Review of Optometry

 

When optometry is a pain in the neck

... or back, or arms, or feet, or wrists. Pain doesn’t have to be the price you pay for practice.
Michelle Paollilo

11/12/2001

There’s this old joke in optometry: If you stand up to refract, you get back problems. If you sit, you get hemorrhoids. Although, if you’ve had either you probably don’t think it’s very funny.

Aches and pains are the price you pay for practice. So a lot of doctors think. “Sometimes health professionals are worse than other people because they ignore their problems,” says Pamela Colman, D.P.M., director of scientific affairs for the American Podiatric Medical Association.

The price of ignoring those aches and pains can be high. Optometrist Irene Sang found that out earlier this year. She was diagnosed with thoracic outlet syndrome—chronic pain caused by inflammation and compression of the nerves, veins and arteries to the arm where they pass through the thoracic outlet in the shoulder.

“I don’t know when I went from ignoring aches and pains to saying, ‘Ooooh, I’m hurting,’ in the middle of the day,” Dr. Sang says. “When the pain woke me up at night, I knew I really had a problem.”

Dr. Sang isn’t alone. The “Live Poll” at Review of Optometry OnLine obtained opinions from more than 200 O.D.s about where they suffer practice-related aches and pains. The back led the way, followed by the neck, feet and wrists. Pain, however, does not have to be the price you pay for practice.

Carpal Tunnel Syndrome
Wrist and arm pain are growing afflictions among optometrists. “With the increased use of computers, we are seeing more carpal tunnel [syndrome],” says Jeffrey L. Weaver, O.D., director of the AOA’s clinical care group. Our own research shows that 95% of O.D.s have computers and 90% use the Internet. This, of course, comes with its own hazards, which have been well documented.

Optometrists place extra stresses on their arms, hands and wrists that are unique to the profession. Much of this involves the art and science of refraction—extending the arm, reaching upward (if seated), bending the wrist backward to a 90-degree angle, and then turning small dials and flipping lenses with the fingers. It’s not a task for which the human body is built.

Optometrist Jeff Ekery of El Paso, Texas, had been in practice about 15 years before it got to him. His right hand began to atrophy and lost its strength. His fingers would not close. “I didn’t even occur to me that I had carpal tunnel [syndrome],” Dr. Ekery says. “My left hand was fine.” A visit to a hand specialist and a second opinion confirmed the diagnosis: motor nerve branch carpal tunnel syndrome (CTS). (There are two types of CTS: sensory nerve branch, the more common; and the variant Dr. Ekery had.) Ten years ago Dr. Ekery had surgery to repair the carpal tunnel. Since then he has been mostly symptom free, though he admits, “I occasionally have cramping if I’m keyboarding too much.”

Anatomical Anomaly
This is what happens in CTS: The median nerve passes from the forearm through a tunnel in the wrist and into the hand, where it connects to the thumb, index and middle fingers. Mukund Patel, M.D., of the Brooklyn Hand Surgery Center, explains that when the wrist is held straight, pressure on that nerve is about 20mm Hg; when the wrist is held backward, the pressure doubles to about 40mm Hg; and when the wrist is inflected, the pressure rises to about 60mm Hg.

“When anybody uses the hand that is continually in inflection or extension, then there is more compression of the median nerve,” Dr. Patel says. “In the initial phase, this cuts off circulation to the nerve. When the wrist is in the normal position, the circulation restores. This is when the patient gets intermittent numbness.”

That’s the first phase of CTS, known as the vascular stage. In the second phase, the myelin sheath—the coating that protects the nerve—begins to break down. Impulses begin to misfire during nerve conduction. This demyelination leads to permanent numbness. In the third phase— the axonal degeneration stage—the nerve fibers become compressed and disconnected, causing a permanent loss of sensation and movement of those muscles the median nerve supplies.

Treatment of CTS depends on the severity. The recommended treatment for stage 1 CTS is to immobilize the wrist with a splint, for which Dr. Patel calls the prognosis “good.” In stage 2, the treatment of choice is an injection of cortisone, which shrinks the lining around the tendon in the wrist and opens more space for the median nerve. That carries a success rate of about 50%. The third phase requires surgery—a five-minute procedure under local anesthetic. Patients typically regain full use of their hands in 10 days to two weeks, Dr. Patel says.

But surgery is not a green light to go back to doing things as you’ve done them before. Says Dr. Ekery: “The surgeon told me I can’t go back to what I’m doing. I’m right handed, and that hand does all the knobs on traditional refraction.” For an optometrist who must refract, this poses a huge problem.

Dr. Ekery found the solution in an electronic refracting lane. His workers’ compensation coverage paid for the equipment, and for more than 10 years now he has kept refracting without skipping a beat. In fact, he thinks his exam has become more focused and efficient, with better results because of it.

