Article Date: 9/1/2007

Optometrist, Heal Thyself
ergonomics

Optometrist, Heal Thyself

Here are five tips that may help you alleviate the strain of practicing optometry.

BY JENNIFER KIRBY, SENIOR ASSOCIATE EDITOR

ILLUSTRATION BY TOMMY HUNT

Rebecca Hutchins, a Niwot, Colo. behavioral optometrist and co-author of the article "Doctor, Ergonomic Thyself," (Journal of Behavioral Optometry) had been practicing for five years when her gym's trainer said her right shoulder was slightly higher than her left and didn't appear to work as well.

"I told her there was no reason for this — not realizing at the time that since I'm right handed and I flipped everything on the phoropter with my right hand and always stood on the patient's left, that this could be causing the problem," she remembers.

In fact, Dr. Hutchins' chiropractor and osteopath identified this as the culprit several years later, she says.

Optometrist Julie Ryan, of Irvine, Calif., presented to her primary-care doctor complaining of neck-ache and dizziness after practicing for six years.

"Initially, my doctor suspected high-blood pressure and then a brain tumor, but it turned out to be a herniated disc as a result of twisting toward the phoropter," she says.

These optometrists suffer from work-related musculoskeletal disorders (WMSDs), defined by the National Institute for Occupational Safety and Health (NIOSH) as a group of conditions that involve the nerves, tendons, muscles and supporting structures, such as intervertebral discs, caused, or made worse, by the work environment. WMSDs can cause pain, tingling and numbness, lost time from work, productivity reduction, an inability to perform job tasks, temporary or permanent disability and an increase in workers compensation costs (think of your staff), according to NIOSH. WMSD risk factors: repetitive, forceful or prolonged exertions of the hands; frequent or heavy lifting, pushing, pulling or carrying heavy objects and prolonged awkward postures.

Your soreness, headaches and tiredness may not be due to stress, but the devices you use and your awkward positioning as a result.

Despite these and other optometric stories of work-attributed shoulder, neck- and backache, optometry isn't listed on the U.S. Department of Labor, Bureau of Labor Statistics most recent report (2005) on occupations linked with musculoskeletal disorders. A possible reason for this omission: Optometrists may be under-reporting their injuries, your colleagues say.

"I think that when it's your livelihood, you just do it, and you don't even think about it," says Dr. Hutchins. "And I think that we all, but men in particular, are taught to suck it up. It's like football, in that they know they're going to get hit and tackled and hurt, but they're told it's all part of the game, so they don't say anything about it."

Optometrist James E. Sheedy, O.D., Ph.D., and Dean of the College of Optometry at Pacific University in Forest Grove, Ore., who has a background in ergonomics, says he thinks optometrists may be missing from this report because they're attributing their soreness, headaches and tiredness to the stress of running a practice and not to the devices they use or the awkward positions in which they place their bodies. (See "What is Ergonomics," below.)

"What we as a profession need to be aware of is that our physical strains may not be due to working too hard, but not working smart," he says.

Here are five tips, provided by your colleagues that may help to alleviate or prevent the onset of WMSD. (See "General Tips To Avoid WMSD".)

Keep in mind, however, that you should seek medical assistance in addressing any musculoskeletal problem, and the success of each tip is relative to your specific situation.

1. Use a height-adjustable stool and/or table

A height-adjustable stool enables you to firmly plant your feet on the ground, which stabilizes the trunk of your body, says Dr. Ryan.

"The stabilization of your body enables the alignment of your shoulders and neck, allowing you to support your raised arms when using diagnostic equipment and prevent elbow strain when writing at your desk," she explains. "You can also keep your spine better aligned by bending from your hips — not arching your back — when reaching forward while on your height-adjustable stool. When you do not have this alignment, you cause unequal stress on your cervical spine, which causes headaches, neck aches, dizziness, etc." (See "To Sit or Stand, That is the Question".)

