The hidden health hazard: back pain
Gordon Waddell’s book, The back pain revolution, states that the cost of back pain has escalated as a result of time taken off work through sickness and insurance claims.
Much of Waddell’s work has centred on the debilitating effect of back pain. He developed the ‘biopsychosocial model’ – how one copes with such a health problem. As he rightly shows, one of the biggest problems associated with back pain is that for decades it has been used as an excuse for absenteeism; thus industry has developed doubts as to the validity of back pain.
But what happens if someone develops back pain? What should they do? Until lately back pain has been very poorly addressed. Rehabilitation has been very much a mixture of wait and see, make an appointment with a manual therapist or get oneself off to the gym and it will right itself!
The ergonomic view
So why do dental practitioners need to be made aware of such an occupational health hazard? Well, mainly due to our lifestyles and poor working postures we are at an increased risk of back problems.
Ergonomists are already reporting that nation-wide back problems are becoming more prevalent because of our sedentary habits and poor postures. Even as children the problem is already setting in, as it is estimated that by adulthood we have spent over 10,000 hours in poor seating positions. Now, as practitioners who have to generate an income by performing our clinical skills while building up a business, a back problem is certainly a condition we do not want to develop.
During our working life, dentists spend on average 40,000 to 60,000 hours sat in the surgery. Professor Trevor Burke (1997) highlighted that back problems are the most common cause of premature retirement. Rundcrantz (1991) and Marshall (1997) demonstrated that 70% to 80% of practitioners will suffer back pain during their working lives.
Ellis Paul (1981) devised the concept of four-handed dentistry to enable the practitioner to work in an ergonomic manner. As he has clearly demonstrated, dentists tend to work in distorted postures.
Now that you have the full picture, what can we do about trying to minimise the risk?
What is back pain?
What your body is telling you is that the musculature supporting you is not doing its job (Panjabi MM, 1992). This is because the muscles that should be supporting the spine in its neutral position where it maintains its curvatures (lordoses) has to recruit other muscle groups to take over its role. They are not designed to do this task, soon fatigue and cannot withstand the loads placed upon the joints. This may lead, in time, to degeneration or prolapse of the discs.
Minimise the risks
Condition your body – the answer lies in core stability. Research from the University of Queensland (Hodges PW, Richardson CA, 1996) has started to show that back pain sufferers have a problem with the core stability muscles. These muscles act as a natural corset and support the lower back. Exercises such as Pilates, yoga and t’ai chi can improve these core stability muscles.
True, most dentists complain of upper cervical pain but the core stability muscles still need to be conditioned, as this is where the spine gets its stability. Upper stabilising exercises for the pectoral/shoulder girdle should be introduced at the same time as those for the core stability muscles of the lower abdomen.
The use of loupes will help reduce postural strain of the neck by keeping it in a more neutral position. The more flexed the spine is, the greater the tendency for the postural muscles to tire (Chaffin DB, 1973) and then performance starts to deteriorate (Gandavadi A et al, 2005).
This increased flexed position also significantly increases the load on your spine (Nachemson A, Morris JM, 1964). Invest in a chair that will help maintain your lower spine in a neutral position to minimise the load on your spinal discs and joints.
Identify the risks
• Distorted positions – learn to work correctly with your nurse by practising four-handed dentistry
• Sedentary – if you don’t believe how sedentary you are in the surgery, invest in a pedometer. We are designed to be ‘hunter gatherers’ and as a result we have become bipedal. Unfortunately, our gluteals (or behinds) have developed the ‘use it or lose it’ phenomenon as we don’t walk enough these days. Invest in some MBT trainers and you’ll soon discover those muscles you thought you never had
• Break for some stretching – the temptation is not to move from the chair while in the surgery. Have a good stretch and stop those muscle imbalances from developing.
Working is only a third of your day. You also need to look at how you sit at home, at your computer workstation and in the car. Do you adopt the characteristic slump position (posterior tilt of the pelvis)? If you do, think about investing in a lumbar support cushion as a sitting aid.
Our legs are a lot stronger than the back. Let them do the hard work when it comes to lifting heavy objects.
