Antidotes for Musculoskeletal Disorders
Maintaining fitness and sticking to a regular exercise routine may help oral health professionals prevent work-related injury.
By Jacquelyn L. Fried, RDH, MS
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
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.
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 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
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
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
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
Stretching and Strengthening Exercise
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.
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.
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
FIGURE 1. A plank requires the participant to tighten and pull in the abdominal muscles while squeezing the gluteal muscles.
CAPDESIGN/ ISTOCK/THINKSTOCKFIGURE 2. To strengthen the core, a supine abdominal draw-in exercise can be performed.
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
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
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
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.
chairside stretching performed daily is designed for tight and static muscles.
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.
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
- Kumar DK, Rathan N, Mohan S, et al. Exercise prescriptions to prevent
musculoskeletal disorders in dentists. J Clin Diagn Res.
- 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.
- Hayes M, Smith DR, Cockrell D. An international review of
musculoskeletal disorders in the dental hygiene profession. Int Dent J.
- Barry R, Esenhaur A, Weber M. Occupational health hazards. Dimensions
of Dental Hygiene. 2014;12(9):58–61.
- Valachi B. Keys to wellness. Available at:
posturedontics.com/pdf/6-Keys-to-Wellness-Article.pdf. Accessed December 16,
- McConaughy F, Perry S. Preventive interventions for musculoskeletal
disorders. Dimensions of Dental Hygiene. 2016;14(1):18–22.
- Centers for Disease Control and Prevention. Report on Physical
Activity and Health. Availabel at: cdc.gov/nccdphp/sgr/chapcon.htm. Accessed
December 16, 2016.
- 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.
- Phedy P, Gatam L. Prevalence and associated factors of musculoskeletal
disorders in young dentists in Indonesia. Malaysian Ortho J.
- 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.
- Cooper K. Aerobics Program For Total Well-Being: Exercise, Diet
and Emotional Balance. New York; Random House; 2013:230.
- 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.
- 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.
- 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.
- 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
- Princeton University Athletic Medicine. Lumbar/Core Strength and
Stability Exercises. Available at:
uhs.princeton.edu/sites/uhs/files/documents/Lumbar.pdf. Accessed December 16,
From Dimensions of Dental Hygiene. January 2017;15(1):18-21.