism or dental amalgam placement andremoval.

James B. Bramson, DDS, ADA executivedirector, said the Life Sciences ResearchOffice report “further substantiates theADA’s position, based on science and clini-cal experience, that dental amalgam is asafe, effective material to fill cavities.

“Countless teeth have been saved byusing amalgam, one of the most durableand affordable cavity filling materialsavailable, especially for large cavities in theback teeth where chewing forces are thegreatest.”

The report concludes there is little evi-dence to support a causal relationship be-tween mercury filling and human healthproblems. The authors noted, however, thatmany research gaps existed and, if ad-dressed, could finally settle the dental amal-gam controversy.

dependent organization with a worldwidenetwork of experts who study issues in bio-medicine, health care, nutrition, food safetyand the environment.

The report, “Review and Analysis of theLiterature of the Potential Adverse HealthEffects of Dental Amalgam,” updates andreaches the same conclusion as two earlierreviews by the U.S. Department of Healthand Human Services. The American DentalAssociation estimates that 71 million amal-gam restorations were placed in 1999, themost recent year for which statistics areavailable.

The basis of the Life Sciences ResearchOffice report is a review of nearly 1,000papers from peer-reviewed scientific litera-ture. All peer-reviewed human, animal,and in vitro studies published since the be-ginning of 1996 that investigated the bio-chemical, behavioral, and/or toxicologicaleffects resulting from exposure to dentalamalgam, mercury vapor (Hg0), inorganicmercury (Hg2+), or organic mercury(methyl and ethylmercury) were consid-ered. The expert panel and the LifeSciences Research Office adopted the U.S.EPA’s General Assessment Factors (2003)to select relevant articles of significant sci-entific merit from the initial pool of 961articles. These assessment factors provideda framework for evaluating the soundness,applicability and utility, clarity and com-pleteness, uncertainty and variability, andevaluation and review of the published in-formation.

Approximately 300 of the studies metcriteria for scientific merit and study de-sign and were used to construct the finalreport. In addition to the literature gath-ered by the Life Sciences Research Officeand the expert panel, recommendationssubmitted by the public in response to afederal Register Request for Informationon Dental Amalgam were considered, aswere oral and written public commentssubmitted by parties interested in theissue. The report involved a multidiscipli-nary panel of experts in fields such as tox-

For More Information

The executive summary of

the “Review and Analysis of

the Literature on the

Potential Adverse Health

Effects of Dental Amalgam” is

available on the Life Sciences

Research Office website at

http:// -www.lsro.org.

Periodontal researchers have found thatphotodynamic therapy is advantageous forsuppressing anaerobic bacteria that lead toperiodontal diseases, according to a recentstudy in the Journal of Periodontology.

“Although this study is still in its earlyphase, with the recent number of reportsabout bacterial strains becoming resistantto frequent doses of antibiotics, PDT couldbe an alternative to conventional peri-odontal therapeutic methods,” saidMichael P. Rethman, DDS, MS, and presi-dent of the American Academy ofPeriodontology. “Antibiotics may be usedas an adjunctive therapy for periodontaldiseases, so there is a pronounced interestin the development of alternative antimi-crobial concepts.”

In the first stage of photodynamic ther-apy, a light-sensitive drug is applied. In

the second stage, a lightor laser is shined onthe area treatedwith the drug.When the light iscombined with thedrug, phototoxic re-actions are induced, de-stroying bacterial cells. The Food andDrug Administration approved photody-namic therapy in 1999 to treat pre-cancer-ous skin lesions of the scalp or face.

“The photosensitizers we investigatedwere able to completely suppress theanaerobic key pathogens leading to peri-odontal diseases; however, facultativeanaerobic bacteria tested responded to alesser extent to PDT,” said Dr. Bernd W.Sigusch, Friedrich Schiller University ofJena, Conservative Dentistry, Germany.

Photodynamic Therapy Possible Option forTreating Periodontal Diseases

Mood Disorder Medications Have Dental Side EffectsThose undergoing treatment for mood disorders may experience adverse dental side effects, according to a study that ap-

peared last fall in General Dentistry.Mood disorders are a group of mental conditions, including bipolar disorder and depression, that affect up to 37 percent of

adults at some point in their lives.Early diagnosis and treatment can greatly reduce the risk of suicide, but medications for treatingmood disorders can result in dry mouth, an increased rate of periodontal disease and caries.

“Many patients who are taking antidepressants will have dry mouth,” said David. F. Halpern,DMD, and AGD spokesman.

“In an effort to curtail any tooth decay, we stress with patients the importance of maintaining anextremely high level of oral hygiene care by brushing, flossing and daily fluoride therapy,” Halpern said.

Sipping water during the day and chewing sugarless gum can help treat dry mouth. Halpernalso suggested artificial saliva substitutes such as liquids, gels, and sprays. Those with dry mouth

should contact a dentist for an evaluation appropriate solution.Preventing gum disease includes removing plaque through brushing daily, flossing and pro-

fessional cleaning.Major depression generally lasts eight to nine months if the individual is not treated. James W.

Little, DMD, lead author, said, “If treated, it will take about one to three weeks to begin to feelbetter and get rid of thoughts of suicide.”

Psychotherapy and antidepressants are common treatments. Bipolar disorder is treated withantidepressants and mood stabilizers to prevent manic episodes. When medication and psy-chotherapy are coupled, more than 60 percent begin to notice improvements.

It is a continuing struggle to managethe growing workloads, health servicesworkers reported in an online survey. In anindustry where quality of care and atten-tion to details are essential, 53 percent re-port their workloads have increased in thelast six months; with 41 percent describingtheir workloads as too heavy. Forty-fivepercent of these workers say they are work-ing under a great deal of stress.

The CareerBuilder.comsurvey, “The Pulse: HealthServices Workers,” wasconducted from Aug. 5-24, 2004, of more than140 health servicesworkers.

“Health servicesworkers know they’re in demand and arenot likely to stay with an employer who isnot affording a positive work experience,”said Rhonda Lipsey, healthcare employ-ment expert at CareerBuilder.com.

“One-fourth of health services workersplan to change jobs by February. Employersare advised to take the temperature of theirworkplace and prescribe new retentionstrategies before they face the consequencesof losing great talent,” she said.

Sixteen percent of health services work-ers say they searched for a new job on aweekly basis; 33 percent said their No. 1

criteria in looking for a potential employeris stability, followed by reputation for fair-ness (12 percent).

The top three factors motivating jobchanges for health services workers are thedesire for better compensation, more ca-reer advancement opportunities, and animproved balance of time spent at workand home. Thirty-nine percent of health

services workers said they are dis-satisfied with compensa-

tion, with 44 percentreporting they didnot receive a raiselast year; 30 percentfelt there is notmuch room forupper mobility at

their organization, and 21 percent saidthey are having trouble managing theirwork and life balance.

Of those who did not expect to changejobs, 11 percent said they are staying withtheir employer for the benefits, while 10 per-cent said it is due to the fear of the unknown.

In collecting data for the survey,CareerBuilder.com commissioned SurveySiteto utilize an e-mail methodology wherethose who are members of the SurveySiteWeb Panel were randomly selected and ap-proached by e-mail invitation to participatein the online survey.

“Employers are

advised to take

the temperature

of their

workplace and

prescribe new

retention strategies

before they face

the consequences

of losing

great talent.”

Rhonda Lipsey

Health Services Workers Experiencing Overload

Imported Mineral Water Provides Excellent Source of CalciumAn Italian mineral water new to the United States is the only bottled water deemed a “good source of calcium” by the

Federal Drug Administration. Drinking eight glasses of the all-natural, lightly effervescent Sanfaustino provides up to 80 per-cent of the adult calcium required daily allowance.

“With osteoporosis on the rise, it is increasingly important to get adequate calcium in your diet,” said Joseph Lane, med-ical director of the Metabolic Bone Disease Service and Osteoporosis Prevention at Cornell’s Hospital for Special Surgery inNew York City. “But the fact is, high calcium foods do not always fit into the rapid lifestyles of Americans. The beauty ofSanfaustino is that you can get small amounts of calcium continuously throughout the day. And because of the properties in-herent in water, the natural calcium content is absorbed in the most efficient way.”

Italians have enjoyed Sanfaustino since 1895. It comes directly from a one-of-a-kind mountain spring in Umbria that gen-erates lightly effervescent water high in calcium. It is available at natural food and gourmet stores, and in the natural foodssection in grocery stores. Sanfaustino is a carb-free, fat-free, calorie-free and sodium-free alternative to other calcium sources.

“Many of my clients find it a challenge to eat three or more servings of dairy per day,” said Heidi Skolnik, MS, leading nutri-tionist and sports nutrition consultant. “Sanfaustino gives consumers another delicious nutritious way to meet calcium needs.”

Dental Care InitiativeLaunched for BabyBoomers

According to a landmark U.S. surgeongeneral’s report on oral health, approxi-mately 60 percent of Americans older than50 have dental insurance and most willlose that benefit when they retire and facefixed or reduced incomes.

As the American baby boom genera-tion inches toward retirement, its rankscontinue to swell. The 50-plus populationwas estimated at 27 percent in 2000; by2020, it is expected to jump by more than115 million, to about 35 percent, accordingto the U.S. Census.

“As the 50-plus population continuesto grow in numbers, and with the currentlack of accessibility, there is a critical needfor affordable dental insurance for thispopulation, as well as public informationfocused on the importance of dental healthas we age,” said Dawn Sweeney, presidentof AARP Services, Inc.

To meet those needs, AARP, through itssubsidiary AARP Services, Inc., teamedwith Delta Dental Insurance Company tocreate the AARP Dental Insurance Planand launch a dental care initiative target-ing those 50-plus years and older.

“Our members have been asking usfor this type of program because they re-alize the value of continuing dentalcare,” Sweeney said. “However, becauseof financial limitations, many have hadto eliminate regular dental care fromtheir budget.”

The AARP plan features comprehensivefamily coverage and the freedom to chooseany licensed dentist. It will initially beavailable to AARP members in 21 statesand D.C. There are plans to make the pro-gram available to all 35 million AARPmembers across the country this year.

The health implications for post-retire-ment dental care are significant, saidHarold C. Slavkin, DDS, dean at theUniversity of Southern California School of

Dentistry and one of the chief architects ofthe landmark Surgeon General’s reportwhich was released in 2000.

“Medicare does not cover routine den-tal services and, in most states, neitherdoes Medicaid,” Slavkin said. “With con-tinued dental care, those who are 50-pluscan avoid a myriad of health problems,including tooth loss, gum disease andmouth cancers. With continued care, wecan all enjoy a robust lifestyle and a widerange of foods, communicate effectively,maintain self-esteem and meet our socialresponsibilities within our family andcommunity.”

The AARP dental insurance plan pro-vides immediate coverage for the most pre-ventative diagnostic and basic restorativeservices, as well as endodontics and oralsurgery. After a year, coverage expands toinclude major restorations, periodonticsand prosthodontics.

“Dental insurance for retirees andthose who are 50-plus is often very re-strictive or simply unavailable, said GaryD. Radine, president and CEO of theholding company that includes DeltaDental Insurance Company. “This newprogram balances the need for immedi-ate benefits with the need for affordablemonthly premiums.”

“Medicare does

not cover

routine dental

services and,

in most states,

neither does

Medicaid.”

Harold C. Slavkin, DDS

Rep. Nancy Pelosi, (D-San Francisco),has obtained $500,000 from Congress tohelp fund capital costs for the FetalTreatment Center at UCSF Children’sHospital.

UCSF’s fetal treatment team is well-known for pioneering fetal surgery as wellas its continuing search for new methodsto detect, cure, ameliorate and preventbirth defects.

The new funding supports a centralizedlocation in UCSF’s Ambulatory Care Centerfor advanced prenatal and postnatal carefor mothers and infants with birth defects,and their families. Pelosi requested the

funding as part of the Fiscal Year 2005Omnibus Spending Bill.

“Congresswoman Pelosi’s support forthis center is an indication of her concernfor a better future for children and theirfamilies,” said Mark Laret, CEO of UCSFMedical Center and UCSF Children’sHospital. “This will allow our specialists,already leaders in care for women andchildren, to have even better tools for help-ing these patients.”

Michael R. Harrison, MD, coordinatingdirector of the center and founder of thefield of fetal surgery, said UCSF’s team,combining the efforts of some of the na-tion’s most respected experts in prenataldiagnosis, high-risk pregnancy, neonatol-ogy, anesthesia and fetal/newbornsurgery, is leading a new standard.

“We are taking the old attitude towardbirth defects, of ‘wait and see’ and replac-ing it with the more optimistic ‘what canwe do,’” Harrison said.

The fetal treatment team at UCSFidentifies serious birth defects prior to thechild being born, working with the moth-er and her doctors to create a plan forcare from the moment the baby is deliv-ered. There are an increasing number ofcases in which the defect can be treatedbefore birth.

In 1981, Harrison and his colleaguesperformed the world’s first fetal surgery,and they continue to set the standards forthis field.

Expected to open this year, the facilitywill include web-based telemedicine, andadvanced diagnostic and treatment capa-bilities. Women and their physiciansthroughout the country already consultUCSF experts about diagnoses of birth de-fects. The new Telemedicine Global Portalmakes the service more interactive andmore easily accessible on a national andinternational basis.

Upcoming Meetings

2005Feb. 2-5 American Academy of Dental Group Practice Annual Conference and

Exhibition, New Orleans, www.aadgp.org

Feb. 24-27 Chicago Dental Society Midwinter Meeting, Chicago, (312) 836-7330.

March 17-19 Thomas P. Hinman Dental Meeting, Atlanta, (404) 231-1663.

April 6-9 Academy of Laser Dentistry 12th Annual Conference and Exhibition,New Orleans, (954) 346-3776.

April 12-16 International Dental Show, Cologne, Germany, www.koelnmesse.de

May 12-15 CDA Spring Session, Anaheim, (866) CDA-MEMBER (232-6362).

Aug. 17-20 Sixth Annual World Congress of Minimally Invasive Dentistry, San Diego,(800) 973-8003.

Sept. 9-11 CDA Fall Session, San Francisco, (866) CDA-MEMBER (232-6362).

Oct. 6-9 ADA Annual Session, Philadelphia (312) 440-2500.

2006Oct. 6-9 ADA Annual Session, Orlando, Fla., (312) 440-2500.

To have an event included on this list of nonprofit association meetings, please send theinformation to Upcoming Meetings, CDA Journal, P.O. Box 13749, Sacramento, CA 95853or fax the information to (916) 554-5962.

UCSF Fetal Treatment Center to Receive $500,000

his issue of the Journal of theCalifornia Dental Association isan attempt to bring to the den-tal profession of California,from many useful sources,

some of the most helpful informationfrom the current literature on exerciseand posture. It is intended to foster thepreservation of musculoskeletal healthof dental health care workers.

Having been a dentist who has grap-pled with back and neck pain for morethan 20 years, my attempts to understandmusculoskeletal pain have been a matterof profound personal interest. I havesearched for truthful and useful informa-tion from the multitude of sources. As Ihave taught “Occlusion and Facial Pain”at the University of Southern Californiafor nearly 20 years, most of my searchinghas been from publications of the facialpain community, the occlusion commu-nity, and the health and fitness commu-nity. These sources have provided muchuseful information about the painful con-ditions that seem to affect so many den-tal health care workers.

Dentists are well-prepared for under-standing pain and dysfunction of mus-culoskeletal origin, as this knowledge isessential to providing treatment formany dental patients. Our training andacademic orientation as dentists give usan academic foundation from which tounderstand the literature from a vast

array of sources outside of our own field.This is especially true of the scientific lit-erature on exercise from which this arti-cle on “functional training” was derived.

My pursuit of useful informationregarding spinal pain led me to an orga-nization I regard as the best source onmatters related to exercise science: theNational Strength and ConditioningAssociation. Having been certified bythis group as a personal fitness trainer, Ihave been immersed in this world ofelite professional coaches for manyyears. Dentists may benefit enormouslyfrom the lessons these individuals havelearned regarding posture and fitness.Their prescriptions for exercise aredeveloping and preserving the most tal-ented athletes in the world; they can dothe same for dental health care workers.

