Bill Klaproth (Host): This is an AAOMS On the Go podcast. I'm Bill Klaproth and with me is Dr. Julie Chavez, an AAOMS fellow, as we talk about work-related pain and the benefits of ergonomics for oral and maxillofacial surgeons. Dr. Chavez, welcome.

Dr. Julie Chavez: Hi, Bill. Thank you for having me.

Host: You bet. It's great to talk with you. So, let me ask you this, how did you develop an interest in ergonomics? And why is it important for oral and maxillofacial surgeons in particular?

Dr. Julie Chavez: Well, I had and continue to have some issues, some musculoskeletal problems myself. And in working through those issues, I developed a keen interest in it and also an interest in how we don't get much training in that throughout all of our residency or even prior to that in dental school, and seeing that as a big learning knowledge gap and hopeful that I can help remedy that in some point in time.

Host: So Julie, you mentioned that you have had and continue to have some issues. Can you tell us what musculoskeletal issues you're facing?

Dr. Julie Chavez: For me, I had developed some shoulder issues. And for right-handed surgery, we're holding a retractor in our left hand almost constantly, and I've developed some limited mobility and some issues in my shoulder. And I knew it was coming from the work and trying to improve my posture and things. But then, I developed some numbness in my fingers on my left hand, on my ring and pinky finger. And then, through our training we do a lot of neurosurgery and so we know that this can be coming from the neck and the cervical vertebrae. So, it was very worrisome. And of course, I was very afraid that this was going to progress or potentially prevent me from practicing. So, I did everything in my capability to rehabilitate with my trainer, who thankfully I have had a really great trainer, Chuck Turner, for almost 10 years now. He helped me a lot, massage, stretching. So, I really got interested in this and I was able to really help myself and rehabilitate. It's always there nagging. But that's been my experience more than back pain and some neck. But the studies show and our study shows that mostly shoulder, neck, back is the highest risk areas for us.

Host: So, you talk with a lot of other OMSs. This sounds like it's something that's common in the industry, would that be right?

Dr. Julie Chavez: Yes. I think unfortunately extremely common.

Host: So, there's a survey that was done of the Minnesota Society of Oral and Maxillofacial Surgeons, and can you share with us any things you learned specifically about ergonomics?

Dr. Julie Chavez: In my journey, it spurred me to investigate. I had many colleagues that were experiencing similar problems and I've had former partners that have had to retire because of musculoskeletal issues. So, we have several meetings, COVID kind of derailed it a little bit, but, you know, often seeing a lot of colleagues at meetings. I had met some occupational health students that were obtaining their PhD in occupational health. So, they helped me develop this survey that was basically a 14-question survey, and I distributed that to colleagues and residents at meetings over about a year period. And it asks questions such as: "Are you currently experiencing pain? And if yes, where?" "Do you attribute this pain to your career?" "Have you missed work because of this?" So, some of those kind of questions, and it was really quite alarming that 47% of the survey participants, and we ended up having about 75, 47% said they were currently experiencing pain and most prevalent at 38% was shoulder like myself, then neck 37% and lower back at 31%. So, that information too spurred me further to think it seems crazy that we don't get any training in this.

And with the help of the occupational health students and then Jim Swift, who was my director and mentor going through residency and my trainer, Chuck, we wrote a paper on using the data that we collected. And I'm hopeful it's been accepted for publication in a journal called WORK, which is an occupational health journal. And I think it was in September we got accepted and it should be within the year. So hopefully, any month now, it'll be coming out. But it does go through those findings and some other findings too.

And with my work with Chuck, as I was a client of his for many years, I found out that he did some work in corporate settings. And he's very fitness-oriented, but he's really in incredible shape, but he's that kind of person that is focused on the six-pack abs and really focused on functional movement and a lot of stretching. So, he's very good at what he does, and I think some people had recognized that he's really motivational. So, he was going to these corporate settings where people were either factory, working on the floor or sitting at a desk for long periods of time. And he would go in and, for the factory workers, every 45 minutes for five minutes, you know, he'd pop up on the screen and he was going through some of these fitness strategies, mainly stretching and to avoid these repetitive motion injuries. And so as I was having my issue and talking with him about that, I thought, "Well, we need something like that for surgeons." So, that's really kind of how the light bulb went on and how I pursued it.

Host: Yeah. Well, some people may be shocked at those statistics you gave us. So given the physical nature of the profession, is it inevitable then that OMSs will develop neck or back or shoulder injuries?

Dr. Julie Chavez: I believe it's preventable. And I think that it's multifactorial. I think if there's good training with ergonomics, which is basically being aware of your posture and your body position while you're doing this. It is a quite physical job. I think that would be number one, is understanding the ergonomic principles that we need to withstand the work that we're doing and then, the fitness strategies to promote strength. I think it's really about strength and stretching and you don't have to be a fitness nut to benefit. And most of these exercises are very simple and straightforward. So, I think a combination of those two could prevent a lot of these musculoskeletal problems, which are the top cause of people becoming disabled and not being able to practice, and it's across the healthcare of surgeons. Dentists, number one, are highest risk of musculoskeletal disorders followed by surgeons. And when we were looking at research, I found, well, there's surgeons and lots of different types of surgeons. Really, there's not much specific data out there on oral maxillofacial surgeons. But I think as a dentist who's specializing in surgery, we're probably at the top of the chain to be highest risk for those problems. But the statistics that we saw is really pretty in line with a lot of the other research out there in other surgical specialties. And, you know, there's oncologic surgeons, there was a lot of OB-GYN, there's really a lot of research out there on many surgical specialties. And at some level, I think we're all doing similar type of work and contorting ourselves in these positions. And yeah, it's a big problem, I think.

