We get into dentistry to help people. One could say we’re natural healers. So it goes without saying that extending my career from dental hygiene into dental ergonomics education and coaching came very easily. During a 21-year career in dentistry (front desk, some assisting, working for Delta Dental and then hygiene), I had seen firsthand what could happen to a body from practicing dentistry long term.
The work we do is dangerous, according to the Occupational Safety and Health Administration.1 In fact, dental professionals experience all of the top five risk factors for workplace injury: awkward position, contact stress, force, repetition and vibration. It’s as if we have a target on our backs, literally. There are the classic physical effects I see and hear about daily such as “hygiene hip” and the ever-recognizable Dowager’s hump to name a couple, but the bigger and most abundant complaint is pain, and lots of it—back, neck, hip, shoulder and hand/wrist pain. It doesn’t take more than a few minutes of scrolling on any given hygiene forum to learn that pain is not only likely, but it’s expected.
What if it doesn’t have to be that way? I have practiced full time for nearly 13 years and have no pain. I’m no bionic woman, so when my co-worker, with only two years of hygiene under her belt at the time, was racking up serious frequent flyer miles with her chiropractor with minimal results, I set out to figure out a way to help her. I used my years of ergonomics training, personal training, body-building background and chairside experience to develop a program that anyone in dentistry could benefit from. In just six weeks of working with me she had significantly less pain and her career was no longer walking a short plank. I knew then that many hygienists could be helped.
Fast-forward two-plus years and dozens of clients. Laura approached me. She spent 15 years working in a left-handed operatory as a right-handed clinician. She was forced to contort her body to fit her workspace when working on her patients. She had to “plant [her] hip in the 10 o’clock position and lean to the right all day long while twisting to get [her] instruments.” For. Fifteen. Years. The consequence: degenerative scoliosis, debilitating pain that regularly required six to eight weeks to recover from and pain to the point of seeing stars during chiropractic therapy.
Laura complained of neck and back pain and wanted relief. She wanted to feel healthy again and get in shape. I recommended that she start with the individual program in which I provided her with a posture analysis, dental-specific stretches, custom workouts, ergonomic strategies, nutritional guidance and weekly accountability calls. Laura, like most of my clients, is coached remotely, which is always a concern for new clients, but she took a chance. I got her full medical and background history along with pictures and videos used to analyze posture and neuromuscular pattern dysfunctions. Some things simply need to be seen to be fully understood. Thanks to the beauty of the digital era, I can coach Laura from across the country if I want to.
Accompanied by her background information were pictures of her standing from different angles, an upper-body X-ray and a note that she was ordered out of hygiene by her doctor. One glance at that X-ray (Fig. 1) and I thought, “What have I gotten myself into?” The damage was incredible. She looked as though she had been broken in half at some point. The vertebral changes to her spine were severe and her body reflected every bit of structural damage that could be seen in her “relaxed posture,” which was nowhere near neutral. She had been through tons of physical therapy, chiropractic work, massage therapy and even some exercise in the past that left her in more pain. She was scared, but at this point she was willing to try anything. I had some doubts as to the extent of relief she could achieve, but I knew I had to try to help her.
Laura’s posture analysis included:
• Forward head posture of about 1.5 to 2 inches.
• Shoulders are anteriorly rolled with slight shoulder blade flare noted from behind.
• Left shoulder sits significantly higher than the right and the upper left trapezius is overdeveloped.
• Left hand is internally rotated due to associated shoulder internal rotation.
• Neither forearm reaches full extension when relaxed.
• Left knee appears internally rotated with slight buckling during squat. Will likely be exaggerated under load.
Working (out) toward a solution
For Laura, as with many others, fixing her pain was more than a matter of merely buying a piece of equipment or having her do a couple of daily stretches. Getting her into neutral posture (ankles in line with knees, in line with hips, in line with shoulders, in line with the ears—all in a plumb line) was the first goal; maintaining it was the second. Musculoskeletal disorders are the result of dysfunction caused by a chronic lack of oxygen, nutrients (blood flow) and innervation. When our natural recovery systems fail, the musculoskeletal system becomes imbalanced and symptoms set in. The body needs balance to function properly, and Laura needed balance like a fish needs water. She needed the entire ergonomic umbrella, as I like to call it. She needed to stretch properly at work (she still practices hygiene part time) and at home; frequent myofascial release of tight musculature through foam rolling; ergonomic coaching from someone who has actually been in the mouth; correct equipment in an ergonomic-friendly workspace (thankfully, she no longer works in that left-hand-oriented operatory); and strengthening of her posture musculature. Her spine needed support in the worst way and that became the goal.
That’s where the magic started. After analyzing her movements, I determined exactly which areas to focus on. I gave her instructions for proper foam rolling to be done twice daily for myofascial release of her mid- and upper-back muscles. I gave her stretches for the back, shoulders, chest and neck, along with the legs and glutes. I also gave her three custom-designed workouts. Each focused on one part of the body at a time (back, chest and legs). Within each of her workouts are strategically organized exercises that are in a specific order to achieve maximum results. Each has a picture of the exercise with the machine to use if needed, which muscle is being worked, why I have her do it, how it is done (in step-by-step fashion) and how it should feel. There are tips on what not to do and ways to modify a movement to make it easier or harder, along with specific modifications unique to her condition.