For the purpose of developing an exer-cise regimen for dental health care work-ers, I spent 12 weeks at the AthletesPerformance Center in Carson, Calif.Their focus on preventing injury by devel-oping superior posture through “torso”training is what I sought to learn. For 12weeks, they coached me. The coachesanalyzed the postural stress of seated den-tal workers and devised a series of exercis-es specifically for their needs. ShadForsythe, the strength and conditioningcoach for Galaxy, our local professionalsoccer team, was my coach and co-authorduring the weeks I spent training at their

Carson facility. This was one of the mostchallenging and rewarding experiences ofmy athletic endeavors. I am very gratefulfor all they have done to improve myhealth and fitness for dental practice.

The scientific literature on posturalissues exists largely in the domain ofphysical therapy. Literature about pos-ture in the context of the work environ-ment falls into the domain of ergonom-ics. There is a small, but useful body of lit-erature in physical therapy and ergonom-ics that is relevant to dental practice. Forthis reason, I have invited Tim Caruso, aphysical therapist and ergonomicsexpert, to contribute to this issue of theJournal as an added guest editor.

Tim is a popular speaker to audi-ences of dental meetings throughoutthe United States. While hosting Tim atone of these meetings, I realized his per-spective on ergonomics and physicaltherapy could help the dental profes-sion. For this reason, I invited him tobring information from his resourcesoutside the realm of dental literature tothe dentists of California in this editionof the Journal.

Guest Editor / Allan C. Jones, DDS,NSCA-CPT, is a certified personaltrainer through the NationalStrength Conditioning Association.He has been on faculty at theUniversity of Southern CaliforniaSchool of Dentistry since 1984 andhas a practice in Torrance, Calif.

Musculoskeletal Pain and the Dental Health Care CommunityAllan C. Jones, DDS, NSCA-CPT

s a reader, you may wonderhow I came to this place inyour professional journal as aguest editor. As a practicingphysical therapist with more

than 20 years of experience, I becameactively interested in the practice of den-tistry while working with a dentalhygienist who had undergone her sec-ond bilateral carpal tunnel surgery. Shecame to my clinic for rehabilitation,expressing grave reservations aboutreturning to work in general and as ahygienist in particular. As I began toevaluate her and the specifics of her job,I wondered why she performed some ofher work tasks in the manner shedescribed and observed others that mayhave caused some of her problems. Thatparticular interaction more than 16 yearsago started my journey. As a physicaltherapist, we are trained to evaluate mus-culoskeletal problems, determine thecausative factors, and recommend solu-tions. These solutions may consist ofmodalities to alleviate pain, exercise tostretch or strengthen tissues, educationto promote independence, and developinjury prevention strategies and jobmodifications to protect the patientupon their return to work. In short, weare detectives looking for clues to solveproblems. Since that encounter in 1989,I have been personally challenged to finda solution to this “problem” and havesince met many other dental profession-als with similar and numerous other

complaints. The list runs the gamut fromheadaches to back pain, numbness, tin-gling, and weakness. The bottom line isthat many dental professionals acceptpain as part of their daily routine.

While much is known about posture,musculoskeletal pain and injury in themedical literature, I have found little sci-entific discussion in the dental literaturethat evaluates these issues and makes rec-ommendations for solutions. In travelingand consulting with dental professionals,I find that many have accepted pain aspart of their daily routine. Many are notcertain how they got it, and fewer areaware of how to alleviate it. I find thistroubling as someone who is passionateabout my work. It is disheartening tothink a career we could be so passionateabout may be harmful to us. Having beeninspired by all of these circumstances andnot having come up with an absolutesolution in all cases, I have attempted toidentify several reasonable solutions forone particular type of complaint in thispublication, namely back/neck pain. Andso my journey continues.

In this edition, Dr. Jones and I haveattempted to provide the readers withinsight into the lives of relatively healthydental professionals while describingsome of the common maladies associat-ed with those suffering with back andneck problems. In addition, this issueintroduces two specific strategies thatmay extend the productivity and careerlongevity of the practitioner. My hope is

to provide a basis from which to achievean improved level of health and fitnesswhile alleviating pain from your dailypractice. As guest editor of this edition ofthe Journal of the California DentalAssociation, I have been invited to bringto the dentists of California informationregarding posture and pain. This infor-mation comes from the domains ofphysical therapy, rehabilitation, engi-neering, and ergonomics. To accomplishthis, I have asked distinguished individu-als, well known in their areas of exper-tise, to contribute to the issues thatuniquely affect the community of dentalhealthcare workers. Our hope is to pro-vide an outstanding regular exercise rou-tine to healthy dental professionalswhile providing injury prevention strate-gies for relief of back and neck pain inpractitioners who work with pain day inand day out. In addition, we hope to laythe foundation for future research in thisarea. Our authors will shed some light onthe effects of career training on dentaland hygiene, along with some of thehabits that seem to be acquired along theway which may create certain muscu-loskeletal problems. Dr. Jones and I have

Work Doesn’t Have to Be PainfulTimothy J. Caruso, PT, MBA, MS, Cert. MDT

Guest editor / Timothy J. Caruso,PT, MBA, MS, Cert. MDT, is a cer-tified mechanical diagnostic thera-pist, staff physical therapist andchair of the ergonomics commit-tee at Shriners Hospital forChildren in Chicago. He is ownerand president of ChicagolandPerformance Consultants.

had a “meeting of the minds” in recom-mending preventive strategies for indi-viduals with and without persistent painand feel that this issue of the Journal willbe a resource for both. Thank you foryour interest.

Dr. Richard Marklin is a researcherand ergonomist in the Department ofMechanical and Industrial Engineering atMarquette University in Milwaukee. Hisarticle presents the results of a study tomeasure the seated working postures ofdentists and dental hygienists. Given thesignificant amount of time spent by thedental professional in a seated position, Ifelt that Dr. Marklin’s findings wouldshed some light on potential risks formusculoskeletal disorders and pain com-monly found in the dental operatory.

Dr. Robert Werner is a physician,epidemiologist, and chief of PhysicalMedicine and Rehabilitation at the AnnArbor VA Medical Center and professorat the University of Michigan. He hasdone extensive work with the AmericanDental Association over the years toquantify the incidence and prevalenceof musculoskeletal disorders in dentalprofessionals attending the nationalmeetings. His article establishes a“baseline” for the musculoskeletal sta-tus among dental and dental hygienestudents as they begin their careers asdental healthcare workers. The baselinedata will be the basis for a longitudinalstudy of musculoskeletal pain amongdental professionals over the coursetheir careers.

David Pleva, PT, MA, Dip. MDT, is apracticing physical therapist. He is adiplomate of the McKenzie InstituteUSA and a practitioner in private prac-tice. Dave has worked extensively withindividuals experiencing back and neckpain. As a faculty member of theMcKenzie Institute USA, he trains phys-ical therapists, physicians and chiro-practors across the country in theMcKenzie approach to treatment ofspinal disorders. CDA

INTRODUCTION

ABSTRACTCONTEXT: Upper extremity musculoskeletal disorders are common among dental professionals.

The natural history of these disorders is not well-understood. These disorders are more common

in older workers, but the prevalence among younger workers has not been well-studied.

OBJECTIVE: The objective of this study was to determine if dental/dental hygiene students had

a similar prevalence of upper extremity musculoskeletal disorders compared to age-matched

clerical workers. We hypothesize students will have a lower prevalence of upper extremity mus-

culoskeletal disorders compared to clerical workers.

DESIGN: This was a cross-sectional design.

SETTING: Dental and dental hygiene students from three schools were compared to clerical

workers from three locations (an insurance company and two data processing plants).

SUBJECTS: There were 343 dental and dental hygiene students and 164 age-matched clerical

workers.

MAIN OUTCOME MEASURES: Regional discomfort was the primary outcome. The secondary

health outcomes were diagnoses of carpal tunnel syndrome and upper extremity tendinitis.

RESULTS: Clerical workers had a higher prevalence of hand symptoms (62 percent vs. 20 per-

cent), elbow symptoms (34 percent vs. 6 percent) and shoulder/neck symptoms (48 percent vs.

16 percent) and a higher prevalence of carpal tunnel syndrome (2.5 percent vs. .6 percent) and

upper extremity tendinitis (12 percent vs. 5 percent). The clerical workers were more obese,

smoked more, exercised less frequently, and had lower educational levels and less control of

their work environment.

CONCLUSIONS: Dental and dental hygiene students have a very low prevalence of upper

extremity musculoskeletal disorders. A longitudinal study is necessary to evaluate ergonomic

and personal risk factors.

Prevalence of UpperExtremity Symptoms andDisorders among Dental andDental Hygiene StudentsRobert A. Werner, MD; Alfred Franzblau, MD; Nancy Gell, PT; Curt Hamann, MD; Pamela A. Rodgers, PhD;

Timothy J. Caruso, PT, MBA, MS, Cert. MDT; Frank Perry, DDS, MEd; Courtney Lamb, DDS; Shirley

Beaver, RDH, PhD; David Hinkamp, MD; Kathy Eklund, RDH, MPH; and Christine P. Klausner, RDH, MS

Authors / Robert A. Werner, MD, is a professor andchief of Physical Medicine and RehabilitationService Veterans Affairs Medical Center; and withthe Department of Physical Medicine andRehabilitation University of Michigan MedicalCenter, and the Department of EnvironmentalHealth Sciences School of Public Health Universityof Michigan, all in Ann Arbor.

Alfred Franzblau, MD, is with the Departmentof Environmental Health Sciences School of PublicHealth University of Michigan in Ann Arbor.

Nancy Gell, PT, is a physical therapist at theDepartment of Physical Medicine andRehabilitation University of Michigan MedicalCenter in Ann Arbor.

Curt Hamann, MD, and Pamela A. Rodgers,PhD, are with Smart Health in Phoenix, Ariz.

Timothy J. Caruso, PT, MBA, MS, Cert. MDT isa certified mechanical diagnostic therapist, staffphysical therapist and chair of the ergonomicscommittee at Shriners Hospital for Children inChicago.

Frank Perry, DDS, MEd, and Courtney Lamb,DDS, are with the University of Illinois School ofDentistry in Chicago.

Shirley Beaver, RDH, PhD, is with the DentalHygiene Program at Kennedy King College inChicago.

David Hinkamp, MD, is with the Departmentof Environmental and Occupational HealthSciences School of Public Health University ofIllinois, Chicago.

Kathy Eklund, RDH, MPH, is with the ForsythInstitute in Boston.

Christine P. Klausner, RDH, MS, is with theDental Hygiene Program University of Michigan, inAnn Arbor.

Acknowledgments and Disclaimer / Support forthis research is provided by the National Instituteon Disability and Rehabilitation Research of theUnited States Department of Education, Grant#H133E980007, “Rehabilitation EngineeringResearch Center.” The opinions contained in thispublication are those of the grantee and do not nec-essarily reflect those of the United StatesDepartment of Education.

pper extremity musculoskele-tal disorders are well-knownproblems among industrialworkers but have also had animpact upon clerical and

white collar workers, especially amongdental professionals. These upperextremity musculoskeletal disorderscost employers billions of dollars eachyear in medical costs, lost wage replace-ment, and reduced productivity.Among dentists and dental hygienists,several studies have demonstrated ahigh prevalence of upper extremitysymptoms and the American DentalAssociation and American DentalHygienists’ Association have reportedthat these musculoskeletal disordershave impacted their professions dramat-ically with more than 20 percent report-ing a leave of absence due to these dis-orders.1-8

According to a survey of practicingdentists performed by the AmericanDental Association, more than 50 per-cent of female dentists shortened theirwork hours due to repetitive motiondisorders.1 Although this statistic mayreflect a sample bias, it still demon-strates that upper extremity muscu-loskeletal disorders have a significantimpact of the professionalís ability towork. It has been reported that 7 per-cent to 12 percent of dental hygienistshave been diagnosed with carpal tunnelsyndrome in cross-sectional studies.3,4

Prior cross-sectional studies of activedentists and dental hygienists havedemonstrated a high prevalence ofsymptoms in the upper extremitiesalthough the prevalence of carpal tun-nel syndrome was only slightly higherthan the general population.9,10

Hygienists have a higher prevalence ofupper extremity tendinitis compared tothe general population and it is similarto the rate among industrial workers.10

It is clear that repetitive motion disor-ders exist among white-collar workersand the dental professionals appear tobe at relatively high risk.

Recent cross-sectional studies ofdentists and dental hygienists havedemonstrated upper extremity muscu-loskeletal disorder problems amongpracticing dental professionals, theonset of these problems and causallyrelated factors can only be determinedby a prospective, longitudinal study. Inan effort to assess workers at the begin-

the general population or haveincreased risk of other upper extremitymusculoskeletal disorders due to therepetitive hand activity.

The authors hypothesized that den-tal and dental hygiene students wouldhave low prevalence of symptoms andmusculoskeletal disorders due to theirage and relatively low exposure torepetitive stress during their trainingyears. The authors hypothesized thatthe age-matched clerical workers wouldalso have low levels of symptoms andmusculoskeletal disorders that weresimilar to the dental and dentalhygiene students.

MethodsDental and dental hygiene students

were recruited from three training pro-grams: the University of Michigan(dental and dental hygiene programs),Forsyth Institute (dental hygiene) andthe University of Illinois-Chicago (den-tal and dental hygiene). All students,regardless of their class standing in therespective programs, were invited toparticipate. All subjects signed a writtenconsent approved by the University ofMichigan and the respective localInstitutional Review Boards. Studentsover the age of 29 were excluded fromthe analyses to avoid potential con-founding of prior ergonomic stress andaging. The clerical workers were select-ed from an earlier study and clericalworkers under the age of 30 were usedas a comparison group.11 These subjectshad completed the same medicalscreening the dental and dentalhygiene students underwent. All cleri-cal subjects had worked on their job forat least six months prior to the study.

The medical screening included thefollowing procedures: completion of aself-administered symptom question-naire (all subjects); a limited physical

According to a survey of practicing

dentists performed by the American Dental

Association, more than 50 percent of female

dentists shortened their work hours due to repetitive motion

disorders.

STUDENTS

ning of their careers, the authorsrecruited dental and dental hygienestudents to participate in a baselinestudy of their musculoskeletal condi-tions and assessment of their medianand ulnar nerve function. Access to asimilar dataset that reflects a large pop-ulation of active clerical workers wasavailable. The authors compared thecharacteristics of the cohort of dentaland dental hygiene students to age-matched clerical workers to determineif their symptom and electrophysiolog-ic profiles were similar.

Clerical workers are known to havea low rate of carpal tunnel syndromecompared to industrial workers, but it isnot known if they are representative of

about nine symptoms (burning, stiff-ness, pain, cramping, tightness, aching,soreness, tingling, and numbness) ineach of 15 body locations (neck, right orleft shoulder, right or left upper arm,right or left elbow, right or left forearm,right or left wrist, right or left hand andright or left fingers). For the purpose ofanalysis these were combined to createthree regions: neck/shoulder/upper arm,elbow/forearm, and wrist/hand/finger.

