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Why Dentists Require Specific Exercise by Bethany Valachi, PT, MS, CEAS

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Dr. Timothy Haines decided to make a New Year's resolution to improve his musculoskeletal health. When he began working with a personal trainer at his gym, the last thing he expected was that certain exercises and gym machines would worsen his musculoskeletal pain. Frustrated after two months of increasing pain, he quit his training sessions and sought treatment from a physical therapist.

This is just one of numerous negative exercise stories I hear from dentists. Unfortunately, most personal trainers and therapists do not realize that dentists are predisposed to unique muscle imbalances. Certain generic exercises that are not a problem for the general population can throw the dentist into a vicious pain cycle. When dentists come to understand these muscle imbalances, the proverbial light bulb appears… “Ah, that's why I always had pain after that exercise.”

When dentists become familiar with their muscle imbalances, they are better able to select exercises and modify existing exercise routines to improve their health - not make it worse. In addition to selecting proper exercises, it is imperative to understand how dentists should strengthen these muscles. Research shows that a method called muscular endurance training can help dental professionals reduce work-related pain.1-4

Developing balanced musculoskeletal health through proper exercise can help dentists avoid work-related pain, injury or early retirement. Before initiating exercise, dentists should resolve operatory ergonomic issues, have full range of motion, resolve their trigger points and be relatively pain-free.5

Pain and Unbalanced Muscles

In order to perform the precision tasks of dentistry, the arms must have a stable base from which to operate. For example, the delivery of dental care requires excellent endurance of the shoulder girdle stabilizing muscles (especially the middle and lower trapezius muscles) for safe shoulder movement and working posture. These shoulder stabilizing muscles tend to fatigue quickly with forward head, rounded upper back and elevated arm postures - all commonly seen among dentists.6 When these muscles fatigue, other muscles (upper trapezius, levator scapula and upper rhomboids) must compensate and become overworked, tight and painfully ischemic.6

This muscle imbalance may result in tension neck syndrome, a frequently diagnosed disorder among dentists. Symptoms include pain, tenderness and stiffness in the neck and shoulder musculature, commonly with pain that radiates between the shoulder blades or up into the occiput. Two contributing factors to tension neck syndrome in dentistry are forward head and elevated arm postures.

Another common imbalance among dentists is in the shoulder, caused by over-strengthening the deltoid and supraspinatus muscles. These muscles already tend to be strong in dentists due to frequent postures with the arms lifted away from the sides of the body. This imbalance can cause improper movement at the shoulder joint, with painful impingement of the rotator cuff tendon.

The muscle imbalance that tends to develop between the abdominal and low back muscles is especially problematic in seated dentistry. Leaning toward a patient repeatedly with rounded back posture can cause strain and overexertion in the superficial low back extensors, while the deep stabilizing abdominal muscles (transverse and oblique abdominals) tend to become weaker.

How to Develop an Effective Exercise Program

An effective exercise regimen for dentists will target specific shoulder girdle, trunk and back stabilizing muscles, without engaging the muscles that are prone to tightness and ischemia. This requires expert knowledge of biomechanics and kinesiology. In addition, specific muscles that are prone to tightness and ischemia must be targeted with stretching exercise and avoid strengthening. Male dentists are especially prone to injuries due to inflexibility and should be diligent with a daily chairside stretching regimen and/or yoga routine.

Studies show that power/strength training is not protective against pain syndromes caused by prolonged, static postures, as in dentistry.1 However, several dental studies show that specific muscular endurance training can reduce or prevent neck, shoulder and back pain.

Since the postural stabilizing muscles perform low-level static contractions for prolonged periods in the dental operatory, they must be trained for endurance.

Click here to view video: www.youtube.com/embed/u4AyD0szkg0

Exercise Wisely:
  • Target the correct muscles with muscular endurance training: Use light resistance and high repetitions (15-20 reps) when training these muscles, usually an elastic exercise band is sufficient for the shoulder muscles, while gravity-resisted exercise on the floor or an exercise ball is good for the trunk muscles.
  • Perform strengthening exercises three times a week, always allowing one day in-between sessions.
  • Target specific tight, ischemic muscles with regular chairside stretching. Stretching should be performed daily.
  • Strengthening exercises should only be performed when there is no musculoskeletal pain and full range of motion is present.
  • Always discontinue exercise if you experience pain.
  • It is a good idea to seek professional guidance from a physical or occupational therapist when beginning any new exercise regimen and to ensure safety and good technique.

Downward Squeeze (Fig. 1)

This targets one of the primary shoulder girdle stabilizing muscles. Position door anchor above head level. Loosely wrap band around both hands and position arms at sides, fingers pointing upward. Make sure the downward angle of the band is about 45 degrees. Maintain optimal head posture (ear-overshoulder, chin tucked) and pull navel to spine, holding this contraction throughout the exercise to avoid arching your low back. Roll shoulders back and down, squeezing shoulder blades downward and together. Pause briefly and slowly return. Repeat 10-20 times. If you have discomfort, decrease the resistance of the exercise band.

Click here to view video: www.youtube.com/embed/Y-f0-OqwIZg

External Rotation (Fig. 2)

This exercise helps correct a painful muscle imbalance in the rotator cuff that frequently occurs among dentists due to elevated arm postures. With the door anchor at elbow height, stand at a right angle to the door holding a small pillow or rolled towel between your elbow and your body. Squeeze shoulder blades together then slowly rotate the arm outward, then return. Keep the elbow pressed firmly against your side throughout the exercise. You should be able to perform 10-20 repetitions easily. Repeat with other arm.