Save Your Back
  • Remember what mom said about good posture. Sit and stand with your head high, chin tucked and toes straight ahead.
  • Adjust your instruments and work area so you can maintain an unstrained, comfortable position with your arms and forearms relaxed.
  • Avoid excessive bending and stooping.
  • Alternate between standing and sitting tasks. When standing for long periods, rest one foot on a low stool. When sitting, rest both feet flat on the floor.
  • Use a chair with good back support and easy-to-use height adjustment. sources: American College of Occupational and Environmental Medicine; American Industrial Hygiene Association.
Trouble in the Shoulder
Many O.D.s refract from the sitting position, which only complicates matters because they must lean forward and reach upward. That makes them more vulnerable to neck, back and arm pain.

It was the reaching upward that mostly affected Dr. Sang, who practices in South Pasadena, Calif. She has been in practice about 17 years, but earlier this year got her first hint of optometric agony when a sharp pain shot down her shoulder to her fingers in both arms. “If you ever had anybody grab your upper arm and squeeze it real hard, that’s how it felt all the time,” Dr. Sang says. Also, her upper and lower extremities were often cold—classic symptoms of thoracic outlet syndrome, or TOS.

TOS is not as common as CTS, Dr. Patel says. In 1999 the Bureau of Labor Statistics documented 28,000 cases of workplace-related CTS. The incidence of TOS is a fraction of that, Dr. Patel says (specific statistics are not available).

Compression of the thoracic outlet occurs in individuals who engage in repetitive activities overhead—painters, electricians, plumbers and O.D.s who sit down to refract. Dr. Sang used to refract from a seated position. No more. That change was part of her three-pronged treatment: NSAIDS, physical therapy to loosen the scalene muscles in the arm, and a change in routine. “It’s a hard habit to break,” she says, “so I had to retrain myself in the routine of the exam.” She considered an electronic refracting lane, but eventually decided against it. “There would be more retraining for me to learn how to use that panel than to learn how to refract standing up,” she says

There are still a few tasks for which she has to reach upward, but she has reduced that activity substantially. “What happens though is that when you develop something like this, you can get some long-term relief, but it’s never really gone,” she says. “You can reactivate it.” Standing to refract hasn’t been much of a challenge; she simply raises the exam chair. The challenge comes when she writes in a chart on the counter: she still has to lean over. She continues to work out her exam regimen, but she has kept up her 28-32 hours a week in the office through it all.

Sitting vs. Standing
Drs. Ekery and Sang learned the hard way that repetitive stress injuries do happen to doctors. Dr. Ekery never sat down to refract. “I know some of my older colleagues had back trouble from always bending over,” he says. “I always raised the chair up and stood up.”

Of course, that depends on your height, too. Ledgewood, N.J., optometrist Randolph Brooks stands 6 feet, 5 inches. “A lot of shorter doctors can do everything standing up,” he says.

Good posture in the exam room can go a long way toward avoiding repetitive stress injuries. The arms do not extend upward and the wrists do not inflect at such a sharp angle from the standing position. And, it may save your back.

“The position of sitting and leaning forward increases pressure inside the intervertebral discs more than just about any position,” says Scott Boden, M.D., orthopedic surgeon at the Emory Spine Center in Duluth, Ga. “It is not clear that this predisposes one to back problems. However, once someone has a back injury or strain, that position could certainly aggravate it or delay the healing/recovery process.”

You don’t want to trade one pain for another. Standing to refract is fine, as long as it doesn’t lead to foot problems, another common cause of the back pain that many health-care professionals suffer. “When you have foot pain, it’s common to compensate,” says Dr. Colman, a board certified podiatrist. “It can give some people what’s called a pelvic tilt.” This can cause an imbalance in the leg and lead to lower back pain.

This is the lowest level of the biomechanical kinetic chain. “What happens in the foot affects the ankle, the leg, the knee, thigh, pelvis, low back and so on,” says chiropractor George McClelland.

A recent poll by the American Podiatric Medical Association found that 30 percent of respondents suffered from plantar fasciitis (heel pain) in the previous 90 days. Ronald Jensen, D.P.M., calls this “an epidemic of heel pain in this country.”

A culprit in many O.D.s’ offices: hard floors. Laminate flooring is becoming more popular, says Lori Estrada, a designer for Fashion Optical Displays. However, she recommends carpeting to her O.D. clients. “Carpet is a warmer look, as well as being more comfortable to stand on all day,” she says.

Even carpeting on concrete makes for a hard surface when one walks or stands on it all day. A pad in the exam room may not be a solution because many doctors use chairs with casters on them.

A good, comfortable and properly fitting pair of shoes can help. Orthoses—custom-made shoe supports for correcting an abnormal gait—are an option, but one study found that over-the-counter arch supports and tension night splints work just as well short-term in some patients.1 “The easiest thing to do when you have foot pain is to change shoes,” Dr. Colman says.

You don’t have to let a shoe problem become a back problem or an arm problem or a hand problem. And, you don’t have to play through the pain like a wounded linebacker on Super Bowl Sunday. If you’re in mid-career like Drs. Ekery and Sang, and you’re ignoring aches and twitches that seem to get progressively worse, ask yourself: What will they be like in 10 or 15 years?

1. Martin JE, Hosch JC, et al. Mechanical treatment of plantar fasciitis: A prospective study. J Am Podiatr Med Assoc 2001 91: 55-62.

Vol. No: 138:11Issue: 11/15/01



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