Subjects were asked to rate eachregional discomfort by defining “cur-rent discomfort” and “worst discomfortin the past 30 days” on a visual analogscale of 0 to 10. Subjects who reported

Subjects completed a self-adminis-tered symptom questionnaire. The ques-tionnaire focused on demographic infor-mation, prior medical conditions, occu-pational history, current health status,and symptoms which may be related toupper extremity cumulative trauma dis-orders. These questionnaires have beenpreviously investigated and demonstrat-ed to have good reliability.13 Subjectswere instructed to report a regionalsymptom if it had been present on atleast three separate episodes, or oneepisode that had lasted more than oneweek, in the 12 months preceding thesurvey. The survey queried subjects

examination of the upper extremitiesand neck (symptomatic subjects only);and limited electrodiagnostic testing ofboth hands (all subjects). The standard-ized physical examination includedtests for range of motion, strength, mus-cle stretch reflexes, and provocativemaneuvers to identify possible tendini-tis and nerve entrapment.12 The physi-cal examinations were conducted by thelead authors (Werner and Franzblau)who were blinded to the results of theother measures. The nerve conductiontesting, the physical examination, andthe symptom surveys were conductedindependently of each other.

the dental students, freshmen repre-sented 26 percent of the sample; sopho-mores, 18 percent; juniors, 26 percent;and seniors, 29 percent. The dentalhygiene students were equally dividedbetween first and second year. Thedemographics, symptom and electro-physiologic data of the dental and den-tal hygiene students are presented inTable 1. The total number of studentseligible for the study was 1005, with a43 percent participation rate. The den-tal and dental hygiene students weresimilar in most respects except for gen-der (dental students 51 percent femalevs. dental hygiene students 93 percentfemale); smoking (dental students 11percent vs. dental hygiene students 23percent); wrist/hand/finger discomfortrating (dental students .5 vs. dentalhygiene students 0.9), and elbow dis-comfort rating (dental students .03 vs.dental hygiene students .2).Electrophysiologic features were alsosimilar in terms of the relative latencyof the median and ulnar sensory laten-cies but the absolute latencies wereshorter in the dental hygiene students.This difference most likely representsthe gender differential.11

The dental and dental hygiene stu-dent data was grouped for the remain-ing analyses. The comparison of the stu-dents versus the young clerical workersis presented in Table 2. There are manydifferences noted between the twogroups. The clerical workers have thesame mean age and gender distribution,but the clerical workers have manymore complaints of upper extremitysymptoms and a history of more ten-dinitis. The clerical workers had threetimes as many complaints ofhand/wrist/finger symptoms (62 per-cent vs. 20 percent, p<.01) andelbow/forearm complaints (48 percentvs. 16 percent, p<.01) and five times as

Franzblau et al.15 Scores ranged from 0to 3 (unlikely, possible, probable anddefinite) with respect to the likelihoodof establishing a diagnosis of carpal tun-nel syndrome. Carpal tunnel syndromewas defined as numbness, tingling,burning, or pain in the distribution ofthe median nerve (based on a hand dia-gram score of “probable” or “definite”)with ipsilateral median ulnar nerve con-duction difference of ≥0.5 msec. These

numbness, tingling, burning, or pain inthe hand and/or fingers were asked toshade in a hand diagram to determine ifthe symptoms matched the distributionof the median nerve in the hand.14,15

Psychosocial variables were assessedusing a questionnaire based on the onedeveloped by Karasek.16 The areasassessed included estimates of skill dis-cretion, job insecurity, perceived stressand job satisfaction based on the deci-sion latitude of the worker and the psy-chological demands placed upon theworker. Each worker was weighed andmeasured for height to calculate thebody mass index (BMI, kg/m2).

Electrodiagnostic studies of themedian and sensory nerves were con-ducted bilaterally with the techniquesdescribed by Kimura.17 These tech-niques have been investigated previous-ly and shown to have high reliabilitywith the median-ulnar peak latency dif-ference being a particularly stable mea-sure.18 The tests were performed withantidromic, supramaximal stimulation,a distance of 14 cm, and ring-recordingelectrodes placed around digits two andfive. A standard distance of 3 cmbetween electrodes was used. Hand tem-perature was recorded and the hand waswarmed if the mid-palmar temperaturewas below 32 degrees Celsius. All studieswere performed or supervised on-site bya certified electromyographer and/or acertified electrodiagnostic technician.There were three physicians and threetechnicians collecting data during thestudy. The peak latency, sensory ampli-tude, and takeoff latency were recordedfor each sensory nerve. A difference of0.5 msec or greater between the medianand ulnar peak latencies was consideredas the definition for a medianmononeuropathy.

The hand diagrams were scoredaccording to the methods described by

Clerical workers had a significantly lower level of job satisfaction, job

security, skill discretion, and social support on

the job compared to the student population.

criteria for defining carpal tunnel syn-drome are consistent with those recom-mendations by expert consensus.19

Consistent with expert consensuscriteria for tendinitis, a diagnosis oftendinitis was established if the sub-ject reported symptoms in a specificarea and the physical examinationdemonstrated focal tenderness to pal-pation and/or reproduced symptomswith specific provocative tests in thesame area.20

ResultsA total of 429 dental and dental

hygiene students were recruited intothe study, but excluded students overthe age of 29 and thus, analyzed datafrom 343 students. This included 232dental students and 111 dental hygienestudents from the three sites. Among

STUDENTS

Table 1

COMPARISON BETWEEN DENTAL AND DENTAL HYGIENE STUDENTSDental students Dental hygienist P

(age<29) (age < 29)n=232 n=111

Demographic variables

BMI 23.8 22.8 0.03

Age 25 24 <0.01

Gender (% female) 51.3% 93.7% <0.01

Hand dominance (right hand) 93.1% 94.55% 0.61

Diabetes 0.86% 0% 1

Rheumatoid arthritis 0.86% 0% 1

Exercise 90.9% 90.7% 0.94

Smoking 11.3% 23.4% <0.01

Regional discomfort variablesWorst discomfort rating in last 30 days

Wrist/hand/finger 0.23 0.37 0.21

Neck/shoulder 0.32 0.56 0.09

Elbow/forearm 0.034 0.22 0.03

Elbow/forearm 0.15 0.38 0.08

Carpal tunnel syndrome variables

CTS based on abnormal hand diagram 0.43% 0.9% 0.62& prolonged median lat. (>=0.5msec)

Median sensory peak lat. 3.1 3.02 0.01(dominant side)

Ulnar sensory peak lat. 3.095 2.99 <0.01(dominant side)

Median peak lat.-ulnar peak lat., 0.005 0.028 0.33dominant side

Regional tendinitis variables

Shoulder tendinitis (our diagnosis) 1.72% 3.6% 0.28

Elbow tendinitis (our diagnosis) 0.43% 0% 1

Wrist/hand/finger tendinitis (our diagnosis) 1.29% 1.8% 0.66

Any upper extremity tendon 5.6% 2.7% 0.28(overall tendinitis based on self-report)

Table 1

DENTAL AND DENTAL HYGIENE STUDENTS COMPARISON WITH YOUNG CLERICAL WORKERS (AGE <29)All students Young clerical workers P<0.01

(age<29) (age < 29)n=343 n=164

Demographic variables

Age 24.7 24.8 0.53

Body mass index (BMI) 23.6 26.5 <0.01

Gender (% female) 65% 73.2% 0.07

Hand dominance (right hand) 93.6% 86% <0.01

Diabetes 0.58% 0% 1

Rheumatoid arthritis 0.58% 0.61% 1

Regular exercise 90.9% 80% <0.01

Smoking 15.3% 31.7% <0.01

Regional discomfort variablesWorst discomfort rating in last 30 days

Wrist/hand/finger 3.2 5.45 <0.01

Elbow 1.52 1.82 0.61

Elbow 3.67 5.4 0.02

Carpal tunnel syndrome variables

CTS (self-report based on questionnaire) 0.58% 2.45% 0.09

CTS (based upon positive hand diagram 0.58% 0% 1and median nerve slowing)

Median sensory peak latency 3.075 3.073 0.92(dominant side)

Ulnar sensory peak latency (dominant side) 3.063 3.005 0.01

Median — ulnar sensory peak latency 0.012 0.067 0.01

Difference (dominant side)

Regional tendinitis variables

Shoulder tendinitis 2.33% 3.05% 0.63

Elbow tendinitis 0.29% 3.05% 0.02

Wrist/hand/finger tendinitis 1.46% 6.71% <0.01

Tendinitis (overall tendinitis based on self-report) 4.66% 11.66% <0.01

Psychosocial variables

Education level* 5.94 4.14 <0.01

Skill discretion** 36.56 20.47 <0.01

Social support** 12.75 11.48 <0.01

Job dissatisfaction** 0.195 0.338 <0.01

Colleague support** 12.75 11.67 <0.01

Job insecurity** 4.16 6.17 <0.01

*Education level: 4=High school diploma, 5=some college, 6=college degree, 7=graduate degree

**Psychosocial variables as defined by Karasac16

Table 2

LOGISTIC REGRESSION MODEL FOR HAND/WRIST DISCOMFORT (YES/NO), ODDS RATIO AND 95% CI.Variable Odds ratio P value 95% CI

Smoking 2.13 .03 1.04, 2.98

Elbow/forearm discomfort 5.41 <0.01 2.74, 10.65

Neck/shoulder discomfort 2.85 <0.01 1.72, 4.72

History of tendinitis 2.71 .03 1.12, 6.55

Skills discretion 0.93 <0.01 0.91, 0.96

N=487, p value for model<.01, Pseudo R2=.26

Table 3

many shoulder complaints (33 percentvs. 6 percent, p<.01). The clerical work-ers had a higher body mass index andwere less likely to exercise regularly.Clerical workers also were more likelyto have a history of carpal tunnel syn-drome or upper extremity tendinitis.The prevalence of both of these disor-ders was low. The electrophysiologicmeasures of the median sensory nerveswere similar however, there was a slightdifference in the ulnar sensory nerves;clerical workers had a shorter peaklatency. Clerical workers had a signifi-cantly lower level of job satisfaction,job security, skill discretion, and socialsupport on the job compared to the stu-dent population.

Table 3 presents the logistic regres-sion model using hand discomfort(yes/no) as the dependent variable andassessing the influence of demographic,psychosocial, symptoms and medicalhistory as independent variable. Thefinal model demonstrated that otherregional symptoms such as shoulderand elbow complaints as well as a his-tory of an upper extremity tendinitis,smoking, and decreased skill discretionwere independent risk factors. Most ofthe psychosocial variables were highlycorrelated and there was a significant

difference when stratified by job classi-fication. The skill discretion variablewas the best fit in the model and if thevariable for job classification (studentvs. clerical) was forced into the model,the psychosocial variables would nolonger be significant in the model. Ageor years in training did not influencethe model.

DiscussionThis study demonstrates that dental

and dental hygiene students start theirrespective careers with few symptomsof upper extremity musculoskeletal dis-orders. They are less likely to complainof upper extremity musculoskeletalsymptoms than age-matched clericalworkers. Age and duration of time intheir respective training program didnot appear to influence their symptoms

or the function of the median nerve;i.e. senior dental students did not havemore symptoms compared to freshmenand their nerve conduction measureswere similar.

Some psychosocial variables, suchas job discretion, appear to influencethe reporting of hand discomfort. Theauthors chose to evaluate a student’sperception of their training in a similarfashion as a “job.” The psychosocialassessment was developed by Karasekfor active workers, not students, but anargument could be made that the train-ing phase is their job.16 This is a poten-tial limitation of the interpretation ofthis study.

Other influences include smokingand reports of other regional upperextremity discomfort. A history ofproximal upper extremity tendinitis orother proximal musculoskeletal com-plaints in the upper limb is stronglyassociated with reporting hand symp-toms. This association of symptoms hasbeen demonstrated in several recentstudies and are known to be associatedwith higher reports of carpal tunnelsyndrome and upper extremity tendini-tis.21,22 This relationship may be due toan underlying diagnosis of carpal tun-nel syndrome and the associated pain

Despite the wide disparity in

symptoms between the students and the clerical workers,

their nerve function was almost identical.

referral patterns to the elbow and theshoulder. Alternatively, these individu-als may compensate for one region ofthe arm by overusing another group ofmuscles. A third explanation would berelated to some underlying genetic pre-disposition to soft tissue injury ordelayed repair of connective tissue.

Despite the wide disparity in symp-toms between the students and theclerical workers, their nerve functionwas almost identical. The differences inthe prevalence of complaints of painare not due to measurable nerveimpairment. The median nerve func-

tion among practicing dental profes-sionals does deteriorate over time withmore impairment in the median nervecompared to the ulnar nerve function.This is the hallmark of carpal tunnelsyndrome.

Unanswered questions include:when does the stress on the mediannerve begin in dental professions; howis it influenced by work activity versusother avocational activities; and arethere changes in psychosocial variablessuch as job satisfaction that may influ-ence later reporting of hand discom-fort? A prospective study is necessary to

fully understand the process. It hasbeen demonstrated among hand inten-sive industries that changes in themedian nerve function can occur in theearly stages of employment in a new,and physically stressful, work environ-ment.23 This is not the case when eval-uating workers who have been on thesame job for many years. We havelooked at prospective studies of indus-trial and clerical workers as well as den-tists who have been working for a num-ber of years and demonstrated that therate of change after the first five to 10years on the job are minimal.21 A

STUDENTS

prospective study of these dental anddental hygiene students would be anideal study to help define the role ofwork versus avocational risk factors. Wehave baseline data that demonstrates avery healthy population and havedemonstrated that these dental profes-sionals will have upper extremity mus-culoskeletal problems during theircareers but, when do they occur andwhich factors are the ones temporallyrelated to their problems? A prospectivestudy would allow cause and effect tobe evaluated and would elucidate pre-ventive measures that could be taken.We hope to evaluate these studentsduring their career to identify the riskfactors for upper extremity muscu-loskeletal disorders, some of which maybe responsive to primary or secondarypreventive measures, and the identifythe timing of the change in mediannerve function. If we can separate thework-related ergonomic factors fromthe aging process, we will greatly con-tribute to an improved understandingof the process associated with upperextremity musculoskeletal disorders.

The practicing dentist and dentalhygienist have a high rate of upperextremity symptoms and musculoskele-tal disorders, however, when starting inthe profession they are relatively symp-tom free. When does the practicingdentist or dental hygienist start todevelop symptoms and how much canbe attributable to the type of work theyperform are questions that remainunanswered. Differentiating the impactof aging from work activity is some-times difficult but this could beassessed with a longitudinal study.Determining when the changesoccurred in these populations willallow for preventive strategies to bedeveloped and tested.

References / 1. ADA, Survey Center, 1997 Surveyof Current Issues in Dentistry: Repetitive MotionInjuries, 1997.

2. Osborn JB, Newell KJ, et al, Carpal tunnelsyndrome among Minnesota dental hygienists. JDent Hyg 64:79-85, 1990.

3. Conrad JC, Conrad KJ, Osborn JB, A shortterm, three year epidemiological study of mediannerve sensitivity in practicing dental hygienists. JDent Hyg 67:268-72, 1993.

4. Corks I, Occupational health hazards indentistry: musculoskeletal disorders. Ontario Dent74(6):27-30, 1997.

5. Fish DR, Morris-Allen DM, Musculoskeletaldisorders in dentists. NY State Dent J 64(4):44-8,1998.

6. Guay AH, Commentary: ergonomicallyrelated disorders in dental practice. J Am Dent Assoc129(2):184-6, 1998.

7. Stockstill JW, Harn SD, et al, Prevalence ofupper extremity neuropathy in a clinical dentistpopulation. J Am Dent Assoc 124(8):67-72, 1993.

8. Liss GM, Jesin E, Kuslak RA, White P,Musculoskeletal problems among Ontario dentalhygienists. Am J Indus Med 28:521-40, 1995.

9. Hamann C, Werner RA, et al, Prevalence ofCarpal Tunnel Syndrome and MedianMononeuropathy Among Dentists, J Am Dent Assoc132:163-70, 2001.

10. Werner RA, Hamann C, et al, Prevalence ofcarpal tunnel syndrome and upper extremity ten-dinitis among dental hygienists. J Dent Hyg76(2):126-32, 2002.

11. Salerno DF, Franzblau A, et al, Median andulnar conduction studies among workers: norma-tive values. Muscle Nerve 21:999-1005, 1998.

12. Salerno DF, Franzblau A, et al, Reliabilityof physical examination of the upper extremityamong keyboard operators. Am J Ind Med37(4):423-30, 2000.

13. Salerno DF, Franzblau A, et al. Test-retestreliability of the upper extremity questionnaireamong keyboard operators. Am J Ind Med40(6):655-66, 2001.

14. Katz JN, Stirrat CR. A self-administeredhand diagram for the diagnosis of carpal tunnelsyndrome. J Hand Surg 15A:360-3, 1990.

15. Franzblau A, Werner RA, et al. Workplacesurveillance for carpal tunnel syndrome usinghand diagrams. J Occup Rehab 4:185-98, 1994.

16. Karasek R, Brisson C, et al, The job contentquestionnaire (JCQ): an instrument for interna-tionally comparative assessments of psychosocialjob characteristics. J Occup Health Psych 3(4): 322-55, 1998.

17. Kimura J. Electrodiagnosis in diseases ofnerve and muscle: principles and practice.Philadelphia: FA Davis, 1983.

18. Salerno DF, Werner RA, et al. Reliability ofnerve conduction studies among active workers.Muscle Nerve. 22(10):1372-9, 1999.

19. Rempel D, Evanoff B, et al. Consensus cri-teria for the classification of carpal tunnel syn-drome in epidemiologic studies. Am J Pub Health88(10):1447-51, 1998.

20. Harrington JM, Carter JT, et al.Surveillance case definitions for work related upperlimb pain syndromes. Occup Environ Med 55:264-271, 1998.

21. Gell N, Werner RA, et al. A longitudinalstudy of industrial and clerical workers: incidenceof carpal tunnel syndrome and assessment of riskfactors. J Occup Rehab 2004 (in press).