Host: So, you were talking about prevention. What are some things OMSs can do or change to avoid discomfort or prevent injury?

Dr. Julie Chavez: With the ergonomic piece, I think just understanding some simple ergonomic principles can go a long way as far as posture. And basically as humans, no matter what kind of work you're doing, you would like to try to avoid having your spine bent greater than 30 degrees off the vertical in a forward back motion or side to side. And the same thing with the neck, you know, as the more we have it bent over, that's going to put you at higher risk. The longer time you spend in that position, greater than 30 degrees, the higher risk you're going to become. And as far as shoulders go, keeping your shoulders down and your arms in close to your body helps relieve a lot of the stress that your shoulders can take. And then, wrist angle, I think we're not as high risk as maybe some people, general dentists or people like hygienists. But the angle that your wrist makes, your hand to your arm, you should not close that down greater than 105 degrees. So, I've given some lectures and I made a slide that is called ergonomics for dummies, and it basically just says 30 degrees, 30 degrees, and greater than 105. And I think the principles are simple because for somebody that's six-foot-five versus myself who's five-foot-five, you know, positioning of patients and tables and it's going to be different. But if you can keep those principles in mind, that's really the goal.

Host: Yeah. And how about standing? Is there anything that we should know about standing? You mentioned posture earlier, and is there any fitness strategies an OMS can utilize?

Dr. Julie Chavez: So, I think for standing, I do think it can be more beneficial. Most oral maxillofacial surgeons stand during their procedures as opposed to general dentists or other dental specialists that are sitting most of the time. And even though the OMSs in our survey, we did report back pain, lower back pain at 31%, but the literature for general dentists and other dental specialists is showing that they are affected by back pain at about 70% incidence and mainly lower back pain. So, the standing may afford some protection to the lower back and the lower back with the posture. A lot of it has to do with core strength and core exercises, and thinking about those things as you're operating. And I think things in my practice, what I try to do is when things are going well and I feel like we're sailing along, then I try to really think about my posture and ergonomics. And of course, when you're struggling or things aren't going great, then you're just doing what you got to do to get the job done.

I think the core strengthening exercises and Chuck and I have developed a project called the Sustainable Surgeon Project, and there's a website and also social media, Instagram, but we have a lot of videos through the website or through YouTube that have some of these simple strengthening exercises targeted at strengthening the upper back to combat the hunched over position, so strengthening the back. We're all stronger no matter what you do, sitting at a desk or whatever, we're all stronger in the front than the back. And so, a lot of that strategy is the core and strengthening of those back and neck muscles.

Host: Yeah. So, it sounds like it's not inevitable that OMSs will develop neck or back injuries or shoulder injuries, especially if they pay attention to ergonomics. And what you said earlier, make sure your shoulders are down to the body, watch your wrist angle, proper standing techniques. And then if you employ fitness strategies, it sounds like you can keep these types of injuries at bay then.

Dr. Julie Chavez: I am a firm believer that if you have that education and are doing those exercises, I think that you would've a much better chance of having a musculoskeletal disorder-free career.

Host: Which is what we're looking for. So, are there additional resources and tools available to surgeons, Julie?

Dr. Julie Chavez: Well, people can go to our website, so it's called The Sustainable Surgeon Project and the YouTube site or Instagram. And so, we've got a lot of videos up there.

And I just came across a paper that the American College of Surgeons put out about three years ago. So, they developed a task force for ergonomics and these kind of fitness strategies. And I think the impetus was for general surgery when they went to doing a lot of robotic and laparoscopic procedures, they were experiencing a much higher incidence of these musculoskeletal disorders. So, that is out there too on the internet. So, it's American College of Surgeons and it's got a nice synopsis. A lot of it is targeted to laparoscopic and robotic procedures that we don't do that type of work much, but I think is still helpful.

Host: Right. So, you called it the Sustainable Surgeon Project, is that correct?

Dr. Julie Chavez: Yes.

Host: And what is the URL for that?

Dr. Julie Chavez: Yeah. Sustainablesurgeonproject.com.

Host: Got it. Sustainablesurgeonproject.com. Well, this has been great, Julie. Thank you so much for your time. As we wrap up, is there anything you'd like to add?

Dr. Julie Chavez: Well, I think that I love the career, the oral surgery career. I think everyone would agree, every day is interesting, never the same. But I do think that we need to be more in the mindset of almost like an athlete, that you're going to go to game day every day, and you need to prepare for that. It doesn't take a lot of preparation, but it does have to be sustained. And you have to drink the Kool-Aid to benefit and not wait until you're developing an injury. And I'm hopeful that I can be instrumental in maybe developing some curriculum that could be implemented for residency and even earlier so that the earlier you know that this is a possibility and have the fundamentals, I think it would go a long way to preventing some of these problems.

Bill Klaproth (Host): Well, Dr. Chavez. That was wonderful. Thank you so much for your time. I love how you put that every day is game day and we've got to be prepared and through your help in work. We certainly will be more prepared. So thank you again, Dr. Chavez. We appreciate it.

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