Antidotes for Musculoskeletal Disorders

The body requires care and main­tenance to effectively function. Although every body features the same anatomy, an individual’s degree of physical fitness, response to muscular movements, and ability to recover from physical strain and injuries considerably vary. Physically fit individuals with strong muscles who can endure static positions may be at less risk for musculoskeletal disorders (MSD) than nonfit individuals.^1,2 

The best interventions to improve physical fitness are unique to individuals and their injuries, weaknesses, and muscle imbalances. This article seeks to explain why exercise and physical fitness benefit individuals who wish to prevent muscle imbalances and discuss how targeted strengthening, stretching, and endurance exercises help alleviate pre-existing discomfort associated with MSDs.

Practitioner wellness is a precursor to the delivery of high-quality patient care. When clinicians feel well physically, they can be more present for patients, students, and clients. When clinicians are in pain or experience discomfort, their listening skills become compromised, their ability to effectively educate diminishes, and their provision of optimal care suffers. The conundrum is that most oral health professionals do not practice pain free.³ More than 90% of dental hygienists may experience MSDs.³ 

Much has been written about preventive measures that can be applied in the practice setting.^3–5 Common sense tips, such as assuming a standing position as often as possible and positioning the body to prevent strain, are routinely recommended. Using ergonomic positioning and customized equipment are other strategies to enhance physical and practice well-being. Situating supplies and equipment in a body-friendly arrangement can contribute to musculoskeletal health. Clinicians have been advised to stretch, take breaks from sitting, and practice yoga, stress reduction, and meditation.^4,5 The use of loupes, ergonomically designed equipment, appropriate seating, and properly fitting gloves also is strongly encouraged.^3–5 Yet, given the dearth of longitudinal studies and randomized controlled trials, evidence to support this array of recommendations is limited.⁶ 

Preventive approaches that deserve continued discussion include aerobic exercise, targeted exercises, and general physical fitness. For many reasons, these measures can help prevent and improve MSDs.^7–9 In the United States Centers for Disease Control and Prevention’s Report on Physical Activity and Health, physical fitness was identified as a means to prevent MSDs.⁷ Poor physical fitness has been associated with MSDs among dentists.⁸ Although little has been published that directly addresses the link between MSD risk and aerobic exercise, inferences can be drawn that demonstrate how aerobic exercise and physical fitness enhance general physical well-being and, in this way, help prevent and possibly decrease pre-existing MSDs. The benefits of exercise and physical fitness can help prevent and negate the effects of sedentary, repetitive, and confining practice lives.⁹ 

Dental hygiene practice is mostly a sedentary activity. Sitting does not promote bone maintenance or improve bone density, which leaves many oral health professionals at risk for osteoporosis. When practitioners are primarily sedentary for extended periods, they use a limited set of muscles throughout a day. The lack of movement contributes to stiffness, reduced blood flow and circulation, and encourages a low metabolic rate.^10,11 From a physiological perspective, aerobic exercise increases circulation, aids in muscle toning, reduces stress, and can assist with weight reduction. Weight bearing physical activity also can enhance bone density.

The demands of dental hygiene practice on the body must be counteracted by ensuring that what is done outside of the dental setting compensates for the damage caused by clinical practice. An assessment of daily practice life is essential to designing wellness plans. Table 1 lists the points that show how exercise can enhance wellness and help prevent or minimize MSDs.^1,7,9–11

Exercises that increase the wellness and fitness of oral health ­professionals are divided into four categories: aerobic, stretching, strengthening, and endurance exercises. Any exercise program should be gradually implemented. All regimens should include a warm-up, an exercise period, and a cool down. Consultation with a an appropriate health care provider is essential before beginning any exercise program. A complete physical assessment should be conducted to establish a customized plan, as ill-planned activity may cause injury.^10,12,13

AEROBIC EXERCISE

Aerobic exercise is physical exertion that strengthens the heart and lungs and trains the cardiovascular system to manage and deliver oxygen more quickly and efficiently throughout the body. Examples of aerobic exercise include brisk walking, jogging, spinning, swimming, and dancing. In order to be of aerobic benefit, these activities must be performed at a moderate level that elevates the heart rate. As aerobic exercise increases blood flow to all of the tissues in the body, the ability to use oxygen is improved. In addition to strengthening the heart and cardiovascular system and improving circulation, participation in regular aerobic exercise increases endurance and energy, improves bone density, and helps reduce the risk of cancer (eg, breast and colon) and osteoporosis.^7,10,11 Aerobic exercise can lower moderately high blood pressure, improve glucose tolerance, and reduce insulin resistance, thereby decreasing the risk for diabetes. It can help control the accumulation of excess body fat and enable participants to reach and maintain a healthy weight. Improved balance and the performance of daily living activities, reduced pain and swelling, and increased likelihood of surviving a heart attack can be attributed to judicious and consistent aerobic exercise. In addition to enhancing total body fitness and physical health, aerobic exercise benefits emotional health by curbing stress and tension, and can alleviate symptoms of depression (in some cases, as effectively as medication or psychotherapy). Additional benefits include: improved mental acuity, better sleep quality, increased high density lipoproteins, decreased triglycerides, improved balance, and the potential for increased longevity.^1,7,9–11