22. Werner RA, Gell N, et al. A longitudinalstudy of industrial and clerical workers: predictorsof upper extremity tendinitis. J Occup Rehab 2004(in press).

23. Kearns J, Gresch EE, et al. Pre- and post-employment median nerve latency in pork pro-cessing employees. J Occup Environ Med 42(1):96-100, 2000.

To request a printed copy of this article, pleasecontact / Robert Werner, MD, chief, PhysicalMedicine and Rehabilitation Service (117), AnnArbor VAMC, Ann Arbor, MI 48105.

ABSTRACTA joint study was conducted by a manufacturer of dental stools in the Midwest of the United

States and Marquette University to measure the occupational postures of dentists and dental

hygienists. The postures of 10 dentists and 10 dental hygienists were assessed using work sam-

pling and video techniques. Postural data of the neck, shoulders and lower back were recorded

from video and categorized into 30-degree intervals: 0 (neutral posture of respective joint), 30, 60

and 90 degrees. Each subject’s postures were observed while they were treating patients during a

four-hour period, during which 100 observations of postures were recorded at random times.

Compared to standing, dentists and dental hygienists were seated 78 percent and 66 percent of

the time, respectively. Dentists and dental hygienists flexed their trunk at least 30 degrees more

than 50 percent of the time. They flexed their neck at least 30 degrees 85 percent of the time dur-

ing the four-hour duration, and their shoulders were elevated to the side of their trunk (abducted)

at least 30 degrees more half of the time. The postures of the trunk, shoulders, and neck were pri-

marily static. This database of postures can be used by dental professionals and ergonomists to

assess the risk dentists and dental hygienists are exposed to musculoskeletal disorders, such as

low back pain or shoulder tenosynovitis, from deviated joint postures. They could use these data

to select dental furniture or dental devices that promote good body posture, i.e., reduce the mag-

nitude and duration of deviated joint postures, which, in theory, would decrease the risk of muscu-

loskeletal disorders.

Working Postures of Dentistsand Dental HygienistsRichard W. Marklin, PhD, and Kevin Cherney, BS

Authors / Richard W. Marklin,PhD, is a certified professionalergonomist and associate professorat the Department of Mechan-ical and Industrial Engineering,Marquette University in Milwaukee.

Kevin Cherney, BS, has abachelor of science degree in

industrial engineering from Marquette Universityin Milwaukee.

umerous studies, including anexhaustive review of the litera-ture,1 have shown that dentistsand dental hygienists work inpostures that make them sus-

ceptible to musculoskeletal disorders.2-4

Dentists and dental hygienists work inpostures that expose them to long-dura-tion static muscle loads that can causemusculoskeletal disorders and pain.Examples of musculoskeletal disordersare low back pain and shoulder tendini-tis. Prolonged exertions of the musclesof the neck, back and shoulders havebeen reported as the greatest number ofcomplaints from both dentists andhygienists,5-6 and these prolonged exer-tions could pose dental professionals torisk of musculoskeletal disorders. To theauthors’ knowledge, no detailed taskanalysis of the magnitude and durationof joint postures have been conducted.Results from a detailed task analysiswould enable dental professionals andergonomists to determine which jointshave the most non-neutral (deviated)postures, and thus, where to direct theirefforts to reduce the deviated postures.

T = talking to the patient while notdoing P or W

0 = out of the room

Seated or StandingMarked one column if seated and

another column if standing

Trunk Posture0 = 0-degree trunk flexion (trunk

vertical)30 = 30-degree trunk flexion (trunk

bent forward 30 degrees from vertical)60 = 60-degree trunk flexion (trunk

bent forward 60 degrees from vertical)

Neck Posture0 = 0-degree neck flexion (neck in

line with the axis of trunk)30 = 30-degree neck flexion (neck

bent 30 degrees forward from axis oftrunk)

60 = 60-degree neck flexion (neckbent 60 degrees forward from axis oftrunk)

Shoulder Posture0 = 0-degree shoulder abduction

(arms at the side of the trunk)30 = 30-degree shoulder abduction

Milwaukee-area dental practices wereselected as sites for data collection. Thedentists and dental hygienists weremonitored in their normal work areas(operatories) while performing theirtasks in a typical manner. Each dentist,hygienist, and the patient being workedon were informed that the work sam-pling data were being collected.

SubjectsWorking postures of 10 dentists and

10 dental hygienists at four differentdental practices in the Milwaukee areawere observed.

ApparatusThe equipment used in the task

analysis was a video recorder and achronograph. The video recorder wasplaced in the best available location inthe operatory to observe the working pos-tures of the dentists and hygienists. It wasset for continuous recording during afour-hour work sampling period, with thevideo tapes being changed at the two-hour mark. The chronograph was used tokeep track of the scheduled observationtimes, which were generated randomlythroughout the four-hour session.

Experimental ProtocolA work sampling packet was created

for each of the 10 dentists and 10 dentalhygienists during the data collectionphase of the task analysis. This packetwas developed from a preliminary analy-sis conducted at the MarquetteUniversity Dental School. Using the pos-tural analysis protocol, the analystrecorded the following data at 100 ran-domly generated times during a four-hour session.7 At each observation time,the analyst estimated the angles of themajor joints of the dentists or hygienists.

Operator StatusP = working on the patientW = working on something other

than the patient

New office furniture or dental devicesthat promote more neutral joint pos-tures could be implemented in operato-ries, which in theory would reduce therisk of musculoskeletal disorders.

In response to reports of dental work-ers’ pain from static postural loading andthe lack of documentation of magnitudeand duration of dental professional’sbody postures, a task analysis consistingof work sampling techniques and videoanalysis was conducted to collect postur-al data of dentists and hygienists.

Method

ApproachThere are many dental procedures

that demand dentists and hygienists tomaintain working postures that putthem at risk of musculoskeletal disor-ders. Previous studies have shown thereis a high frequency of musculoskeletalproblems among both dentists anddental hygienists.2,3,5 In 1987, theannual income lost due to muscu-loskeletal complaints in dentistry was$41 million; the present amount inannual income would be much greaterthan $41 million, given the effect ofinflation.6 While statistics have beenrecorded for the incidence of muscu-loskeletal disorders in the dental profes-sion, there is a lack of data concerningthe working postures of dentists andhygienists.1 Quantitative data on theworking postures of dental profession-als could be used to design dentalequipment in order to improve pos-tures and reduce the risk of muscu-loskeletal disorders.

The approach of the task analysiswas to use work sampling techniques inorder to collect postural data from den-tists and dental hygienists at work.Preliminary data collection and analy-sis were conducted at the MarquetteUniversity Dental School in order todevelop the appropriate procedures andprotocol. After this was completed, four

WORKING POSTURES

0Seated Standing

Figure 1. Percentage of time dentists andhygienists spent sitting vs. standing.

DentistsHygienists

to P+W+T in the Experimental Protocolsection.) The hygienists spent 66 per-cent of working time in a seated posi-tion. The main reason for this differenceis that the hygienists spent a portion oftheir working time cleaning the roomand equipment between patients, whilethe dentists had their assistants cleanand prepare the room for the nextpatient. The trunk posture data provid-ed in Figure 2 reveals that the dentistsspend almost 58 percent of their work-ing time in some degree of trunk flex-ion, whether seated or standing. Atrunk flexion of approximately 30degrees is most prevalent, occurringalmost 45 percent of the time. The pos-tural results for the hygienists are quitesimilar to that of the dentists. As shownin Figure 2, the hygienists flexed theirtrunk 30 degrees about 50 percent, sim-ilar to the 53 percent for dentists.

Figure 3 provides the neck posturedata for the dentists, which indicate den-tists exhibited at least 30 degrees of neckflexion 86 percent of the time whileworking in the room, 35 percent of thetime at 30 degrees and 51 percent of the

finding out their personal opinions ontheir posture, the dental stools current-ly in use, and what improvements theywould like to see.

ResultsOperator status reveals the percent-

age of time actually spent working inthe operatory where the work samplingand video taping was taking place. Thedentists were in the room approximate-ly 70 percent of the time and thehygienists were in the room 80 percentof the time. The percentages on jointposture were based on the time spentworking in the operatory. For instance,as shown in Figure 3a, the dentistsflexed their neck approximately 30degrees 35 percent of the time whilethey were actually observed in theroom, not 35 percent of the entire four-hour observation period.

As shown in Figure 1, the seated vs.standing data showed that the dentistsspent about 78 percent of their workingtime seated and only 22 percent stand-ing. (Note: working time is the timespent in the operatory, which is equal

(arms elevated 30 degrees to side of trunk)60 = 60-degree shoulder abduction

(arms elevated 60 degrees to side oftrunk)

90 = 90-degree shoulder abduction(arms horizontal to the side of trunk)

The information recorded aboveformed the basis of the task analysis.The video camera was set up inconspic-uously in a corner of the room, and theanalyst minimized his presence by mak-ing the observations from outside theworking area. At the beginning of thefour-hour period, the camera wasturned on and observations wererecorded whether the dentist or hygien-ist began working on a patient or not.Each patient during that period was toldwhat type of study was being conductedand then asked for his/her permissionto be filmed during the procedure. Thesession was filmed for four hours, dur-ing which time the 100 observationswere made. In addition to the data col-lected on the work sampling charts,other valuable information was gainedduring the task analysis simply byspeaking with each of the subjects and

00 30 0Dentists Hygienists

Figure 2. Percentage of time dentists andhygienists worked with different angles (indegree) of trunk flexion (from vertical). The per-centage of time spent in a posture greater than 60degrees was less than 3 percent.

Figure 3. Percentage of time dentists andhygienists worked with different angles (indegrees) of neck flexion. Zero-degree neck posturewas the posture when the neck was in line withthe trunk.

Figure 4. Percentage of time dentists andhygienists worked with different angles (indegrees) of left shoulder elevation (abduction).Zero-degree shoulder elevation was the posturewhen the arm was at the side of the trunk.

SeatedStanding

0 30 60

DentistsHygienists

0 30 60 90

DentistsHygienists

external forces acting on dentists’ andhygienists’ joints are from the weightsof their body segments, which have tobe maintained at flexed and abductedangles at least half of the time spentworking on patients. The clinical conse-quences of prolonged, flexed or abduct-ed postures of the joints can be numer-ous, such as muscle pain in the neck,shoulder, and lower back musculature;rotator cuff syndrome in the shoulder,and low back pain or disorders. Posturaldata from this study can be used bydesigners of dental equipment andinstruments as a baseline to either mod-ify existing or design new equipmentand instruments that would promotemore neutral joint postures. Reductionsin back and neck flexion and shoulderabduction would, in theory, improvethe occupational health of dentists anddental hygienists.

References / 1. Murphy, DC (editor), Ergonomicsand the Dental Care Worker. American PublicAssociation, 1998.

2. Oberg T, Oberg U, Musculoskeletal com-plaints in dental hygiene: a survey study from aSwedish country. J Dent Hyg 67(5):275-61, July-August 1993.

3. Osborn JB, Newell KJ, Rudney JD,Stoltenberg JL, Musculoskeletal pain amongMinnesota dental hygienists. J Dent Hyg 64(3):1328, March-April 1990.

4. Smith CA, Sommerich CM, Mirka GA,George MC, An investigation of ergonomic inter-ventions in dental hygiene work. Appl Ergon33(2):175-84, March 2002.

5. Shugars DA, Williams D, Cline SJ, FishburneC, Musculoskeletal back pain among dentists. GenDent 32(6):481-5, November-December 1984.

6. Shugars D, Miller D, Williams D, FishburneC, Strickland D, Musculoskeletal pain among gen-eral dentists. Gen Dent 35(4):272-6, July-August1987.

7. Armstrong, TJ, Foulke JA, Joseph BS,Goldstein SA, Investigation of cumulative traumadisorders in a poultry processing plant. Am Ind HygAssoc J 43(2):10316, February 1982.

Additional reference: / Green EJ, Brown ME, Bodymechanics applied to the practice of dentistry. J AmDent Assoc 67: 67997, November 1963.

To request a printed copy of this article, pleasecontact / Richard W. Marklin, PhD, Department ofMechanical and Industrial Engineering, MarquetteUniversity, P.O. Box 1881, Milwaukee, WI 53201-1881.

and upper extremity postures and notexact angles.

The data from this task analysisagree well with postural data and inci-dence of musculoskeletal disordersreported in the published literature.The seated vs. standing data showedthat the dentists spent about 78 percentof their working time seated and only22 percent standing, which agrees withthe literature.5 A trunk flexion ofapproximately 30 degrees is mostprevalent, occurring almost 45 percentof the time, which may explain whypain is often reported in the lower backof dentists.2,3,5 The dentists spent morethan half of their working time withtheir neck flexed approximately 60degrees, which agrees with the resultsfound previously in the literature thatthe neck is an area of primary con-cern.2,3,5 The reason for the differencein the abduction angle between theright and left shoulders is due to theright-handed dominance of all the den-tists and hygienists surveyed. The typi-cal working position for right-handeddentists and hygienists is to abduct theleft shoulder and hold the right armclose to the trunk.

The postural data from the taskanalysis of both dentists and dentalhygienists show that they spent at leasthalf of their time working with theirnecks flexed 60 degrees or greater, theirtrunks flexed 30 degrees or greater, andone of their shoulders abducted.Because of the mechanical disadvantageof the muscles with respect to theirjoints, flexed and abducted joint pos-tures require high muscle forces to holdthese static postures. The high muscleforces then produce high compressionloads on the joint. The posturesassumed by dentists and dental hygien-ists can require sizeable muscle forces,and concomitantly, high compressionloads on the joint. Except for the weightof small instruments, and an occasionalpush or pull from the hand, the only

WORKING POSTURES

0 30 60 90

Figure 5. Percentage of time dentists andhygienists worked with different angles (indegrees) of right shoulder elevation (abduction).Zero-degree shoulder elevation was the posturewhen the arm was at the side of the trunk.

DentistsHygienists

time at 60 degrees. The hygienists exhib-ited results similar to those of the dentistsin that hygienists had at least 30 degreesof neck flexion 86 percent of the time,the same percentage as the dentists.

The shoulder posture data shows thedentists had some degree of elevation(abduction) more than 50 percent of thetime in the left shoulder, as seen inFigure 4, but only about 25 percent ofthe time in the right shoulder, as shownin Figure 5. The hygienists’ left shoul-ders were abducted 45 percent of thetime, while their right shoulders wereabducted 34 percent of the time.

DiscussionIn this study, the analyst estimated

the postural angles in discrete 30-degreeincrements for ease of observation andanalysis. Although this technique hasbeen used previously to record upperextremity posture in a poultry process-ing plant, this method does have limita-tions due to the low resolution of themeasurement intervals.7 Therefore; theresults from this study must be inter-preted to show only patterns of trunk

ABSTRACTAthlete’s Performance, an organization of spe-

cialists in the development of athleticism and

injury prevention, has analyzed the seated pos-

tural demands of dental health care workers

for the purpose of developing an exercise pro-

tocol appropriate to the dental profession. As

with their individualized exercise prescriptions

for some of the world’s most acclaimed ath-

letes, the conditioning of the torso is the focus

of a prescription for exercise when injury pre-

vention is emphasized. An analysis of the seat-

ed postural demands common to dental health

care workers is the basis for an exercise proto-

col intended to strengthen the torso and

encourage “good” seated posture.

Functional Training forDentistry: An ExercisePrescription for DentalHealth Care PersonnelAllan C. Jones, DDS, NSCA-CPT, and Shad Forsythe, MS, ATC, CSCS

Guest Editor / Allan C. Jones, DDS,NSCA-CPT, is a certified personaltrainer through the NationalStrength Conditioning Association.He has been on faculty at theUniversity of Southern CaliforniaSchool of Dentistry since 1984 andhas a practice in Torrance, Calif.