The workouts are done as they fit into Laura’s schedule, since she does them on her own. After all, this is a lifestyle change and it needs to be convenient for each individual. In Laura’s case, she is a very active person with a busy life, so having the flexibility to take care of herself on her schedule was essential. There are times when she would send a video or picture of a piece of equipment or want her form checked, which has been key to her progress. I have an open-door policy and am available at any time for consultation on fitness, nutritional or ergonomic needs. I also listen to “life stuff” as needed. As hygienists, we are the counselor for our patient’s “life stuff,” so in this program the hygienist gets to be the person being heard. The resulting friendship is a bonus!
Laura, like all ErgoFitLife clients, was given three workouts. Form is the first thing we work on to establish the mind-muscle connection and neuromuscular patterns of movement. The workouts are broken up by body part so that one area is focused on at a time and that the area has adequate time for recovery.
Leg Day: Posture isn’t just what we do with the space between the shoulders and the neck. The spine doesn’t stop at L5. The lumbopelvic hip complex and sacrum are also part of the package that provides stability and support for the spine. Said differently, the quads, hamstrings and glutes provide strength that then reduces the load on the lumbar spine. Strong glutes also provide the majority of the support for the hips. Hip extensions, squats, etc., are all part of leg day.
Back Day: The mid-back is the focus of back day. It is the weakest area for dental professionals and the area that lends to the majority of our pain. The more strength we can build, the longer we can maintain neutral posture. The longer we can maintain neutral positioning, the longer we can avoid injury. The muscles in the back are complex. They vary in size and orientation, ranging from the tiny rhomboids to the large and overpowering upper traps. I use specific exercises that use a variety of pulling motions incorporated into each movement, like rows or stiff leg deadlifts.
Chest Day: It’s a common misconception that we don’t want strong chest muscles in dentistry because our chest muscles are very tight, which contributes to our dysfunction. The latter is true—our chests are tight, but it has little to do with the size of the muscle and more with the fact that we don’t stretch it after leaving it in a shortened state for long periods. I also incorporate the shoulders and rotator cuff with this workout. Strengthening these areas with exercises that push away from the body, like pushups, are key components of a strong and balanced body.
Another crucial part of the program is stretching. As mentioned above, stretching is vital to helping reverse the symptoms brought on by structural changes that occur in the body from working in awkward positions. If a muscle is shortened for long periods (be it in a contracted state or not), it will have a propensity to stay that way until manually stretched back to its normal state. If that muscle is chronically shortened, the shortening becomes more and more ingrained into the muscle fiber and requires more stretching to reverse.
I provide many, many stretches for the client to do frequently. There are chairside stretches to be done throughout the day, specific body-part stretches to go with the accompanied workout, and then a full-body stretch to be done weekly. Seems like a lot, right? Not really. The chairside stretches take approximately 60 seconds. The workout stretches take three to five minutes, and the full-body stretch is a weekly 15 to 20 minutes. I also recommend an in-person weekly yoga class so the instructor can see the client’s form and provide feedback. One stretch I recommend frequently is the QL stretch for hip and lower back relief.
On the road to recovery
From the very first message, Laura was determined to be successful. She got a gym membership and did her workouts consistently. She stretched and foam-rolled and worked very hard. Laura did everything I asked and was open to suggestions. She frequently asked questions and expressed concerns when they arose. I may have provided the key, but she turned it. She put in the work. Her dedication has paid off handsomely. For Laura, there will always be occasions when she has pain. For her, though, the difference is the frequency, severity and duration of the pain. Before starting the ErgoFitLife program, a flare-up would leave her debilitated for six to eight weeks at a time. During her 90 days in the program she had only two flare-ups, one lasting just under a week and the other about two weeks after more than two weeks of doing heavy clinical hygiene and waking suddenly in the middle of the night and twisting her neck.
Laura’s pain is significantly reduced, and she rebounds quickly when it acts up. She knows how and when to stretch, and when to rest. She has built a foundation of musculature for structural support around her spine, which lends to proper posture. She has an understanding of what neutral posture feels like through established neuromuscular patterns, which became the foundation of a mind-muscle connection. It is that connection that has provided her with the means to correct her posture when she becomes fatigued. That’s where the magic continues.
Getting to neutral posture is one thing. Maintaining it under fatigue is an entirely different story. This isn’t the end for Laura. Maintaining this level of success will require continued dedication to her newly found habits, but it was a major win for us. I take great pride in the work I do to help people and to change their lives, but Laura’s success brings me tears of joy. I am excited for Laura’s continued progress and look forward to the results we will achieve in the future because I will always have her back (literally!)
Katrina Klein is a registered dental hygienist, a
certified ergonomic assessment specialist and a certified personal trainer.
After 20 years of working in dentistry, Klein founded ErgoFitLife, a company
that helps dental professionals avoid workplace injuries and reduce
work-related pain. Information: ergofitlife.com. Klein enjoys participating in
fitness competitions, training clients, teaching ergonomics to dental teams and
keeping the ErgoFitLife Facebook page updated with ergonomic, fitness and
nutritional help. When away from the dental arena, she enjoys traveling to new
places, soaking in the sun, relaxing on the beach and enjoying the outdoors
with her family.