Dr. Hutchins recommends an electronic height-adjustable table. "I see children who are six months old through adults in their 90s, and the push-button table is great because it moves so that my patient, regardless of his height, can be at the right height for the instrument, and I can change my chair height," she says. "The table also enables me to spend more time talking with my patients because I no longer have to conserve my breath to crank a manual table, which, incidentally, now sits on my back porch. Being that I see a lot of brain-injured patients, they need time to understand what I'm saying, and they need a lot of reassurance."

What is Ergonomics?
Taken from the Greek term "ergon," which means "work" and "nomos," which means "laws," ergonomics is the scientific discipline that deals with the understanding of interactions among people and other elements of a system and the profession that applies theory, principles, data and design methods to optimize human well-being and overall system performance, according to the International Ergonomics Association (IEA) (www.iea.cc).
The field of ergonomics is comprised of three specialities: physical, cognitive and organizational. The IEA defines physical ergonomics as the human anatomical, anthropometric, physiological and biomechanical characteristics of physical activity. This includes working postures, materials-handling, repetitive movements, work-related musculo-skeletal disorders (WMSDs), workplace layout, safety and health.

2. Avoid sitting side-saddle

In optometry school, we're taught to sit side-saddle when facing the patient because straddling doesn't look professional. This causes the back to twist, says optometrist Jeri Schneebeck, of Centennial, Colo. and co-author of "Doctor, Ergonomic Thyself."

"Because it's better for your body to face the patient, you can straddle the patient by keeping your legs really low and bending at your knees, which are locked together," she says. "This is very discreet, and it works."

General Tips To Avoid WMSD
1 Have good lighting. Naked bulbs in your light fixtures cause glare, which makes you alter your body in an unnatural way, says Dr. Sheedy.
2 Be mindful of your light-switch locations. Light switches and manual controls located in areas where you have to reach across and twist your body to operate them can cause musculoskeletal problems, says Dr. Sheedy.
3 Consider wearing occupational progressive lenses. "In normal progressive-addition lens designs, you need to adjust your posture to use the right portion of the lens to interact with the patient. This can cause musculoskeletal problems," says Dr. Sheedy.
4 Exercise regularly. Exercise your lower back muscles along with your abdominal muscles (core). You can do this by utilizing balance boards, for instance, says Dr. Tebby. Using balance products and visual tracking to stimulate accommodation greatly increases core strength. By increasing core strength, you tone the muscles around the trunk (ie all the supporting muscles of the spine).

Alan Tebby, a Charlotte, N.C. chiropractor, who specializes in ergonomics and has worked with O.D.s, adds that you may want to consider using a "drummer's throne" (a padded, height-adjustable, armless-seat designed for drummers) that provides back-support during exams.

3. Have right- and left-handed exam rooms

If you stand during the examination, your exam room is most likely set so you stand on one particular side of the patient every time. This repetition can cause constant twisting on one side of your body, which could lead to problems, says Dr. Schneebeck.

"I made some of my exam rooms left-handed to even out the usage of my body's muscles and avoid fatigue. I also concentrate on not coming at patients from the side," she says. "I try to angle myself so that I can kind of keep my arms equidistant from the patient. You can't do this completely due to the design of the phoropter, but I concentrate on how I'm standing, so I don't skew my body so much."

Dr. Tebby point outs, however, that unless you're ambidextrous, this method could be a time squeeze.

"I would suggest you make the very best attempt at keeping your nose lined up between your toes, and try not to twist to such a degree that your upper body rotates outside of your feet," he says. "Obviously, if you are sitting, don't rotate your upper body outside your knees."

4. Consider automated equipment

Purchasing automated equipment is a good investment, as it enables you to reduce repetitive stress injuries and therefore your need to provide worker's compensation to staff and/or make-up the financial loss from lost work due to such injuries.

"Because I'm a behavioral optometrist, I do a 21-point exam, which takes a good 15 to 20 minutes with switching the eye-chart targets and flipping lenses on the phoropter. This was really hurting my shoulder, so I decided to switch to a remote-control projector," says Dr. Hutchins. "This purchase made the biggest impact on relieving my shoulder stress because now, all I have to do is push a button and sit next to the patient. In addition, the time I've saved from having to operate the manual projector has enabled me to spend more time talking with patients about their care."