Author / Shad Forsythe, MS, ATC, CSCS, is a certi-fied strength and conditioning specialist. He isdirector of athletic training services and a perfor-mance specialist and training operations manager atAthletes’ Performance, Los Angeles, in Carson, Calif.

hat do dental health careworkers have in commonwith elite athletes? Morethan one might think. Asdental health care workers,

there are enormous physical demandson the back, neck, and shoulders whileperforming daily work. We must main-tain exquisite fine motor control ofarms, hands and fingers, while forceful-ly and continuously recruiting themany muscles required for maintaininga stable working position. Seeking visu-al access to small and poorly illuminat-ed areas of the oral cavity, dental prac-tice often requires an extreme posture,with numerous spinal articulationsplaced at the limits of their ability tomove. Athletes must also completetheir work by moving their hands andarms with great precision from often-

muscular elements through their recruit-ment with each and every movement.Exercises performed in this manner cre-ate optimal posture of the spinal columnthat are intended to reduce the forcesborne by the vertebral disks. This posture-specific exercise tends to foster not onlyideal upright posture while training, butalso the development of the uprightmovement of the torso for all functionalmovement. The ability to achieve stableupright posture through posture-specifictraining movements bears great relevanceto dental practice as it has profoundimpact on the dental health care worker’sability to resist the negative conse-quences of leaning forward and rotatingto view the oral cavity.

Prolonged postural stress, that sooften occurs as a dental health carepractitioner leans forward and rotatesthe head, is especially problematic forthe finite supply of connective tissuewithin the spinal column that investsand supports the skeletal elements ofthe torso. Chronic excessive loadingfrom this “poor posture” will pre-dictably result in damage to these tis-sues in many vulnerable practitioners.

is developed by exercises that are derivedfrom functional movements. Well-edu-cated athletic trainers are presently teach-ing such movement in a very popularprotocol known as “functional”training.7 This method of training forathletic movement emphasizes therecruitment of muscles that work in har-mony to complete a certain task or move-ment. Functional training does not seekto isolate muscles in a fashion that is typ-ical of machine-based exercises commonto most health clubs. Unlike machine-based exercises, functional trainingmovements require the practitioner toexercise with feet firmly grounded, andthe torso unaided in support.Additionally, when performing move-ments of all types that are intended toenhance the function of the torso,whether seated or standing, the traineecreates a specific postural adjustment ofthe torso by drawing in the abdominalmusculature to narrow the waist and tolengthen the spinal column to its fullupright extent. As a result of performingtraining movements with this drawn inand upright posturing maneuver, theseexercises will train the torso to maintainstable upright posture by development ofall relevant musculoskeletal and neuro-

extreme positions. Elite strength andconditioning specialists now emphasizethe function of the torso in providing astable foundation for athletic move-ment of the extremities.1 They teachthat fitness of the torso is essential toconferring control during athleticmovements because the athlete’s torsois the biomechanical core from whichall controlled movements of theextremities emanate. It is well knownthat dysfunction of the torso and itsspinal elements is not only compromis-ing to the quality of athletic movement,but may ultimately limit the ability ofdental health care workers to functionprofessionally.2-6 The common need foroptimal function of the torso, com-bined with prevention of injury to itssupporting structures, unites dentalhealth care workers and professionalathletes in common purpose concern-ing functional torso development.Through the application of conceptsdeveloped for the enhancement of ath-letic torso function, dental health careworkers can perform better profession-ally and be more resistant to injuries ina manner that is exactly the same asprofessional athletes.

Optimal function of the human torso

FUNCTIONAL TRAINING

Figure 1. USC School ofDentistry clearlydemonstratespoor posturaltendencies.

Figure 2. This demonstration shows thatuse of a microscope promotes upright posture ofthe torso.

bruxism, or the dental health care work-er with chronically poor working pos-ture, affected joints may degeneratepainfully so as to become the cause ofmusculoskeletal pain and movementdysfunction of chronic duration. Spinaldysfunction and pain, when viewed inthis manner, can be understood asoccurring by a process that is similar tothe process that affects the temporo-mandibular joint. Our efforts as dentiststo preserve the articular disk of the tem-poromandibular joint through the cre-ation of a bite that optimizes its posi-tion, and by preventing the overloadingof parafunction, is the same as theefforts of those who coach athleticmovement in preserving the vertebraldisks of the spine. “Good” working pos-ture of the athletic spine tends to pre-serve its connective tissue just as a“good” bite tends to preserve the con-nective tissue of the temporomandibularjoint. The exercises presented herein areintended to preserve the vertebral disksof the spine in a similar fashion to theefforts of dentists to preserve the articu-lar disk of the temporomandibular joint.

Exercise Prescription

Movement PreparationAt the beginning of an exercise pro-

gram, it is essential to “warm up,” thatis, to increase the temperature and thus,the pliancy of those tissues about to bestretched and stressed. Since all exerciserequires dynamic changes in the lengthof muscles, their investing connectivetissues and articulations, we describewarming up as preparation for move-ment, or the “movement preparation”phase of our regimen. This phase is alsointended to stimulate and prepare theneurological systems that control move-ment and balance for optimal kinesthet-ic function. “Movement preparation”prescribed for these purposes is com-prised of four elements: (1) increasing

the spinal column. The result of thistypical working posture is the mostextreme form of biomechanical stress tothe vertebral disks of the spinal col-umn.8 As with the athlete, dental healthcare workers do not function optimally,nor do they age well, when the joints ofthe torso are chronically subjected tosuch an extreme position or “poor pos-ture.” This is an orthopedic conceptthat dentists know intimately as theyare experts in the articulation they

Vertebral support, when compromisedby the degenerative process, may ulti-mately fail, leaving the nerve roots thatpass through the vertebrae without ade-quate room for function. The resultingnerve root impingement, or radiculopa-thy, may disable dental health careworkers with back and neck pain, alongwith dysfunction of the extremities.While dental health care workers strug-gle for visibility through extreme pos-tural maneuvering, their torsos becomea battleground between operator move-ments to maintain stability and the per-turbing force of gravity. As they leanforward and rotate, gravity exertsextreme compressive forces to thespinal column that is borne by connec-tive tissue and resisted by the muscles ofthe torso. If the muscles that uprightthis biomechanical core of the torso arenot conditioned adequately so as toresist gravity, spinal health may be thecasualty of a lengthy battle lost to itsinexorable force. The exercises present-ed in this article are given as an antidoteto the negative forces of chronic postur-al stress that is all too common in den-tal health care workers.

What’s wrong with the posture ofdental health care workers? A recenttour of the simulation laboratory of thesecond-year class at the University ofSouthern California School of Dentistryclearly demonstrates the postural ten-dencies induced by the unique chal-lenges of working within the oral cavity(Figure 1). Unless one is blessed withthe aid of a microscope, as are theselected residents at USC (Figure 2),upright posture of the torso is rarelyobserved in these students. Instead, wesee flexion and rotation of the spinalcolumn, along with forward head posi-tioning and internal rotation of theshoulders. Invariably, the weight of theupper body is borne asymmetrically bythe seated pelvis with the load of gravi-ty borne asymmetrically by one side of

The common need for optimal function

of the torso, combined with prevention of injury

to its supporting structures,unites dental health careworkers and professional

athletes in common purpose concerning

functional torso development.

monitor in every day of clinical dentalpractice, the temporomandibular joint.

The loaded fibrocartilage of thespine — the vertebral disk — like theloaded fibrocartilage of the temporo-mandibular joint — the articular disk —becomes a source of joint inflammationwhen subjected to overloading. A jointso afflicted will not only hurt whentouched, but the muscles that move itwill hurt and persist in a contractedstate that will limit movement.9,10

Temporomandibular joint inflamma-tion will cause muscle contraction thatlimits jaw opening while vertebralinflammation will initiate a similarprocess that limits torso movement. Ifoverloading and joint inflammationbecome chronic, as in the dental patientwho is afflicted by malocclusion with

Table 1.1

DYNAMIC FLEXIBILITY

Exercise How to Elongation Activation

Knee hugs

Back lunge and twist

Leg cradles

Inverted hamstring

Lateral squat

Forward lunge withelbow to instep

Maximus of flexed legWalking forward, bringone knee to chest andhold. Next, extend toelevate the heel of thedown foot.

Gluteus maximus ofstanding leg

Hip flexorStep back and dropback knee straightdown. Contract “glute”of back leg and turntowards up knee witharms extended.

Gluteus maximus

Gluteus maximus, abductors, hip flexors,hamstrings

Large step forward,keep back leg straightand drop same sideelbow to the ground,place hand outsideknee and straightenextended leg.

Gluteus maximus

Piriformis, hip rotatorsGrab knee with samearm and ankle withopposite and lift kneeand rotate ankle uptoward chest.

Opposite gluteus maximus

HamstringArms up straight outto side of shoulders,turn thumbs towardthe back and rotate atthe hip pushing heelback, making yourselfas long as you canfrom head to heel.

Opposite gluteus maximus

AbductorsStand with feet doubleshoulder width, leanand sit hips backbehind knee, keepingknee outside of footand back leg straight.

Keep toes forward.

Hip abductors

ration exercises should be maintainablefor 30 seconds before the next phase isundertaken.

Neural activation is the final phaseof movement preparation. Jumpingrope for three 15-second periods, with30 seconds of rest after each period, isrecommended for this endeavor. Theseexercises will challenge the nervous sys-tem such that working muscle connec-tions are ready to train.

Torso TrainingAs a dental health care worker, the

most important component of thetraining program is torso training. Thisphase will tend to combat problems

core body temperature; (2) increasingblood flow to working muscles; (3)actively elongating our musculaturewith safe mobilization of our joints; and(4) activating our nervous system.

To increase the temperature of tis-sues needed for movement, we rely onthe metabolic production of heat alongwith heat dispersion achieved by perfu-sion of blood. For this purpose, a shortbout of nonstressful movement on anexercise machine is optimal. Five to 10minutes of biking, elliptical machine, orwalking on a treadmill is recommended.This phase should result in a light sweatat its completion. In this warm-upphase, exercises are preferred that sub-ject the body to low impact and thus,low stress during this critical early phasewhen the body is not prepared for therigors of athletic movement.

Static stretching (lengthening mus-cles with externally applied, nonfunc-tional force while remaining at a givenlocation) is a thing of the past for pre-exercise warm-up routines. The stretch-ing that lengthens muscles and jointswell beyond their functional range ofmotion does not prevent athletic injuryand tends to impair balance and musclefunction.11-14 As an alternative tostretching, movement preparation actu-ally improves total body strength andbalance. These movements achieve flex-ibility with a functional movement rou-tine that elongates specific muscleswhile activating others needed formobility and stability (Table 1.1).

Repeat each of these exercises untilstability is achieved. Typically, as youattempt to stand on one foot, you areinitially unable to maintain therequired posture for more than a fewseconds. With repeated efforts, you maybecome confident in your ability tomaintain this posture for a prolongedperiod. This confident sense of stabilityheralds the readiness for more demand-ing movements to follow. Each of thepositions described as movement prepa-

exercising public. To assist in choosingamong the multitude of exercises, theauthors offer four groupings of exercis-es: (1) lower body-push/knee domi-nant; (2) lower body-pull/hip domi-nant; (3) upper body push; and (4)upper body pull. A recommended pro-gram involves choosing one exercisefrom each group and doing three tofour sets of 10 repetitions two to threetimes per week. Table 1.3 lists exerciseprogressions for each category.

Interval TrainingThe last phase prescribed in this

exercise program is training of thebody’s energy producing system thatoxidizes glucose for the work of move-ment. Interval training, achievedthrough bursts of intense exercise withsubsequent rest intervals, will increaseaerobic capacity; that is, its ability tofully oxidize glucose to carbon dioxide.When oxidation of glucose within mus-cle cells is incomplete, lactic acid is pro-duced and accumulates within the cel-lular cytoplasm. This phenomenondegrades muscle function. Withincreasing aerobic capacity, there is animproved work capacity of the individ-ual. Interval training is intended todevelop all of the intracellular mecha-nisms utilized for producing energyand minimizing the accumulation oflactic acid.

Interval training is the most chal-lenging and yet the most transformingelement in this exercise prescription.One must be medically cleared and ver-ifiably capable of enduring the rigors ofthis physiological stress before under-taking this phase of the exercise pre-scription. Machines such as the VersaClimber, treadmill, elliptical, NordicTrack, Stairmaster, and others offerexcellent options for this type of work.Whichever exercise or exercise machinethat is used for this training, the tech-nique is the same; maximal exertion for10 to 15 seconds followed by resting for

It is recommended that one consume

protein and carbohydrateswithin the first hour

after exercise.

that may arise from a “poor” seatedposture. “Torso training,” frequentlyreferred to as “core training” by fitnessprofessionals, describes the exercisesintended for the midsection of thebody (the body exclusive of the head,neck, and limbs). For our purposes, theauthors separated the torso into threecomponents that confer stability: (1)the shoulders, including the scapu-lothoracic articulation; (2) the abdomi-nal muscles; and (3) the hips, includingall muscles that stabilize the hips instanding or seated position. Table 1.2describes a regimen for training yourtorso effectively and safely.

Strength/Resistance TrainingResistance training will increase

lean metabolically active tissue andincrease total body strength. Selectingexercises can be a complex process as somany choices present themselves to the

Ys, Ts, Ws, Ls In prone position withtorso supported by phys-ioball, make the letterswith your arms by mov-ing from your shoulderblade first.

2x8-15 reps each

Promote scapular stability and preventrounded shoulder posture

Stick crunch In hook lying position,place hands or dowel onmidthigh, arms extended,draw in abdominals,bring chin to chest, holdthis position and try tobring hands or stick overknees.

2x10-15 reps

Promote transverseabdominus, internaloblique, and rectusabdominus strength

Reverse stick crunch In hook lying position,hold hands or a stickstraight above shoulders,draw in abdominals, holdthat position and bringheels to butt, lift hips offground and try to bringknees under the stick.Keep head in contact withthe ground.

2x10-15 reps

Promote transverseabdominus, externaloblique, and rectusabdominus strength

Sit on a physioball withknees flexed at less than90 degrees. Face a wall.Draw in abdominals. Coilto the right. Throw andreceive the ball whilemaintaining torso pos-ture. Repeat to the left.

2x10 reps each side

Promote stability ofthe torso while rotating

Sit on a physioball withknees flexed at less than90 degrees and leftshoulder facing the wall.Draw in abdominals. Coilto the right. Throw andreceive the ball whilemaintaining torso pos-ture. Repeat to the left.

2x10 reps each side

Promote stability ofthe torso while rotating

Table 1.2

TORSO TRAINING

Exercise How to Purpose

Seated medicine ball

Parallel throws

Seated medicine ball

Perpendicular throws

Side bridge,right and left

Lie on right side with elbowdirectly under shoulder andfeet on top of one another.Draw in abdominals. Keep elevated shoulder back.Squeeze underside hip. Liftand hold for 20 to 30s andrepeat on the left side,

2 reps each side

Increase lateral hipstability

“Glute” bridge Lie on your back with heelsonly on ground; knees flexedto 90 degrees. Draw in abdominals by pulling bellybutton to spine. Contractgluteal muscles to lift the hipsoff the ground.

2x10 reps

Seated cablechop

With the rope of a cablemachine set to its high position,sit on a physioball with shoul-der perpendicular to the cable.Grasp rope with both handswhile rotating the shoulders toface the cable. Pull to yourchest, rotate around to faceaway from the cable and pushaway. Repeat on the other side.

2x10 reps each side

Increase rotarystrength and stability

Seated cablelift

Seated one-armcable row

With a handle on cable machineset to its low position, sit on aphysioball with shoulders perpen-dicular to the cable. Rotate shoul-ders and grasp handle. With insideleg and hip, accelerate cable androtate through the torso until thehandle is on the opposite hip.Repeat to the other side.

2x10 reps each side

Exercise How to Purpose

With the rope of a cable machinein its low position, sit on a phys-ioball with shoulder perpendicu-lar to the cable. Grasp rope withboth hands as shoulders rotateto face the cable. Pull to yourchest. Rotate to face away fromthe cable with arm going overthe cable. Press away and up.Repeat to the other side.

2x10 reps each side

Lower bodypull/hip

Dominant exercise

Progression

Upper bodypush

Exerciseprogression

Upper bodyPull

Exerciseprogression

Promote single legstrength and stabilitywithout the risk of lowback injury

Promote appropriatehip extension usingprimarily gluteousmaximus and secon-darily the hamstrings

Promote chest andshoulder strengthwhile enhancing over-all torso and scapularstability

Promote backstrength for scapu-lothoracic and lowback stabilization

1. Split squat rear footelevated

2. Balance squat

1. Double leg bridge fortime

2. Single leg bridge forrepetitions

3. Physioball bridgewith curl

1. Incline pushup feetelevated

2. Alternating incline DBpress

1. Natural grip pull-up/neutral grip pull-down in front

2. One arm, one leg DB rows

Table 1.3

STRENGTH TRAINING

Exercise Progression Purpose

Lower bodypush/knee

Dominant exercise

Progression

Associated with Clinical Dentistry. J Calif DentAssoc 30(2): 139-48, 2002.