Consider also the following:
• Sleeping positions – we spend a lot of time asleep. Is your mattress giving you support? What is your general lying position? Sleeping with a small pillow in-between the legs while on your side can help if you are suffering with acute lower back pain, as it will tend to give the pelvis greater support
• Activities/sports that may exacerbate back problems – going to the gym might actually be making things worse, as the muscles you are isolating with weights exercises may be making them tighter.
Core stability training starts by working on the postural muscles and building these up first. After this initial training, the body can be subjected to heavier loads since we now know that the body can hold good posture. This training routine has proved popular with Australian sports coaches following rehabilitation research work from Queensland University (Hodges PW, Richardson CA, 1996).
So what do I do if I develop a back problem while working?
You need to see your physician/GP to ensure that the problem is simple/mechanical back pain. This means that the stability musculature of the spine has become dysfunctional and can no longer give the support it required (Hides JA, 1996). This is why you may start to experience periods of locking/jarring of the back. Periods of general aches and pains are just the warning signs that you are abusing your back.
You need to keep your back moving. The temptation is to lie down and not move because it hurts too much. However, getting the back moving is the best way to try to reduce some of the protective spasm you may be experiencing.
So who do I see now?
You need to go to a manual therapist. Most back pain is treated through massage and manipulation. Although randomised controlled trials have failed to show any conclusive long-term improvements (UK BEAM trial team, 2004), from my personal experience they can provide some relief from day-to-day back pains.
Manual therapists (physiotherapists, osteopaths and chiropractors) who try to get the core stability muscles working are the people you need to see. You need to retrain your body and get the necessary muscles working correctly again, otherwise you’ll never fully rehabilitate from such an injury (Hides JA, 1996). Then you need to start to make the lifestyle changes that I have already described.
It’s like one of your patients needing a filling. You can restore the tooth but if your patient doesn’t change his oral health habits, then next time you see him he will need another, then another and so on.
The approach to treating and looking after your back is exactly the same principle. This is why, with any healthcare issue, education and prevention should be the focus. Back pain, if constantly ignored, will plague you until you do something about it. If you don’t do something now, you will end up spending your health-related, early retirement in a lot of discomfort. For further help, visit www.backcare.org.uk.
A final note
This article is a small piece of advice for anyone suffering with back pain. There are no quick fixes and it is something for which you will have to make lifestyle changes that promote good posture and conditioning of your body.
My views are personal and some of the things that I recommend are based upon what I did when I had a back injury to help me manage my daily activities.
Burke FTJ, Main JR, Freeman R (1997) The practice of dentistry: An assessment of reasons of premature retirement. BDJ 182: 250-254
Chaffin DB (1973) Localised muscle fatigue – definition and measurement. Journal of Occupational Medicine 15(4): 346-54
Gandavadi A et al (2005) Effect of two seating positions on upper limb function in normal subjects. Int Journal Therapy and Rehabilitation 12(11): 485-490
Hides JA (1996) Multifidus muscle recovery is not automatic after resolution of acute, first episode LBP. Spine 21: 2763-69
Hodges PW, Richardson CA (1996) Inefficient muscular stabilisation of the lumbar spine associated with low back pain: a motor control evaluation of transversus abdominis. Spine 21: 2640-50
Marshall ED et al (1997) Musculoskeletal symptoms in New South Wales dentists.
Australian Dental Journal 42(4): 240-6
Nachemson A, Morris JM (1964) In vivo measurement of intradiscal pressure: discometry, a method for the determination of the pressure in the lumbar discs. Journal of Bone and Joint Surgery 46A: 1077-1092
Panjabi MM (1992) The stabilizing system of the spine. Part 1. Function, dysfunction, adaptation and enhancement. Journal of Spinal Disorders 5: 383-389
Paul E (1981) Are you sitting comfortably? Dental Update Nov/Dec: 559-566
Rundcrantz BL (1991) Swedish Dent J supplement. 76: 1-102
UK BEAM trial team (2004) United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial. BMJ 329, 1377
Waddell G (1998) The back pain revolution. Churchill Livingstone