Of Ophthalmologists & Aching Backs

With repetitive stress injuries, the doctor becomes the patient. Here's how to protect your body — and your practice.

By René Luthe, Senior Associate Editor

For jobs that entail heavy lifting or long periods of time spent in one position — construction work, cooking and truck driving, for instance — it has become widely accepted that ergonomics are vitally important for avoiding injury. Employees are trained in proper positioning, employers provide supportive aids and on-the-job injuries receive prompt attention. Many would be surprised, however, to learn that the prestigious, white-collar occupation of physician carries some significant physical hazards as well — and that ophthalmologists may be especially at risk.

Mitchell Jackson, MD, of Lake Villa, Ill., could be the poster boy for the havoc that a high-volume surgical practice can wreak on the physician's body. He's had four herniated discs, beginning about 12 years ago.

Three times they occurred in his lower back, resulting in such severe pain in his leg that he couldn't sit. “My neurosurgeon says it's all from doing thousands of eye surgeries, not from any injuries.” Another herniated disc in his neck a few years later caused him to lose sensation in the three key fingers of his left hand. He was treated with epidural injections and took up swimming after the neck injury. “I've been symptom-free since,” he reports.

Dr. Jackson attributes his problems to the compression of his spine over time, “after doing 50,000+ procedures. Whether it's LASIK, cataracts, it doesn't matter.” And according to his neurosurgeon, Dr. Jackson's case isn't unique. “He told me the spine is a very common problem area for ophthalmologists.”

The extreme nature of Dr. Jackson's experience may surprise you — or then again, maybe it doesn't. According to attendees at last fall's American Academy of Ophthalmology meeting, the ergonomics presentations were packed with physicians who wanted to learn more. One of those presenters, Anna Kitzmann, MD, of the University of Iowa, says that a review of available research shows that anywhere from 33-69% of ophthalmologists report neck symptoms of repetitive stress injuries, while 30-80% report lower-back symptoms, and 27-33% report upper extremity symptoms.

Such presentations, plus an upcoming study, represent a concerted effort on the part of ophthalmology and industry to safeguard the health of physicians. Here's a rundown of what is currently known and the roles that correct posture, exercise and better-designed equipment can play.

Spotlight on MSDs

A growing body of evidence helped lead the Academy to form its Ergonomics Task Force last year, according to Jeffrey Marx, MD, the group's head. In a survey published in the American Journal of Ophthalmology in 2005, 30 to 40% of the survey's respondents reported having symptoms of musculoskeletal disorders (MSDs) — chiefly cervical spine and lower back problems, and carpal tunnel syndrome. Other studies also showed a high rate of MSD symptoms among ophthalmologists, and there were plenty of anecdotal reports as well. The Academy found the evidence persuasive enough that it commissioned an ergonomics specialist from the Mayo Clinic and the formation of the task force.

Among its findings thus far is that MSDs are not only the problem of older ophthalmologists. “Age is not the most important factor,” says Dr. Marx. “Clearly the volume of patients and the number of surgeries play a major role, probably more important than age alone.”

And even ophthalmologists who spend most of their day in an exam room are just as much at risk for MSDs as surgeons. Most of an ophthalmologist's time is in fact spent in the clinic, Dr. Marx points out. “It's that constant bending and awkward, static postures for a very long time that play a role.” As well as a tendency to be too rushed to pay attention to the things that might spare your back. The pressure to see more and more patients, Dr. Marx notes, tends to lead to sloppiness. “I read an interesting time-motion study amongst dentists, looking at positioning of the patient for a dental examination,” Dr. Marx says. “It concluded that it took on average five seconds to correctly position a patient. Dentists however, on average took three seconds for this critical function. For only about two additional seconds, the patient would have been positioned correctly, resulting in a significant decrease in risk for the doctor.” What doctors tend to do is allow themselves to position a patient badly while in haste, telling themselves that they are just so busy and will do it right next time — but the next time, the very same thing occurs. “We prioritize the patient — our waiting rooms are chock-full of patients and we have to keep up,” Dr. Marx says. It's a very natural response, but also one that is a sure path to MSDs.

Figure 1. In the image on the left, the ophthalmologist slumps toward the slit lamp, placing strain on his neck and back. On the right, he uses correct posture, bringing the slit lamp in to his eyes. COURTESY OF JEFFREY MARX, MD.

Dr. Kitzmann agrees. “I think ophthalmologists take ergonomic concerns seriously; I am not sure if we are proactive in preventing injuries at this point.”

One of the task force's goals, Dr. Marx reports, is to educate AAO members about how important ergonomics is to avoiding potentially serious repetitive stress injuries. For instance, the task force plans on creating a Web site for members with an “ergonomic tip of the week,” he says.

Equipment manufacturer Haag-Streit is participating in another effort to get a handle on MSDs among eyecare professionals. The company is finalizing a partnership with a leading university to implement the research. The study will incorporate field measurement and laboratory simulations to quantify the risk factors from the postures and motions ophthalmologists typically engage in.