7. Boyle M, Adding Functionality to YourProgram. Functional Training For Sports, HumanKinetics: 1-5, 2004.

8. Nachemson, The Lumbar Spine, andOrthopedic Challenge, Spine (1): 59-71, 1976.

9. Mense S, Simons DG, et al, ReflexlyMediated and Postural Muscle Pain. Muscle Pain:Understanding Its Nature, Diagnosis, andTreatment, Lippincot Williams & Wilkins: 131-57,2001.

10. Simons DG, Travell JG, et al, Perpetuationof Trigger Points. Travell & Simons’ Myofascial Painand Dysfunction: The Trigger Point Manual,Williams and Wilkins. Vol. 1: Upper Half of Body:452-4, 1999.

11. Behm DG, Bambury A, et al, Effect onAcute Static Stretching on Force, Balance, ReactionTime, and Movement Time. Med Sci Sports Exerc 8:1397-1402, 2004.

12. Cramer JT, Housh TJ, et al, Acute Effects ofStatic Stretching on Peak Torque in Women. JStrength Cond Res 18(2): 236-41, 2004.

13. Power K, Behm D, et al, An Acute Bout ofStatic Stretching: Effects on Force and JumpingPerformance. Med Sci Sports Exerc 36: 1389-96, 2004.

14. Thacker SB, Gilchrist J, et al, The Impact ofStretching on Sports Injury Risk: A SystematicReview of the Literature. Med Sci Sports Exerc 36(3):371-8, 2004.

15. Ziegenfuss TN, Postworkout Carbohydrateand Protein Supplementation. Strength Cond J 26(3):43-4, 2004.

16. Bosher K, Potteiger JA, et al, Effects ofDifferent Macronutrient Consumption Following aResistance-Training Session on Fat andCarbohydrate Metabolism. J Strength Cond Res18(2): 212-9, 2004.

17. Faigenbaum A, Maximize Recovery. NatStrength Cond Assoc 26(4): 77-8, 2004.

To request a printed copy of this article, pleasecontact / Allan C. Jones, DDS, NSCA-CPT, SkyparkProfessional Building, 23560 Madison St., Suite111, Torrance, CA 90505.

function of the mandible, chronic“poor” working posture of dental healthcare workers may cause painful maladyand dysfunction of the spine. “Good”posture, like a “good” bite, tends not tocreate a biomechanical load that isexcessive and destructive to the relevantmusculoskeletal elements as it places thearticular disks in their most favorableload-bearing position. Analogously,positioning the torso to its most uprightposition is optimal for maintainingspinal health. The muscles of the torsothat function against the force of gravityto elevate the spine to its most uprightextent can be developed with an exer-cise protocol described herein. Theseexercises are a part of the training proto-col for injury prevention in some of theworld’s most elite athletes. They arecomprised of functional movementsthat are performed while seated orstanding with feet firmly grounded andthe abdomen drawn in. This is believedby expert strength and conditioningspecialists to achieve optimal spinal pos-ture during training movements intend-ed to enhance the function of the torso.Through the recruitment of muscles ofthe torso, “good” posture is reinforcedwith all dynamic exercises performed inthis prescription. In the same manner,recruitment of the torso muscles willencourage “good” posture by the dentalhealth care worker while engaged in thepractice of dentistry.

References / 1. Verstegen M, Williams P, TheFoundation: Building Your Pillar of Strength. CorePerformance: the revolutionary workout programto transform your body and your life, Rodale, 27-31, 2004.

2. Finsen L, Christensen H, et al,Musculoskeletal disorders among dentists and vari-ation in dental work. Appl Ergon 29(2): 119-25,1998.

3. Lalumandier JA, McPhee, SD, et al,Musculoskeletal pain: prevalence, prevention, anddifferences among dental office personnel. GenDent 49(2): 160-6, 2001.

4. Marshall E, Duncombe DLM, et al,Musculoskeletal symptoms in New South Walesdentists. Aust Dent J 42(4): 240-6, 1997.

5. Ratzon NZ, Yaros T, et al, Musculoskeletalsymptoms among dentists in relation to work pos-ture. Work 15(3): 153-8, 2000.

6. Rucker LM, Sunell S, Ergonomic Risk Factors

30 to 45 seconds of recovery. Repeat thisprocess six to 10 times. Progress is madeby lengthening the exertion intervals,increasing the number of intervals, orshortening the rest period.

Recovery and Postexercise NutritionThe low-carbohydrate fad does a

great disservice to one’s athleticprogress. For little more than an hourafter intense exercise, muscle tissues aredepleted of glucose and in need ofamino acids for repair. Insulin andinsulin growth factors are essential tothis process as these hormones areessential to their transport across cellmembranes. After exercise, muscle tis-sues are grossly depleted of nutrientsessential to their restoration andenhancement in adapting to exercise.Immediately following exercise, the rateof uptake of amino acids and glucose isenhanced such that protein synthesis is350 percent of normal if postexercisecarbohydrate and amino acid sourcesare optimal.15-17 It is recommended thatone consume protein and carbohy-drates within the first hour after exer-cise. This will enhance muscle develop-ment and recovery.

ConclusionDental health care workers often

attempt to gain access to the oral cavitywith seated posture that is stressful andpotentially harmful to the spine.Especially stressful is that most com-monly observed position that isachieved by leaning forward throughflexion of the lower back with protru-sion of the neck. This posture is addi-tionally made worse by tilting the bodyto one side while rotating the headtoward the patient. Dental health careworkers are well known to suffer painfulmalady of the low back and neckinduced by this “poor” posture. Just as a“poor” bite, chronically endured, maycause painful changes in the temporo-mandibular joint along movement dys-

ABSTRACTDental health care workers are vulnerable

to back and neck pain resulting from poor

occupational posture. While numerous

choices exist for treatment, this article will

provide them with a practical approach to

seeking out appropriate care for this common

malady. The McKenzie treatment approach is

discussed and recommendations for its appli-

cation are presented to provide the reader

with a starting point for treatment. For the

dental health care worker experiencing pain

and dysfunction of the back and/or neck, as

more than half will during their careers, this

article will seek to provide an overview of

potential causes while creating a roadmap for

seeking the most appropriate conservative

“antidote” for their care.

rthopedic research has shownthat 70 percent to 80 percent ofthe population will experiencetransient neck or low back painduring the course of their

lives.1,2 Studies have found that 23 per-cent to 79 percent have symptoms thatpersist or recur.3-6 A majority of dentistsand hygienists have musculoskeletalcomplaints related to the back andneck.7-9 Although dental practicechanged from standing to sitting pos-tures in the mid-1960s, ostensibly todecrease the incidence of back and neckproblems, a decrease in the prevalenceof reported discomfort has not beenobserved.10 Numerous choices exist fortreatment of spinal ailments includingbut not limited to: massage, acupunc-ture, chiropractic, yoga, Rolfing, Pilates,physical therapy, osteopathic, orthope-dics and surgery. While there is not aone-size-fits-all approach to caring forback pain, with the proper training andadvice, the majority of dental healthcare workers with pain can learn to treattheir condition independently.

Classification systems may be a clin-

Getting Your Back Back To Work: Pain Relief — Where to Start?Timothy J. Caruso, PT, MBA, MS, Cert. MDT, and David J. Pleva, PT, MA, Dip. MDT

Guest editor / Timothy J. CarusoPT, MBA, MS, Cert. MDT, is a cer-tified mechanical diagnostic thera-pist, staff physical therapist andchair of the ergonomics commit-tee at Shriners Hospital forChildren in Chicago. He is ownerand president of ChicagolandPerformance Consultants.

Author / David J. Pleva, PT, MA, Dip. MDT, is apracticing physical therapist. He is a diplomate ofthe McKenzie Institute USA, and in private practicein Wood Dale, Ill.

previously limited until all activitieshave returned to normal. For example, apatient may present with low back painalong with referred symptoms into thethigh. Following the performance ofextension exercises, the thigh symptomsare abolished and remain better follow-ing completion of the exercises. Thisdemonstrates mechanically producedpain that responds to the performance ofthe exercise in the correct direction.According to McKenzie, in most cases,the pain one experiences, at least initial-ly, will have a combination of chemicaland mechanical components. He pro-posed three nonspecific mechanical syn-dromes – posture, dysfunction andderangement syndromes, which are nowwidely used in the musculoskeletal careof the spine.18 These three separate syn-dromes can be identified by their uniqueclinical presentations and throughassessment of a specific sequence of load-ing strategies. Each syndrome respondsto repeated and/or sustained end-rangeloading in different ways. Within thesethree syndromes we can identify anddiagnose the vast majority of non-specif-ic spinal problems18.

Postural SyndromePostural pain syndrome is thought

to be due to poor seated or standingposture, which stresses soft tissue struc-tures at their end range of movementwithout any actual pathology. Thispoor posture position, if held over time,tends to decrease the blood supply tothe area and overloads the supportingsoft tissue structures, thus causing backpain. The hallmark of postural syn-drome is that once the poor posture iscorrected and the end-range stress isremoved, the pain resolves. McKenziegives the example of stressing one’s fin-ger by pushing it into an “over extend-ed” position toward the wrist and hold-ing it (Figures 1 and 2). As this positionis held, pain begins to develop andtends to worsen with time. Once the

advises that self-treatment should notbe performed by individuals with thefollowing complaints:17

■ A first episode of back pain thatpersists for more than 10 days

■ Bowel and bladder symptomsassociated with back pain

■ Back or neck pain caused bytrauma

■ Leg pain with symptoms belowthe knee including numbness, tinglingor weakness

■ Malaise■ Pain that disturbs sleepIn the event of any of these symp-

toms, treatment must be administeredby a qualified medical professional.17

ically relevant way to characterize differ-ent sub-groups of back and neck painand thereby to offer pain managementstrategies while excluding serious spinalpathology.11-14 This article will present aclassification system for the treatment ofspinal pain created by physical therapistRobin McKenzie. According toMcKenzie, the majority of low back painappears to be mechanical in nature, hav-ing been initiated by excessive mechan-ical forces. Such an event may resultfrom bending down to pick somethingup, or getting items out of a car trunkafter prolonged sitting.15 Mechanicalpain is thought to involve injury to softtissue. There is no single reason formechanical low back pain, but thegamut of possible causes is vast consid-ering the number of structures in thespine that have a nerve supply and aretherefore capable of producing pain.16

The benefit of the McKenzieapproach lies in identifying the move-ment “preference” of an individual withback or neck pain in order to alleviatethe symptoms. The approach has hadfavorable clinical acceptance amongtherapists and patients and offers a con-servative alternative to treating backand neck pain. The article will providean overview of the McKenzie approach,in order to provide the reader withback/neck pain basic information todetermine the most appropriate courseof action for conservative treatment oftheir disorder.

The McKenzie physical examinationassesses four areas of relevance: 1) sit-ting and standing postures; 2) range ofmovement; 3) neurological testingassessing strength, sensation, reflexes,and dural status; and 4) directionalmovement preference testing. Therepeated movement testing is a series ofdynamic movements and loadingstrategies that attempt to determine adirectional preference. This preferenceis determined by assessing the effect ofthe movements on pain. McKenzie

The treatment for mechanical pain involves identifying the correct direction to move the

spine and alleviating thesymptoms while limiting

movements and activities that aggravate the

symptoms for a period of time.

In the McKenzie assessment scheme,mechanical pain is characterized by: 1)pain that can be constant or intermit-tent, 2) limited range of motion of theback or neck that improves as symptomsdiminish, and 3) movements in certain“incorrect,” or exacerbating directionsincreases the pain while simultaneouslydecreasing range of motion in the oppo-site direction. The treatment formechanical pain involves identifyingthe correct direction to move the spineand alleviating the symptoms while lim-iting movements and activities thataggravate the symptoms for a period oftime. As symptoms improve, activitiesare reintroduced that may have been

increase of unprotected movement ofthe lumbar spine and thought to placeit at greater risk of injury. He went onto say that sustaining a flexed posturealso reduces the resistance of the spinalligaments. This reduction in resistancemakes the spinal support structuresweaker and thus, increases the chanceof injury. In animal studies, it wasfound that the amount of time to causethe creep phenomenon to occur was aslittle as 20 minutes. Recovery tookmore than 24 hours and never returnedto the original resting tissue length. Ithas been theorized that the combina-tion of diminished muscle activity,combined with ligamentous creep may,in fact, lead to musculoskeletal cumula-tive trauma disorders over time as theamount of soft tissue damage exceedsthe rate of repair and recovery inhumans. It may also explain why indi-viduals may experience ongoing orchronic low back pain over time withno apparent pathological conditionwith radiographic and other specialstudies.19 Clinically, individuals withback pain may seek treatments thatonly address their symptoms and donot get at the cause of the problem.Having a one-hour massage may allevi-ate the discomfort for that particularday, while returning to the sameslouched seated posture the next daycauses a return of the symptoms.

McKenzie theorized that the behav-ior of the lumbar discs mimics that of asoap cake between one’s palms, whereinsqueezing the palms backwards, the soapmoves forward and squeezing the fingerstogether, the soap moves toward thewrist. This being the case, it can be seenthat compressing the anterior aspect ofthe disc during forward flexion of thespine will cause the nucleus to migrateposteriorly and stretches the posteriorannulus.20-23 With spinal flexion, thevertebral canal is lengthened and thisplaces tension on the spinal cord andperipheral nervous tissues. Flexion caus-

coming to light in the literature.Recently published studies have con-firmed that slouched sitting causes thespinal musculature to diminish itsactivity and place increasing stress onthe posterior ligamentous structures ofthe spine resulting in increased lengthor “creep.”19 Bogduk defines creep as aconstant force, that if left applied for aprolonged period to collagen tissue willresult in further movement or length ofthe ligamentous tissue.16 This creepphenomenon when combined withdiminished muscular activity isthought to result in an imperceptible

position is released, the pain subsides.In many cases the treatment is just assimple as that, once again enforcingwhat our mothers always told us, to “situp straight.”

In the case of the dental health careworker, poor posture is defined as for-ward head with rounded shoulders,flexed thoracic and lumbar spine, withthe pelvis posteriorly tilted; also calledslouching (Figure 3). Whether due totraining, habit, or fatigue, slouchedposture appears to be a regular part ofthe working day in the dental clinic.The ill-effects of poor seated posture are

Figure 1.Overex-tending a finger.

Figure3b.Slouchingposture.

Figure3a.Slouchingposture.

Figure2. Overex-tending a finger.

PAIN RELIEF

stress, and fatigue in the working day, itis easy to see how this scenario canbecome problematic. For dental healthcare workers, good posture is a keyingredient to successful practice. For thepurpose of clarity, we will define goodposture as that position which placesthe ear over the shoulder, the shoulderover the hip, while the legs are support-ed and parallel or slightly inclined(knees lower than the hips approxi-mately 5 degrees) with the feet support-ed on the floor (Figure 4). In a recentarticle by Pynt et al., the authors con-cluded that lordosed seated posture, reg-ularly interspersed with movement, isthe optimal seated posture and assists inmaintaining lumbar postural healthand preventing low back pain.33

Balancing the spine while seated pro-vides a more stable base from which towork with less stress.

McKenzie promotes the use of a“lumbar roll” in order to re-establishand support the natural lordosis of thespine and a cervical roll for sleeping tosupport the neck. He theorized that oneof the main culprits causing low backpain is the loss of this lordosis in thelumbar and cervical spine, combinedwith excessive flexion of the spinethroughout the day. In speaking withthe average dental practitioner, theyreport not using the back of the opera-tor chair regularly. In fact, some reportnot adjusting the chair prior to begin-ning their treatments. As a simple pre-ventive strategy, adjusting one’s chairprior to beginning work may counteractthe ill-effects of poor seated posture. Byadjusting the chair and oneself in agood, balanced, seated posture wherethe spine has assumed its naturalcurves, surviving the stresses of thework day becomes much easier. Withthe spine balanced, the head is over theshoulders and the natural spinal curva-ture is returned (Figures 5 and 6). Forback pain of postural origin, the act ofsitting up straight consistently through-

ward flexed posture greater than 50 per-cent of the time that they are workingwith their patients.28 When a flexed pos-ture is maintained, the stress of holdingthis position will fatigue the posteriorannulus of the disc, overcoming itsstrength. If overstretching of the annulusexceeds 4 percent, irreversible damagewill result.29 As dental health care work-ers, sitting in this relatively poor positionfor extended periods of time is a naturalpart of the working day and may, in fact,lead to debilitating spinal disorders.