The advantages of aerobic exercise are extensive.^1,7,10,11,13 The ­US Surgeon General recommends 30 minutes or more of accumulated moderate intensity physical activity on five or more days per week to improve health and fitness.¹⁴ Dental hygienists should choose aerobic exercises they enjoy. It is advisable to do at least two types of aerobic exercise regularly to enable cross training and prevent boredom. Aerobic exercise can counteract many of the physical constraints placed on dental hygiene professionals. Weight-bearing aerobic exercise such as walking and jogging can promote bone health. Balancing the realities of the employment setting with a vigorous exercise routine can increase physical fitness and potentially enable practitioners to practice pain free.^1,7,10,11 

STRETCHING AND STRENGTHENING EXERCISE

Oral health professionals are prone to muscle imbalances. Daily engagement in repetitive motions, static positioning, and the use of limited muscles can elicit muscular contraction, tension, stiffness, pain, and possible injury.⁴ When clinicians are delivering care or faculty are demonstrating a particular technique to students, core sets of muscles are activated.⁴ These muscles are shortened or lengthened depending on how they are used. If discomfort is isolated to a specific area of the body, targeted exercises that restore muscle relaxation and homeostasis are indicated.

Targeted exercises can stretch or strengthen activated muscles. Stretching exercises concentrate on the muscles that tend to tighten in prolonged dental postures. Muscles that are short, tight, or have limited blood flow should be stretched, not strengthened. Strengthening exercise concentrates on the muscles that are appositional to the tight muscles.¹ Strengthened appositional muscles will help balance the load borne by overused muscles. Kumar et al¹ state that strengthening exercises increase the power and endurance of a muscle.¹ Prior to beginning strengthening exercises, muscles should not be tired or in pain. If muscles with trigger points or pain are over-strengthened, pain may worsen.

ENDURANCE EXERCISES

Recent studies suggest that depending on the clinician’s physical status and individual needs, endurance exercises may be more beneficial than strengthening for certain muscle groups.^1,5,10,12 Muscular fitness is composed of the functional parameters of strength, endurance, and power. Muscle strength is the ability to exert a maximal amount of force for a short period. Muscle endurance is the ability to do something over and over for an extended period of time without tiring. Using the example of weight lifting, lifting a heavy barbell for a limited number of repetitions would increase muscle strength, while doing more repetitions with lighter weights will help build muscle endurance. Many types of resistance-training equipment can effectively be used to improve muscular fitness, including free weights, machines with stacked weights, and resistance bands. Muscular fitness exercises that use the body as resistance include planks, push-ups, and squats. A plank requires the participant to tighten and pull in the abdominal muscles while squeezing the gluteal muscles (Figure 1). Arm, shoulder, back, and leg strength increase as these muscle groups support the body’s weight. Planks that are held for extended periods increase muscle endurance. Performing greater numbers of squats and push-ups heightens the benefits for both muscle strength and endurance.¹⁵

Core strength exercises address low back pain—a chronic problem for those in sedentary positions. To strengthen the core, a supine abdominal draw-in exercise can be performed (Figure 2). Participants should lie on their backs with knees up and feet flat on the floor. The abdominal muscles should be pulled in, while the lower back is pushed into the floor.¹⁶ 

Endurance exercises are critical to maintaining a stable core and often pre-empt the use of strengthening exercises in certain situations.^1,5 The postural stabilizing muscles perform low-level static contractions for prolonged periods during the practice of dental hygiene and they must be trained for endurance and to strengthen the core.^1,5,10,12 These muscle groups include the shoulder girdle and trunk-stabilizing muscles. Dentists with better endurance of the back and shoulder girdle muscles were shown to experience less neck, back, and shoulder pain.^1,12

SUGGESTED REGIMEN

Valachi⁵ prescribes a detailed regimen of targeted exercises with images to guide the user. These exercises address endurance, strengthening, and stretching.