“The researchers are trying to put this into measurable terms, correlating posture and positioning with injury risks so that they can develop recommendations for avoidance of MSDs,” Haag-Streit's vice president, Steve Juenger, explains. The company will contribute equipment and expertise, he says, as will Heine. The study does not yet have a start date.

Know the Stressors

The primary emphasis of the University of Connecticut study, according to Mr. Juenger, will be on the slit lamp and indirect ophthalmoscope due to the daily bending and leaning they entail. “We're always hunched over the slit lamp,” Dr. Jackson agrees. “And think — you do that 40-60 times a day, five days a week, maybe 300+ days a year. After 20 years, that adds up!”

Dr. Marx suspects a redesign of both instruments may be in order.

For the ophthalmic surgeon, of course, the chief problem is operating with one's head in the microscope. Though many newer models allow the surgeon to manipulate the scope in any position, “you are still operating in a scope,” with its attendant stress on the neck and back, Dr. Jackson says.

Stools that can't be adjusted low enough pose another challenge, he finds. Particularly when he uses the YAG laser, Dr. Jackson says he cannot position the stool low enough to operate comfortably on elderly patients, who often tend to be smaller. At 6′1″, even if he lowers the stool as much as possible, he can't always go low enough. “I'm almost at a 45-degree angle as I'm lasering, looking into the YAG laser scope.”

In the top image, note the straight line behind microscope oculars, showing that the surgeon is leaning his upper body in to meet them. In the bottom image, the line indicates the oculars have been moved 20 degrees toward the surgeon, allowing him to stand straight. COURTESY OF JEFFREY MARX, MD.

Douglas Katsev, MD, a refractive and corneal surgeon in Santa Barbara, Calif., believes that part of the problem for ophthalmologists is a tendency to accept the “that's the way we've always done it” mindset. He expects that attitude will change as younger people accustomed to video games and computers increasingly come up through medical school and ophthalmology residency. “They will have grown up with 3-D screens at the movie theater,” he says. “They expect these features to be the norm. That quantum shift is starting to happen.”

Industry Rising to the Challenge

Many in the ophthalmic industry have been working to bring such body-friendly innovations to their products.

Automation in eyecare equipment has grown by leaps and bounds in the past 10 years or so, and according to Marco's executive marketing director, Michael Crocetta, repetitive stress injuries were a major impetus. “They really drove the conversion from ‘Which is better, one or two?’” he says. Touch-friendly technology makes the ophthalmologist's life much easier, he explains, eliminating the stress of turning knobs and cranking pieces of equipment into position.

In the operating room, surgeons now have the option of TrueVision's stereoscopic high-definition visualization system, which displays the surgical field of view in real-time on a 3D flat-panel display. It is no longer necessary to sit at the microscope, holding a rigid position, to operate. According to the company, it can be used for any surgery that requires a surgical microscope.

Dr. Katsev, who was an initial investor in the company, initially purchased the system simply because he thought it was a good idea. It was only after he began using it that he realized it was more comfortable and beneficial for his posture. There's no more “sticking my head into a little operating microscope and not being able to move it,” he says.

“Anything that we learn from these studies that will help us build a better product, one that is ergonomically correct, that's what we are interested in,” says Mr. Juenger.

Should you still be leery of the idea of shelling out more money for new equipment, Mr. Crocetta points out that automated instruments also increase efficiencies — “tremendously,” he says. Automated, faster instruments also translate into savings by eliminating the need for remakes. “With automation comes the ability to put pretty much any staff member behind the device and have a consistent result,” Mr. Crocetta says. “To standardize those results is very important when you have a busy practice with multiple MDs and ODs and technicians. It's not about working longer, but needing to see more patients daily. Automation not only delivers greater speed, comfort and consistency — it is the only way to achieve the efficiency needed in practices of the future.” Mr. Crocetta.

What About Exercise?

Technology, of course, isn't the only answer to combating MSD problems. Dr. Jackson notes that since he began a regular regimen of swimming and core training nine years ago, he has been symptom free. Yet despite that success story, exercise may not be as much of a solution as one might think. The jury, according to Dr. Marx, is still out. While he believes that strength training is important and that the physically fit probably have a lower incidence of MSD symptoms, he reports that the AAO Task Force is divided when it comes to exercise. One member, for instance, does not believe that stretching plays a significant role in decreasing risks, while another member believes it helped him recover from his own back problems.

Steve Charles, MD, a retinal specialist and high-volume vitreoretinal surgeon from Memphis, is very skeptical of the purported value of stretching. It increases the risk of dislocation, he points out. “Every peer-reviewed sports medicine journal will tell you that stretching is overdone,” he says. “The idea that moving shoulders, elbows and knees into extreme positions somehow improves health is ridiculous.” Thus he remains less than enthusiastic about yoga, despite its popularity among some well-known doctors. “Dr. Oz is a big fan, but I find it a bit silly. If it constitutes excessive range of motion of hips, shoulders and knees, it actually leads to dislocation and doesn't solve problems.”

Abdominal exercises will help to strengthen the lower back, Dr. Charles notes, but there is no good exercise for the neck. “Just keep it straight and try to relax it.”