When back pain sufferers are evalu-ated, measurement of their backstrength has been found to be dimin-ished.30-32 The question of whether theweakness is a result of the back pain, orthe back pain is a result of the weaknessremains to be answered. There is, how-ever, evidence to show that isolatedstrengthening of the back extensormuscles had a positive effect on com-plaints of low back pain.30-32 Clinically,we often see significant weakness of theback extensor and posterior scapularmusculature with an associated tight-ness of the anterior chest and shouldermusculature in individuals having backand neck pain. Additionally, we findweak abdominal musculature and tight-ness of the suboccipital soft tissue struc-tures. If we were to combine the effectsof weakness with limited mobility,

es an increase in intradiscal pressure ofup to 80 percent.24 Conversely, extensionof the spine compresses the posterioraspect of the disc moving the nucleusanteriorly.19-23 The intradiscal pressure isdecreased up to 35 percent with exten-sion.24 Andersson identified changes inintradiscal pressure with changes in pos-ture in an historical publication.Slouched seated posture with weightedupper extremities demonstrated thehighest intradiscal pressure of all pos-tures measured. He found that in theunsupported sitting position, the highestlevel of myoelectric activity was in ante-rior sitting and the lowest in posteriorsitting. Both myoelectric activity anddisc pressure were found to decreasewhen the back was supported, particular-ly as the lumbar support was increasedand armrests were used.25 Anatomically,it is known that the posterolateral aspectof the disc is the weakest point of thestructure with less radius, not as firmlyattached to the vertebral end-plate, andnot covered by the posterior longitudinalligament.26,27 If the “creep” phenome-non evidenced above holds true, recov-ery takes up to 24 hours irrespective ofthe load. Dentists and hygienists havebeen observed to assume a notably for-

Figure4. Goodposture. Note the ear,shoulder andhip are inline.

By adjusting the chair and oneself

in a good, balanced, seated posture where the spine has assumed

its natural curves, surviving the stresses

of the work day becomesmuch easier.

■ Several episodes of back/neckpain have been experienced over thepast few years

As a general rule to follow for theMcKenzie exercises: If pain does not cen-tralize, decrease, or otherwise improvewith the exercises; if pain was gettingworse before starting the exercises anddoes not improve after the first two days;or if symptoms worsen following perfor-mance of the exercises and remain worse,seek advice from a medical doctor as thisprogram may not be appropriate.18

As a first step, correct poor seatedposture by way of a technique called“slouch-overcorrect.” In this procedure,one assumes an extreme, slouched posi-tion. From this position one “rises” intoan exaggerated, lordotic posture(Figures 7 and 8). One can repeat thisprocedure 10 times and then “reposi-tion” oneself back into a good seatedposture with appropriate lumbar lordo-sis. This can be repeated throughout theworking day as a simple chairside exer-cise. Repeat the process eight to 10 timesthroughout the day. After completion ofthe slouch-overcorrect maneuver, makesure to resume the good seated posture.This is the key to ongoing success.

■ Periods in the day when you haveno pain

■ Pain is confined to areas abovethe knee

■ Symptoms are generally worsewith sitting for prolonged periods andbetter with standing or walking

■ Symptoms are worse with bend-ing or stooping and with inactivity

■ If symptoms are better with lyingface down

out the working day and while driving,alleviates symptoms entirely.

As a dental health care practitioner,tuning into good posture, while addinga few general chairside exercises, mayease the day-to-day stiffness and dis-comfort experienced during a typicalworking day. While there is sparse sup-port in the dental literature, at least onepublication has identified the benefitsof exercises performed by video displayunit operators.34,35 It was found thatexercises performed while working atthe video display resulted in short-termdecreases in both musculoskeletal dis-comfort and postural immobility.36

Another study found limited evidencebased on randomized trials and epi-demiological studies that exercises tostrengthen back or abdominal musclesand to improve overall fitness, candecrease the incidence and duration oflow back pain episodes.37 So, wheredoes one start? Family practitioner,orthopedist, chiropractor, physical ther-apist, massage, acupuncture? Howabout doing it yourself? Try theMcKenzie approach.

McKenzie recommends self-treat-ment exercises under the followingconditions:15

Figure 5. A balanced spine. Figure 6. A balanced spine with back support.

Figure 7.An extremeslouched posture.

Figure 8.An exaggerat-ed lordoticposture.

PAIN RELIEF

lasting effect of imperfect healing.Dysfunctions are time dependent andtake at least six to eight weeks after theonset of injury to develop.18 The painfrom dysfunction is intermittent innature and felt locally, in the neck orlow back regions without extremitysymptoms. The symptoms from dys-functions are only produced when theshortened tissues are placed on stretch,and cease when the loading has stoppedor decreased. Additionally, movementof the spine will be limited in the direc-tion of the pain. The pain one feelsfrom dysfunction syndrome will persistuntil full range of motion of the spinalsegments has been recovered, andremodeling of the affected soft tissuestructures has been achieved.

In order to remodel a dysfunction,the soft tissues need to be stressed regu-larly throughout the day in order toreturn them to their normal restinglength and full function. In dysfunctionsyndromes, the direction of movementin which this syndrome is treated is theone that causes discomfort. An initialpain that wears off gradually as you com-plete more repetitions is appropriate,whereas pain that is increasing with eachrepetition or moving distally is not, andone should stop the exercise. For exam-ple, if flexing forward causes discomfortconfined to the back, without any symp-toms into the buttocks or extremities,and improves as you increase the num-ber of repetitions, then flexion in lying isthe exercise of choice (Figure 11).Flexion in lying is performed while in asupine, hook lying position with theknees bent and the feet flat on the floor.Gently bring the knees up toward thechest until a feeling of pull or stretch isfelt in the back. Repeat these exercises insets of eight to 10 repetitions until thefeeling of stretch subsides or until theknees reach the chest easily with no dis-comfort. Once the knees are brought tothe chest easily, the progression is toflexion in sitting and standing.

up the suboccipital space. A feeling ofpulling or pressure in the cervical regionat the end range of movement with nopain is normal. Retractions can be per-formed eight to 10 repetitions through-out the working day. The beauty of thepostural syndrome is that the exercisesto relieve it fit very neatly into the workday.

Even though the postural syndromeis an entity in its own, poor posture alsoplays a significant role in the next twosyndromes described by McKenzie. Thesitting posture of individuals identifiedwith dysfunctions and derangementsmust also be addressed in order to effec-tively resolve their conditions.

Dysfunction SyndromeMcKenzie theorized that the dys-

function syndrome is thought to occurwhen structural changes affect the jointcapsules or adjoining soft tissues. Pain isexperienced when the end range ofmovement is attained in one or moredirections. Analogous to the dysfunc-tion syndrome is a Colle’s fracture ofthe wrist. Once the cast is removed fromthe wrist, movement of the wrist causesthe shortened soft tissues to stretch andproduce pain. As movement improves,pain decreases. Dysfunctions can bedescribed in a variety of ways such asshortened, contracted, adhered, scarred,or fibrosed. Dysfunctions result frompoor posture, trauma or surgery and the

Extension in standing is anotherexercise used for counteracting poorpostural habits. It requires one to standwith feet apart, shoulder width; placinghands in the small of your back or at thetop of your buttocks; bending yourtrunk backward as far as possible whilekeeping the knees straight, and usingthe hands as a fulcrum (Figure 9).Repeat the process eight to 10 repeti-tions. This exercise can also be repeatedfour to six times throughout the day oras often as needed to counteract thestresses of forward flexion.

In the case of neck pain of posturalorigin, good seated posture is the firstactivity to master. One can choose fromseveral other movements to perform.Included are neck flexion, extension,and retraction. Since cervical flexionand extension are quite common,retraction will be discussed. While sit-ting up straight, retraction consists ofmoving the head posteriorly on theneck and shoulders as if someone ispushing your face gently backward(Figure 10). The movement itselfreverses the cervical lordosis and opens

Figure 9.Extension instanding.

Figure 10.Cervical retrac-tion.

ments and is characterized by the iden-tification of a movement that reducesthe distal symptoms with a concomi-tant increase in local neck or back pain.With this decrease in symptoms, onewill notice a dramatic, simultaneousincrease in range of motion of the cer-vical or lumbar spine. The oppositeoccurs when a movement worsenssymptoms or peripheralizes them intothe extremities. Centralization includesthe restoration of full movement withreduction or abolishment of symp-toms.18 For those facing a possible sur-gical intervention, this represents a rea-sonable treatment to try prior to under-going more invasive treatments.

Clinically, the majority of patientswith a derangement respond to theextension principle of movement, how-ever the treatment strategy for derange-ments is based strictly on identifying adirectional preference. In other words,directional preference is determined byidentifying the direction that decreases,abolishes or centralizes the symptomswhile simultaneously increasing the lostrange of motion of the spine. Donelsonet al. reported that directional preferenceis guided by centralization.38 Long-termcorrection of this condition is alsodependent upon eliminating poor pos-tures, whether sitting, standing or lying,which can be a contributing or underly-ing causative factor in the persistence ofthis condition. Research has shown cen-tralization to be a reliable indicator indetermining which patients will have agood prognosis.39-42 Eighty-seven percentof the patients who centralized had goodor excellent outcomes when comparedto those who did not centralize.38 In thechronic back pain population, 47 per-cent centralized and of the group thatdid centralize, 68 percent returned towork versus 52 percent of the noncen-tralizing group.42 Donelson et al. report-ed that centralization most often occurswith extension.43 In the case of the “cen-

Derangement SyndromeThe second condition McKenzie

described is the spinal derangementsyndrome. As previously mentioned,self-treatment for individuals withderangements is ill-advised and poten-tially dangerous. This discussion ofderangement syndrome is for informa-tional purposes only in order to pro-vide readers with a conservative alter-native to be considered prior to under-going a potential surgical procedure forpain of discogenic origin. According toMcKenzie, spinal derangements are themost commonly seen clinical condi-tion.18 A displacement or disturbancein the normal resting position of aspinal motion segment is the cause ofderangement. The disruption will bepain provoking until it is reduced. Inregard to the spine, this disruption canbe anywhere in the motion segment,which is defined as the vertebrae aboveand the vertebrae below including thedisc and soft tissues associated withthis joint. This disruption can lead to aloss of one or more movements in thecervical or lumbar regions with associ-ated pain.

Derangements have varying clinicalpresentations, but usually respond tospecific loading strategies. Symptomscan be felt locally in the spine, distallyin the extremities or both. The hall-mark of treating the derangement syn-drome is called centralization.Centralization only occurs in derange-

In the cervical spine, if extension ofthe neck is limited and a feeling ofpulling, stretching or pressure confinedto the neck is felt with no other symp-toms; extension in sitting is the exerciseof choice (Figure 12). Extension in sit-ting consists of raising the chin upwardwhile extending the neck. The head isextended back until a feeling of pulling,stretching or pressure in the neck is felt.Return to the starting position, rest andrepeat eight to 10 times throughout theday. As the exercise progresses, range ofmovement will tend to improve withless feeling of pulling or pressure.

Several points of caution need to bemade. It is known that the spinal discshydrate during the night and that exces-sive flexion early in the morning mayplace individuals at risk for injury.18

Snook et al. found that controlling lum-bar spine flexion in the early morning wasan effective form of self-care with poten-tial for reducing nonspecific low backpain.20 McKenzie recommended that flex-ion exercises always be followed by exten-sion exercises, either extension in stand-ing or lying (Figure 13). He theorized thatperforming extension after flexion couldrestore any distortion caused by flexionexercises. In the cervical spine, knownpathology such as arthritic conditions,abnormal signs or symptoms, such asdizziness, disorientation or confusionwith performing extension of the cervicalspine is an absolute indication to stop andseek medical advice.

Figure12.Extension ofthe neck.

Figure 11. Flexion in lying.

PAIN RELIEF

Continued on Page 155

leg pain significantly reduced versus thekyphotic group.39 When experiencingsymptoms consistent with the derange-ment or dysfunction syndromes, seekingprofessional guidance by an experiencedpractitioner initially during your carewill assure a successful recovery. Havinga complete McKenzie evaluation mayallow one to more accurately directone’s own care and the return to pain-free, daily activities in a timely manner.With the McKenzie system, individualsbeyond the scope of conservative treat-ment can often be identified within areasonable number of visits (three tosix), rather than an extended period oftime. If successful conservative interven-tion cannot be achieved, individuals canbe referred to the appropriate practition-er with a written report in order to makean educated decision about more inva-sive treatment options. In the caseswhere surgery is indicated, returning toa McKenzie-trained practitioner follow-ing a surgical procedure can facilitate areturn to pain-free function.

PreventionPrevention as a result of exercise has

not been strongly supported in the lit-erature, however; there is ample evi-dence that healthier, stronger individu-als are at significantly less risk ofhealth-related maladies including mus-culoskeletal disorders. One study hassuggested that good dynamic trunkextension performance may protectagainst back-related permanent workdisability.44 Weakness of the spinal

tralization phenomenon” described byMcKenzie, the pain can be a bit unnerv-ing to individuals who may report feel-ing a worsening of their symptoms whileexperiencing it. A thorough explanationof symptom identification, understand-ing of potential pain behavior and loca-tion allows individuals to monitor andcontrol their pain. Individuals must beassured that increasing central low backpain is desirable if distal, radicular symp-toms in the arm or the leg are resolvingor abolished. Once a treatment regimenhas been established, ongoing posturaleducation and awareness is a key ingre-dient to a successful treatment program.

Derangements can be summed up asa condition that is inconsistent andrapidly changing.11,18 To support theconcept of sitting in lordosis with thederangement population, Williams tookpatients with back and referred pain anddivided them into two groups. Onegroup was to sit in lordosis, and theother group was instructed to sit inkyphosis for 24 to 48 hours. The groupthat sat in lordosis had their back and

Figure13a.Extension instanding.

musculature in individuals with lowback pain has been identified in the lit-erature, and general poor health hasbeen associated with back/neck pain inolder individuals.45 Spinal extensormusculature has been shown to havelarge potential for strength increase.44

Medx is one particular treatment strat-egy utilizing a frame which specificallyisolates the lumbar spine in order tostrengthen back extensor musculatureand has met with good results.30 Lastly,the benefit of good working posturecannot be overstated. Poor seated pos-ture may be a result of the combina-tion of equipment choices and train-ing.46 (See Dr. Allan Jones article onPage 137.) Marklin noted that poorseated posture is quite prevalentamong dentists and hygienists.28

While the cause of poor seated postureis often difficult to pinpoint, severaltheories have been proposed includingequipment selection, muscle weaknessand debilitation, training techniques,work habits, workload, years in prac-tice or some combination of these fac-tors. Suffice to say, there is not onesimple solution to this multifactorialproblem. The addition of exercisealone to the dental health care work-er’s daily routine is only part of a com-plete solution. Several exercises havebeen recommended, however having aspecific program customized for one’sspecific needs is the most appropriateapproach to beginning an exercise pro-gram, particularly if there is underlyingpathology. Having a complete muscu-loskeletal evaluation by a trained prac-titioner is a great place to start.

Choosing an ergonomicallydesigned workspace and properly fit-ting equipment may further reduce therisk associated with some of thesecausative factors. Denis et al. foundthat EMG activity of dental hygienists’upper trapezius musculature was signif-icantly reduced with the elbows sup-ported by armrests on the operator

Figure 13b. Extension in lying.

Continued from Page 152

SYNDROME SYMPTOMS STRENGTH SPINAL TREATMENTRANGE OF MOTION

Posture Local, Intermittent +/- weakness of trunk No limitation Postural correctionGeneral strengthening

Dysfunction Local, Intermittent +/- weakness of trunk Limited, painful End range stretch inat end range direction of pain throughout

the dayGeneral strengthening

Derangement Local/distal/both +/- weakness of trunk/ Limited, painful during Rule out serious pathologyRadicular pain extremities range of movement with physician.Possible sensory and/or at end range Determine directional changes, motor deficits preference underbowel/bladder symptoms trained practitioner.

Exercises performedthroughout the day Centralization

Table 1

stools during the working day.47

Reducing this type of stress is one partof the resolution. Looking at the layoutof the clinic is a good place to start andanalyzing the specifics of your dentalpractice. Answering the following ques-tions may be informative:

■ Is scheduling helping or hinder-ing the work flow?