Optometrist Keith Wan, of San Diego, says he injured his shoulder playing volleyball almost three years ago, making it impossible for him to elevate his hands above his shoulders.

"Luckily, in my first practice we had a completely wireless system that controlled the chart and phoropter via remote control," he says. "It was almost like watching TV while refracting. I didn't have to be directly in front of the phoropter in order to effectively manipulate all the controls. It really saved me."

Dr. Wan also uses a device that he terms a "whole refracting lane."

"I actually bought this instrument for efficiency and not ergonomics, but I got both. It contains diagnostic equipment, such as a slit lamp and keratometer. It has a backlight, which aids both emerging and current presbyopic doctors in reading the dials, large print and it actually sends results directly into my electronic medical records (EMR) software," he says. "Because it takes care of the patient from A to Z, it saves me about eight- to 10 minutes per patient, which really adds up in terms of me being able to spend more time talking with patients. And, the set up allows me to remain seated in a comfortable position and access all the instruments. I don't even need to move my chair."

To Sit or Stand, That is the Question
Drs. Hutchins and Schneebeck examined whether it's better to sit or stand during an examination in their article, "Doctor, Ergonomic Thyself." Their findings:
The body-mechanic professionals (physical therapists) with whom they spoke supported a standing position because they said that leaning forward while in a sitting position was more harmful to the lower back and hips than doing so while standing. In addition, these same professionals said that standing does not demand you raise and extend your arms as much as sitting.1
Still, these same experts warned that standing can also cause problems if you don't:
  • maintain good posture (meaning you shouldn't arch your lower back or favor one foot for balance)
  • have carpet padding
  • have supportive and comfortable shoes.

  • All of these bullet points allay the effect of being on one's feet for long durations, these professionals say.1

    Optometrist Stephen Glasser, of Washington, D.C., who specializes in computer ergonomics, recommends you consider patient-information software.

    "Most practice-management programs offer drop-down lists, which include 'Prescription,' 'Readings,' etc., where you simply click on that option to enter that information. This prevents the long-term strain on the arms from holding a pen or a pencil and the awkward positioning of balancing a clipboard on your lap, for instance, while facing the patient," he says. "Writing out information is more of a sustained task than turning and clicking on a computer."

    5. Consider a hand-held tonometer

    Often times, the tonometer requires you to hold the patient's lid up, hold the joystick and adjust the tonometer measurement to make sure the patient's eye, tonometer and mires for a pressure reading are aligned, says optometrist Marc Bloomenstein, of Scottsdale, Ariz.

    "This multi-tasking causes us to arch around the slit lamp, so we're twisting and turning and constantly standing and then sitting, all of which puts stress on the back — especially when you have a patient who keeps moving back," he says. "With a hand-held tonometer, you can actually check the patient's intraocular pressure (IOP) from a complete standing position. You just bring the device up to your eye level, and you don't have to bend or arch all over the patient. You're in a normal scanning position."

    Dr. Tebby adds that if you're going to be standing for an extended period of time, you may want to put a small box on the floor and place one foot on top of it to relieve the strain placed on the lower back.

    Remember: "No single body position is good for very long periods of time. You need to have a variety of positions to move throughout the day," says Dr. Sheedy. "So, if you're sitting or standing too long, for instance, look at ways of introducing a variety of postures into your life."

    The bottom line: Your body doesn't have to suffer so you can provide the best care to your patients, so look into ways of alleviating the strain of practicing optometry. OM

    Special thanks to Dr. Alan Tebby, of Tebby Chiropractic and Sports Medicine Clinic in Charlotte, N.C. for taking the time to review the article and in particular, the tips offered by those interviewed.

    1. Hutchins R, Schneebeck J. Doctor, Ergonomic Thyself. Journal of Behavioral Optometry. 2004 April;4(15):87-89.



    Optometric Management, Issue: September 2007