Other than this general advice, though, there's still too much uncertainty to warrant signing up for a rigorous exercise program. “At this time the Task Force is looking at recommendations from experts regarding exercise, strength training and stretching, but we have not gotten a consensus from experts on recommendations,” says Dr. Marx.

An Idea Whose Time Has Come

While it seems that the work of bringing the benefits of ergonomics to ophthalmology is just getting started, Haag-Streit's Mr. Juenger reports that it is already influencing the conversations industry and physicians are having. The information now available is creating a buzz. “Before awareness was heightened, there was an ‘it is what it is,’ attitude about an instrument's ergonomic comfort,” he says. “Now these concerns are part of our daily communications with doctors who come shopping for a new piece of equipment.”

Mr. Crocetta believes that the new focus on equipment that is body-friendly will not go away any time soon, and that its importance has actually been amplified by recent economic realities. “We are in a time where people need to work longer, and that includes doctors,” he says. Ergonomically designed equipment helps clinicians work longer without stress or injury. OM

How to Maintain Good Form By Steve Charles, MD, FACS, FICS Whether in the OR or in the clinic, there's no getting around it: posture matters. Stress on your cervical spine matters; stress on your lumbar spine matters. The different locales typically require different postures, though — here's what you need to know to practice healthful postures in each. In the OR Sitting up straight is critical. Back support is essential for this, but let me emphasize that it has to be the right sort of back support. You should have a backrest, but it should not be curved. A curved backrest forces the arms forward, preventing your upper arms from being in the necessary vertical position. Now your shoulder muscles have to support your arms against gravity, instead of them just hanging loose at your sides. The backrest should be small, positioned at the lumbar spine. This forces you to sit up straight — and both the lumbar spine and the neck should be poker straight. Upper arms, again, should be vertical, with elbows and lower arms at a right angle to the upper arms. Arm rests, or wrist rests, are a major no-no. They can improve your comfort, but they decrease the mobility of your hands and we've had patients who move in the OR. Arm rests impede the surgeon's ability to follow the patient's head should it move, creating the possibility of inadvertently damaging intraocular tissue. The patient's head acts as a resting place — for the surgeon's hands. The heel of your hand needs to rest on the patient's forehead; both hands should rest on the patient's forehead. That way, you are mechanically referenced, or mechanically grounded, to the patient's head. If they move, you move with them. As for your legs, adjust the height of your chair and of the operating table so the back part of your legs is not angulated over the chair, cutting off circulation in the legs and increasing the risk of deep venous thrombosis. There should be minimal distance between the back of the patient's head and the tops of the surgeon's thighs. Don't angulate the patient upwards by putting a stack of pillows under their head; instead, if the patient is short of breath, use a tiltable table to lower their feet and raise your chair to accommodate them. Let me emphasize again that your neck should never be bent. Operating microscopes have tiltable oculars, enabling the surgeon to look forward as he works, rather than down. In the Clinic Here, too, it's crucial to avoid neck angulation, particularly with the indirect ophthalmoscope, a primary cause of cervical spine problems. While some strive to avoid neck angulation by walking around the head of the table to the patient's sides, that strategy wastes precious time and requires more office space. Instead, electrically raise and lower the chair, as well as tilting it at the optimal angle. More importantly, learn to — as the horse people say — supple the patient's neck. This entails placing your hand on the patient's forehead and gently rotating the head from side to side as you ask them to relax their neck. Tell the patient, “I'm going to turn your head a little so you won't have to look so far to the left, Mrs. Jones. Now, I'm going to have you look to the right, but I don't want you to have to look so far to the right so as to make your eyes uncomfortable, so I'm going to rotate your head a little bit to the right to help you do that.” When sitting facing the patient, adjust your chair height so that you can sit up and underneath the slit lamp, rather than leaning forward into it. Usually that means that the patient's legs are together, with your legs on the outside of theirs. Just as in the OR, the height of the chair should be adjusted so that your back and neck are straight and your legs are not angulated over the chair. Also, as in the OR, stools should have a back support — that doesn't curve around you, limiting upper arm motion — and there should not be any arm rests, impeding forearm motion. Inexpensive office chairs, ones that don't offer sufficient height and tilting adjustments, are, I believe, a “false economy.” Because lower reimbursements mean that the ophthalmologist needs to see more patients per day, it is important that patient chairs help increase efficiency. We want the chair to quickly go up and down in a motorized fashion, tilt back at the right angle so we can look at patients who might be overweight, or short of breath, or have skeletal deformities. We should be able to adjust the chair to accommodate them. What is key for the surgeon is to learn in a sort of Zen way to read your body position and your body stress, and alleviate that. That way you can be relaxed emotionally and focus on the task at hand.

Steve Charles, MD, FACS, FICS, has performed over 29,000 vitreoretinal surgeries and authored a leading textbook in the field;. He is a Clinical Professor at the University of Tennessee and an Adjunct Professor at Columbia College of Physicians and Surgeons. In addition to his degree in medicine, Dr. Charles is a mechanical and electrical engineer with 106 issued or pending patents.