■ Is needed equipment within easyreach while working with patients?

■ Can you get close to the patient?Do you have them move to accommo-date your needs?

■ How is the lighting in the opera-tory? Do you use magnification? Doesit help?

■ Are you using fitted gloves of theappropriate size?

■ Is your chair adjustable? Is itcomfortable? Does it provide you thesupport to assume a good seated pos-ture?

■ Have you had your postureobserved or have you observed othersin your office? Are you able to take asmall break between patients to per-form a few simple exercises?

■ Are you stressed during theday? Have you had to modify your

work hours/techniques due to discom-fort or pain?

■ Take a picture of your seatedwork posture. What does it look like?

Being aware of the things we cancontrol is extremely important. Theconcept of caring for our most impor-tant instrument, our body, is invalu-able. Becoming aware of our aches,pains and general health is a vitalpart of attaining and maintaining apain-free life. For years, dental healthcare workers have been constrainedby the limitations of their own workenvironment and have paid the pricephysically. Equipment that does notwork properly, adjust properly or lim-its lighting and visibility, along withincreasing workloads, and poorergonomic awareness and training,may all play a role. Fitting the workerto the work can have significantphysical costs. Working with discom-fort can only negatively impact theprofitability of a dental practice.Likewise, career satisfaction, fromquality of work to patient satisfac-tion, can also be greatly affected. It isoften advantageous to have an objec-tive third party perform a practice

analysis to determine if the workenvironment is to blame for muscu-loskeletal aches and pains.

ConclusionGiven the numerous exercise rou-

tines and recommendations for treat-ing back pain along with the countlesshealth care practitioners available toseek advice from, it’s always an advan-tage to be able to help yourself. There isan old proverb that goes something likethis: “Feeding an individual a fish takescare of their hunger, while teachingthem to fish allows them to survive forlife.” The benefit of having a custom-tailored home program based on yourparticular needs will allow you to beproactive with your back/neck pain. Inmost cases, “nipping it in the bud”before an annoying pain becomes morechronic and self-limiting is an obviousadvantage.

The authors have attempted tosummarize the characteristic symptomsof mechanical back/neck pain, alongwith providing a logical approach forseeking the most appropriate conserva-tive care. As an ongoing treatmentstrategy, the McKenzie approach fits

PAIN RELIEF

NONSPECIFIC MECHANICAL SYNDROMES

with Chronic Low Back Pain. J Spinal Dis 5: 175-82,1992.

32. Leggett S, et al, Restorative Exercise forClinical Low Back Pain: A Prospective Two CenterStudy with One-Year Follow-up, Spine 24: 889-98,1999.

33. Pynt J, et al, Seeking the Optimal Posture ofthe Seated Lumbar Spine. Physiotherapy Theory andPractice 17: 5-21, 2001.

34. Shugars D, Managing Dentistry’s PhysicalStresses: Chair Side Exercises for Dentists & DentalAuxiliaries. NC Dent Rev 2(2), 1984.

35. Valachi B, Valachi K, PreventingMusculoskeletal Disorders in Clinical Dentistry:Strategies to Address Mechanisms Leading toMusculoskeletal Disorders. J Am Dent Assoc 134,December 2003.

36. Fenety A, Short-Term Effects ofWorkstation Exercises on MusculoskeletalDiscomfort and Postural Changes in Seated VideoDisplay Unit Workers. Physical Therapy (82)6:578-89, 2002

37. Pollock M, et al, Effect of ResistanceTraining on Lumbar Extension Strength. Am J SportsMed 17(5), 1999.

38. Donelson R, Grant W, et al, Pain Responseto Sagittal End-Range Spinal Motion: A Prospective,Randomized Multi-Centered Trial, Spine 16(6S):S206-S12, 1991.

39. Williams MM, Hawley JA, et al, AComparison of the Effects of Two Sitting Postureson Back and Referred Pain, Spine 16(10): 1185-91,1991.

40. Karas R, McIntosh G, et al, TheRelationship between Non-organic Signs andCentralization of Symptoms in the Prediction ofReturn to Work for Patients with Low Back Pain.Physical Therapy 77(4): 354-60, 1997.

41. Long A. The centralization phenomenon.Its usefulness as a predictor of outcome in conserv-ative treatment of chronic low back pain, Spine20(23): 2513-21, 1995.

42. Sufka A, Hauger B, et al, Centralization oflow back pain and perceived functional outcome.JOSPT 27: 205-12, 1998.

43. Donelson R, Murphy K, Silva G.Centralization phenomenon: its usefulness in eval-uating and treating referred pain. Spine 15(3): 211-3, 1990.

44. Rissanen A. et al, Does Good TrunkExtensor Performance Protect Against Back RelatedWork Disability? J Rehab Med 34: 62-6, 2002.

45. Hartvigsen J, et al, Back and Neck Pain MayExhibit Many Common Features in Old Age: APopulation-Based Study of 4486 Danish Twins 70-102 Years of Age. Spine 29: 576-80, 2004.

46. Jones A, et al, Functional Training forDentistry: An Exercise Prescription for DentalHealthcare Personnel. In press.

47. Denis M, et al, Reducing MusculoskeletalStrain with the Use of Movable Elbow Supports in aDental Clinic. Proceedings Article Self-ACEConference — Ergonomics for Changing Work,2001.

To request a printed copy of this article, pleasecontact / Timothy J. Caruso, PT, MBA, MS, Cert.MDT, P.O. Box 143, Itasca, Ill., 60143-0143.

Rotation, and Sitting at Work Risk Factors for NeckPain? Results of a Prospective Cohort Study.Occupational Environmental Medicine 58: 200-7,2001.

10. Rundcrantz BL, Pain and Discomfort in theMusculoskeletal System Among Dentists. LundSweden: Department of Physical Therapy,University of Lund, 3-59, 1991.

11. McKenzie R, The Lumbar Spine: MechanicalDiagnosis and Therapy. Spinal Publications, 1981.

12. McKenzie R, The Cervical and ThoracicSpine: Mechanical Diagnosis and Treatment. SpinalPublications, 1990.

13. Spitzer WO, LeBlanc FE, et al, ScientificApproach to the Activity Assessment andManagement of Activity-Related Spinal Disorders.Spine 12(7): S1-55. 1987

14. Delitto A, Erhard RE, Bowling RW, ATreatment-Based Classification Approach to LowBack Syndrome: Identifying and Staging Patientsfor Conservative Treatment. Physical Therapy 75:470-89, 1995.

15. Nachemson A, Jonsson E, Jonsson editors.Neck and Back Pain. Lippincott, Williams andWilkins, Philadelphia, 2000.

16. Bogduk N, Twoomey L, Clinical Anatomy ofthe LumbarSpine. Churchill Livingstone, New York,1987.

17. McKenzie R, Kubey C, Seven Steps to a Pain-Free Life: How to Rapidly Relieve Back and Neck Pain.Plume/Penguin Publishing, New York, 2001.

18. McKenzie R, May S, The Lumbar Spine:Mechanical Diagnosis and Therapy 2nd editionSpinal Publications, 2003.

19. Solomonow M, et al, Biomechanics andElectromyography of a Common Idiopathic LowBack Disorder, Spine 28(12): 1235-48. 2003.

20. Snook SH, et al, The Reduction of ChronicNon-specific Low Back Pain through Control ofEarly Morning Lumbar Flexion, Spine 23: 2601-7,1998.

21. Shah JS, Hampson W, Jayson M, TheDistribution of Surface Strain in the CadavericLumbar Spine. J Bone Joint Surg 60B: 246-51, 1978.

22. Sheppard J, Rand C, Knight G, et al,Patterns of Internal Disc Dynamic, Cadaver MotionStudies. Orthopedic Transcripts 14: 321, 1990.

23. Sheppard J, In vitro study of segmentalmotion in the lumbar spine. J Bone Joint Surg77B(Suppl 2): 161, 1995

24. Edmondston SJ, Song S, MRI Evaluation ofLumbar Spine Flexion and Extension inAsymptomatic Individuals. Man Therapy 5: 158-64,2000.

25. Andersson BJ, et al, The sitting posture: Anelectromyographic and discometric study. OrthopedClin N Am, 6(1): 105-20, 1975.

26. Adams MA, Biomechanics of the LumbarMotion Segment. In Grieve’s Modern ManualTherapy. (2nd Ed). Eds. Boyling JD, Palastnaga N.Churchill Livingstone, Edinburgh, 1994.

27. Edwards WT, Ordway MS, Peak StressesObserved in the Posterior Annulus. Spine 26: 1753-9, 2001.

28. Marklin R., Cherney K, Working Posturesof Dentists and Dental Hygienists, in press.

29. Hickey DS, Hukins DWL, Relation betweenthe Structure of the Annulus Fibrosis and theFunction and Failure of the Intervertebral disc.Spine 5(2): 106, 1980.

30. Sini M, MEDX Clinical Data, Kerlin-Jobe/HealthSouth Clinic, Los Angeles, California.

31. Shirado O, et al, Trunk Muscle Strengthduring Concentric and Eccentric Contraction: AComparison between Healthy Subjects in Patients

very nicely into a regular workout rou-tine and can be advanced to include acomplete strength and conditioningprogram. McKenzie creates a frameworkwithin which one can perform all oftheir daily activities as well as theirnightly activities safely, without pain.The ultimate success of the programcombines the expertise of the trainedhealth care practitioner including pos-tural awareness, compliance of thepatient and his/her self-treatmentstrategies. Making a conscious effort toinclude these components into dailyand nightly activities will generallyassure a much greater level of success. Ingeneral, being “tuned in” to how youfeel will make a significant difference inyour life, your staff, and in the lives ofyour patients. (Table 1).

Footnote: It is strongly encouragedyou seek the advice of a trained healthcare provider when experiencing lowback or neck pain prior to beginningany type of exercise program to rule outserious pathology. If experiencingsymptoms consistent with dysfunctionor derangement syndromes it is advisedto have these evaluated under the guid-ance of a trained professional.

References / 1. Spratt KF, Lehmann TR, et al, ANew Approach to the Low Back PhysicalExamination: Behavioral Assessment of MechanicalSigns. Spine 15: 96-102, 1990.

2. Kelsey JL, White AA, Epidemiology andImpact of Low Back Pain. Spine 5: 133-42, 1980.

3. Toroptsova N, Benevolenskaya L, et al,“Cross-Sectional” Study of Low Back Pain amongWorkers at an Industrial Enterprise in Russia. Spine20: 328-32, 1995.

4. Croft PR, Macfarlane GJ, et al, Outcome oflow back pain in general practice: a prospectivestudy. British Med J 316: 1356-9, 1998.

5. Carey TS, Garrett JM, et al, Recurrence andcare seeking after acute back pain. Results of a LongTerm Follow-up Study. Medical Care 37: 157-64,1999.

6. van den Hoogen, Koes BW, et al, On theCourse of Low Back Pain in General Practice. A one-year follow up study. Ann Rheumatol Disab 57: 13-9,1998.

7. Oberg T. et al, Musculoskeletal Complaintsin Dental Hygiene: A Survey from a SwedishCountry. J Dent Hyg 67(5): 257-61, 1993.

8. Murphy D. editor, Ergonomics and the DentalCare Worker. American Public Association, 1998.

9. Ariens, GAM, et al, Are Neck Flexion, Neck

director at the Boston-based Institute forHealthcare Improvement, concurred.“We’ve seen it work in every kind of clinicimaginable,” she beamed. The AmericanAcademy of Family Physicians and the U.S.Department of Veterans Affairs have alsoadopted open access as their goal.

Open access is an electrifying idea, par-ticularly as a recent survey in 15 cities re-ports the average wait for a cardiology examis 19 days. The cooling heels period for adermatology appointment is 24 days, and23 days for an obstetrics-gynecology exam.

The changeover toopen access isn’t

orty-three year-old Dr. Gordon Moore ofRochester, N.Y., has had an epiphany. Ei-ther that or he is embroiled in the greatestmedical hoo-ha since George Hull perpe-trated the Cardiff Giant shenanigan in1869. Hull, you may recall, sculpted a slabof gypsum into an antediluvian giant 10-feet tall with 21-inch feet. It was secretlyburied on a remote farm in upstate NewYork and “discovered” later by workerswhile ostensibly digging a well. A gulliblepublic lined up by the hundreds to view thefake at 50 cents a look. Their acceptance ofthe validity of the hoax was based on theirdesire to believe it, a faith shared years laterby UFO devotees.

This same public, older, butnot necessarily wiser, is aboutto be tested again. The med-ical profession with its sensi-tive fingers on the public’spulse has become increas-ing aware of the vast dis-satisfaction engendered byHMOs, long waits for ap-pointments and even longerones in reception rooms. Ac-cording to a dispatch fromthe Associated Press, Dr.Moore is one of agrowing group ofdoctors nationwidewho have adopted theconcept of same-day ser-vice. The idea, AP reported,is that scheduling patientsimmediately for evenroutine physicals willkeep them healthier andhappier, while at the sametime saving them money inthe long run. This is knownin the industry as “open ac-cess.” Marie Schall, a training

Dr. Bob

Waiting Room Blues

fThe one-on-onetime with your

personal healthprovider is

variouslyestimated to be

between 45seconds and five

minutes,comparable to

the quality timereceived atAlbertson’s

checkout line.

Robert E. Horseman, DDS

Continued on Page 169

Meanwhile, if you are ever findyourself in Cooperstown, N.Y., drop bythe Farmer’s Museum where, for a merepittance, you may have same-day view-ing of the Cardiff Giant, on display as“America’s Greatest Hoax.” Until now,anyway.

exactly a piece of cake. Kurt Mosley ofMerritt, Hawkins & Associates, a na-tional firm that recruits medical work-ers, warned: “You have to get rid of thebacklog first. You have to stop long-term scheduling cold turkey. Doctorsaren’t used to that. You have to havean office manager who takes controland says, ‘You’re not going to fill upyour schedule on this day’” Huh? Al-ready the one-on-one time with yourpersonal health provider is variouslyestimated to be between 45 secondsand five minutes, comparable to thequality time received at Albertson’scheckout line. Inviting the ailinghordes in for instant servicing appearsto place the scheduler in an awkwardposition of writing more names in themargins of the appointment bookwhile at the same time not filling upthe doctor’s day.

It seems to us that a 3-year-oldchimpanzee could come up with aworking hypothesis that might illumi-nate the problems, if not the solutionfor this new medical breakthrough.Bonzo, our own primate, delicately fin-gered the worn keys of his ancient Un-derwood, offered this:

J. Elwood Goodpants, DMD, FamilyPractice/Cosmetic/Implants/Braces/Teeth Whitened While-You-Wait, hassummoned his team of dedicated auxil-iaries to evaluate the initial impact oftheir new Same-Day Service Open Ac-cess scheduling.

Doctor: Everybody clear on this?Patient calls for an appointment, hegets one today, no waiting, no excep-tions? Got it?

Marilouanne: Got it! Here’s yourschedule for today: 47 patients, no

lunch hour. These people have been ledto believe that “same-day service” actu-ally means today! We can close at 9:30p.m. if there are no more calls. Andwe’re on the clock for time-and-halfafter 5.

Anastasia: There are 14 people inthe waiting room right now, doctor.They’re saying they like the idea ofsame-day service, but the two-hourwait to see you stinks! If this “open ac-cess” thing includes your private office,they’d like to talk to you.

Doctor: Would you get Dr. GordonMoore, Rochester, New York, on thephone for me? I have some questions.

So do we, Elwood. Although Dr.Moore said he was tired of workinglong hours with patients double andtriple booked into time slots, he felt theopen access plan is working just fine.We must be missing something here.

Marie Schall attempted to clear itup: “It’s all very data driven and basedon predictions and having a clear un-derstanding of your supply and de-mand.” Oh. Nice try, Marie!

Moore agreed, saying he is able toaddress several needs of patients all atonce, rather than refer them to a spe-cialist or schedule a later appointment.Great idea! Who wants to wait 24 daysto have a dermatologist sort out yourvarious dermal deficiencies when youcan wait right here in this waitingroom until they heal spontaneously?

We have, in spite of all this con-gratulatory evidence, decided to post-pone implementing open access in ouroffice until we see how the guy downthe hall does with it. This is the samechap who bought Caridex and theMystique veneers.

Dr. Bob

Continued from Page 170

These people have been led to believe that “same-day service”actually means today!

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