• When engaged in muscular endurance training, light resistance and a high number of repetitions are recommended. An elastic exercise band can be used for shoulder muscle endurance training, while gravity-resisted floor exercise is most beneficial for the trunk muscles. Fifteen repetitions to 20 repetitions are advised.
• Strengthening exercises should be performed three times a week, with a day of rest in between each session. Strengthening exercises should not be performed if pain or a limited range of motion is present.
• Routine chairside stretching performed daily is designed for tight and static muscles.

Dental hygienists are members of a health profession. As such, they are charged to serve as role models who strive to achieve wellness. Physical fitness should be a goal they hope to attain. Patient education is no longer confined to oral health. Discussions related to obesity, nutrition, blood pressure, and sugar intake are germane to many patient interactions. As dental hygienists embrace broadened health education responsibilities and holistic roles, their lifestyles should reflect what they prescribe to patients.

SUMMARY

The benefits of exercise and physical fitness in preventing MSDs are many. As the exercise needs of dental professionals are unique and specific, professional oversight to establish activities that ameliorate or prevent MSDs may be warranted. An individualized program designed by a physical therapist may be a good first step. As emphasized by Valachi,⁵ exercise programs must be designed judiciously. Improper exercise can lead to unplanned injury and pain.¹¹ A well-balanced exercise program can help dental hygienists prevent work-related pain, avoid injuries, extend their careers, and improve their quality of life. Balancing the realities of practice with a well-thought and tailored exercise routine can enhance mental health, reduce stress, and benefit physical well-being.

REFERENCES

1. Kumar DK, Rathan N, Mohan S, et al. Exercise prescriptions to prevent musculoskeletal disorders in dentists. J Clin Diagn Res. 2014;8:ZE13–ZE16.
2. Talpos-Niculescu C, Lungeanu D, Anghel M, Stefan-Ioan S, Bucur A. The role of physical exercise in preventing musculoskeletal disorders caused by the dental profession. Timisoara Medical Journal. 2010;60: 293–298.
3. Hayes M, Smith DR, Cockrell D. An international review of musculoskeletal disorders in the dental hygiene profession. Int Dent J. 2010;60:343–352.
4. Barry R, Esenhaur A, Weber M. Occupational health hazards. Dimensions of Dental Hygiene. 2014;12(9):58–61.
5. Valachi B. Keys to wellness. Available at: posturedontics.com/pdf/6-Keys-to-Wellness-Article.pdf. Accessed December 16, 2017.
6. McConaughy F, Perry S. Preventive interventions for musculoskeletal disorders. Dimensions of Dental Hygiene. 2016;14(1):18–22.
7. Centers for Disease Control and Prevention. Report on Physical Activity and Health. Availabel at: cdc.gov/nccdphp/sgr/chapcon.htm. Accessed December 16, 2016.
8. Rambabu T, Suneetha K. Prevalence of work related musculoskeletal disorders among physicians, surgeons and dentists. A comparative study. Ann Med Health Sci Res. 2014;4:578–582.
9. Phedy P, Gatam L. Prevalence and associated factors of musculoskeletal disorders in young dentists in Indonesia. Malaysian Ortho J. 2016;10:1–5.
10. Valachi B, Valachi K. Preventing musculoskeletal disorders in clinical dentistry: strategies to address the mechanisms leading to musculoskeletal disorders. J Am Dent Assoc. 2003;134:1604–1612.
11. Cooper K. Aerobics Program For Total Well-Being: Exercise, Diet and Emotional Balance. New York; Random House; 2013:230.
12. Valachi B. Why all exercise is not necessarily good exercise for dentists. Available at: dentalproductsreport.com/dental/article/why-all-exercise-not-necessarily-good-exercise-dentists?page=0,5. Accessed December 16, 2016.
13. O’Keefe JH, Patil HR, Lavie CJ, Magalski A, Vogel RA, McCullough PA. Potential adverse cardiovascular effects from excessive endurance exercise. Mayo Clinic Proceedings. 2012;87:587–595.
14. Centers for Disease Control and Prevention. Physical Activitiy and Health: A Report of the Surgeon General. Available at: cdc.gov/nccdphp/sgr/sgr.htm. Accessed December 16, 2016.
15. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;42:1334–1359.
16. Princeton University Athletic Medicine. Lumbar/Core Strength and Stability Exercises. Available at: uhs.princeton.edu/sites/uhs/files/documents/Lumbar.pdf. Accessed December 16, 2016.

From Dimensions of Dental Hygiene. January 2017;15(1):18-21.