Side Lift (Fig. 3)

Research supports endurance training of the quadratus lumborum in preventing low back pain.3 Lie on your side with arms crossed. Pull navel to spine and hold as you slowly lift both legs off the floor, making sure your pelvis does not roll forward or backward. Briefly hold and repeat 10 times on each side. Repeat for the other side (page 72).

Click here to view video: www.youtube.com/embed/-h8TpeGXGSA?list=PL-inlgCvSl8ni3RPY6MOUA06egrqIQ5Yp

Lower Abdominals (Fig. 4)

Studies show that individuals who effectively utilize and train their natural “back belt” - the transverse abdominal muscles - have less low back pain.7 Lie on your back with knees bent and feet on the floor. Place your hands under your low back and pull navel toward your spine. You should now feel your back pressing into your hands. Be sure that you maintain this contraction throughout the exercise and do not arch your back, which may cause strain or injury. Lift one leg until the hip is at 90 degrees. Continue breathing while slowly straightening the leg. Lightly touch the floor, hold, then return the leg to 90- degree position. Repeat with the same leg 5-10 times. Now repeat the exercise with the opposite leg.

Advanced version: Pull navel to spine and bring both legs to 90 degrees. Slowly straighten the right leg, without letting it touch the floor. Return it to the 90-degree position, then straighten the left leg without letting it touch the floor. Repeat 10-20 times. Make sure back stays on floor and your neck is relaxed!

Click here to view video: www.youtube.com/embed/lu9JZ5z8CVI?list=PL-inlgCvSl8ni3RPY6MOUA06egrqIQ5Yp

Pointer Dog (Fig. 5)

This is one of the best time savers as it targets four essential stabilizers with endurance training in one exercise! Position yourself on hands and knees over the ball with your chin slightly tucked. Contract the lower abdominals and pull your navel up toward your spine. Hold this contraction throughout the exercise. Make sure your back is flat and hips are level. Slowly lift the right arm, thumb pointing up, hold, and then lower it. Slowly lift the other arm, hold, then lower. Repeat for the right and left legs. Continue to perform five lifts on each arm and leg.

Advanced version: Lift the right arm and left leg together and hold. Make sure you are still contracting your lower abdominals! Repeat for opposite arm/leg.

Hamstring Stretch (Fig. 6)

Research shows that in seated occupations, such as dentistry, tight hamstrings can cause flattening of the lumbar spine.9 Sitting on the ball (or a chair), extend one leg in front of you so the heel rests on the floor. Ensure the knee stays straight throughout the exercise. Keeping the back straight, pivot forward at the hips. You should now feel a stretch at the back of your thigh. Hold 20-30 seconds or longer. Be sure to keep your head and chest up. (Don't look at your feet!) Repeat with the other leg.

Click here to view video: www.youtube.com/embed/HiDFviy4rKA?list=PL-inlgCvSl8ni3RPY6MOUA06egrqIQ5Yp

Conclusion

Embarking upon an exercise program requires prudence and discretion, considering team members' predisposition to certain muscle imbalances. Selecting improper exercises can lead to imbalance, ischemia, nerve impingement and other pain syndromes. Developing balanced musculoskeletal health with a well-designed exercise program can help dentists prevent work-related pain, avoid injuries, extend their careers and improve their quality of life.

References
  1. Lehto TU, Helnius HY, Alaranta HT. Musculoskeletal symptoms of dentists assessed by a multidisciplinary approach. Community dentistry and oral epidemiology 1991; 19:38-44.
  2. O’Sullivan PB, Mitchell t, Bulich P, Holte J. The relationship between posture and back muscle endurance in industrial workers with flexion-related low back pain. Manual Therapy 2005 June 10
  3. McGill S. Low Back Disorders: Evidence-Based Prevention and Rehabilitation. Human Kinetics, Champaign, IL. 2002
  4. Rundcrantz B, Johnsson B, Moritz U. Occupational cervico-brachial disorders among dentists. Swedish Dental Journal 1991; 15:105-115.
  5. Valachi B. Practice Dentistry Pain-Free: Evidence-based Strategies to Prevent Pain & Extend Your Career. Posturedontics press, Portland, OR. 2008.
  6. Novak C, Mackinnon S, Repetitive use and static postures. J Hand Thera 10(2):151-9, April –June 1997.
Author's Bio
Bethany Valachi is a physical therapist, dental ergonomic consultant and author of the book, Practice Dentistry Pain-Free. She is CEO of Posturedontics, a company that provides research-based education, and is clinical instructor of ergonomics at OHSU School of Dentistry. Valachi lectures internationally at dental meetings, schools and study clubs and offers additional articles, videos and continuing dental education on her website at www.posturedontics.com.

The exercises in this article come from the new research-based second edition, “Smart Moves for Dental Professionals On the Ball” Home Exercise DVD. Based on the latest research on dental ergonomics, neck pain, back pain and biomechanics, the DVD includes three complete exercise routines (24 exercises) and also describes which exercises, routines and gym machines can worsen dentists' health. It is available at www.posturedontics.com. Enter discount code OTB2013 upon checkout to receive a special discount.
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