Ever finished the day with a sore neck and shoulders? Or a sore lower back? You’re not alone.

A recent study that investigated musculoskeletal pain among eye care professionals in Saudi Arabia found 66.7% of the 514 participants suffer from this very issue. The prevalence was significantly higher among females (76.2%) and those over 50 years old (71.4%).1 Published in Cureus, part of Springer Nature, the study found that while back and neck pains are common among all adults, they are “highly prevalent among eye care professionals”.

The study confirms previous research. A 1994 survey of 325 ophthalmologists in the United Kingdom found 54% of them had significant attacks of back pain, with those longest in the field having more frequent back pain.2 In the United States, a 2005 survey found 52% of the 697 ophthalmologists polled reported pain symptoms in the prior month, with 15% limiting their work as a result.2 In 2010, a survey of 130 US ophthalmic surgeons revealed 72.5% reported pain associated with operating; with nine stating they had to give up operating as a result.2

In this issue of mivision, Ilsa Hampton, CEO of Optometry Victoria/South (OV/SA) has recounted a discussion with an optometrist who said that as she neared retirement she was seeing a physiotherapist fortnightly, “merely to make practice work tolerable”. Having reviewed the evidence, Ms Hampton has initiated a project that aims to help address occupational injuries. You can read more about this in the mioptometry column, later in the journal.

But the problems aren’t confined to optometrists, ophthalmologists and orthoptists. Optical dispensers, who spend their days on their feet or leaning over patients to fit frames, are susceptible to musculoskeletal pain. And sales reps, who drive long distance then drag heavy cases into practices to showcase their frames or equipment are equally vulnerable.

MUSCULOSKELETAL DISORDERS

Musculoskeletal disorders (MSDs) are injuries or disorders of the muscles, nerves, tendons, joints, cartilage, and spinal discs. Work-related musculoskeletal disorders (WMSD) are conditions in which:

1. The work environment and performance of work contribute significantly to the condition; and/or

2. The condition is made worse or persists longer due to work conditions.

3. Excluding slips, trips, falls etc, musculoskeletal system and connective tissue diseases and disorders – such as sprains, strains, and tears; back pain; carpal tunnel syndrome, and hernia can occur due to a “bodily reaction, (e.g., bending, climbing, crawling, reaching, twisting), overexertion, or repetitive motion)”.3

Common MSDs for ophthalmologists include disabling back pain, neck pain, numbness in the hands and legs, and carpal tunnel syndrome.4

As well as impacting an eye care professional’s daily physical comfort and ability to concentrate, musculoskeletal disorders can potentially cause a person to change their area of specialisation, reduce their workload, or even step back from their career entirely.

Speaking at a ProVision conference in 2022, Leon Green, a Melbourne-based physiotherapist from Life Ready Physio and Pilates, said “there’s a very good business case” for not having presentations of pain in your practice. He said people with headaches lose 3.6 hours of productive work while people with back pain lose 5.8 hours of work per week.

Along with lost productivity, business owners can incur costs in absenteeism, and in some cases, workers’ compensation.

Avoidance is a better option for all concerned.

THE MAIN CULPRITS

Some of the biggest causes of neck, shoulder and back pain for optometrists and ophthalmologists are the slit lamp, the phoropter, the microscope, and the chair.

As one optometrist observed, “you need to have line of sight when you’re using a slit lamp or a phoropter; you need to ensure the patient’s gaze is correct”.

This may mean stooping for many taller eye care professionals or standing on tippy toes for those who are shorter, unless they recognise the ergonomic issues of lining up eyes and find ways to get around it.

Ophthalmologist Dr Christolyn Raj said protecting yourself against musculoskeletal disorders is about being mindful. “I think we develop bad habits in the very early stages of our careers, as registrars. We’re concentrating so hard on what we’re doing that we’re not thinking about how we’re holding our bodies and so we develop bad habits.”

Like many mivision spoke to, Dr Raj had not thought much about neck and back pain until approached for an interview.

“Until you mentioned it, I hadn’t noticed it, but now I realise I’m getting neck pain once every three weeks or so – I’m having an episode of a wry neck now,” she said.

“But I think it’s the physically bigger surgeons who have the most problems. They scrunch down on little chairs and have to bend over surgery beds that can’t be adequately raised.”

Ophthalmologist Dr Patrick Versace, who said he is very aware of his posture, insists on bringing the patient to his level. “You don’t want to be stooped forward over a slit lamp. Everything needs to be adjustable – the patient chairs and the slit lamp – so that you don’t have to stoop.”

Clinical Associate Professor Smita Agarwal, who is diminutive compared to many of her ophthalmology patients, said she politely asks each patient to bend into the slit lamp.

“Yes, we can move the slit lamp up and down to suit shorter and taller people, but this takes time when you’re using the equipment eight hours a day, and it’s inconvenient if more than one person is using the same piece of equipment. I ask patients to bend to my level (to avoid straining my neck and back muscles) – they only have to do it once, whereas I’d be making adjustments 40 times a day.”

For optometrist Mark Koszek, who is taller than most, switching to a stool in the consult room was the turning point.

“For me, the early days of practice were more problematic. Going from a high back chair to a stool made the difference – I think because it forced me to improve my posture by using my abdominal muscles. In general, I’ve found that keeping supple and maintaining abdominal strength is the key to avoiding pain.”

“As a tall person, I can’t avoid stooping over a slit lamp, however I try to minimise the impact by choosing equipment with ergonomics to suit. There are some slit lamp tables that will rise higher than others, for example, and of course, I make sure my computer screen is at eye level.”

EVOLVING EQUIPMENT ERGONOMICS

All the eye care professionals mivision spoke to were acutely aware that new equipment coming through is making a significant difference to ergonomics in the consult room and the surgery.

In well-funded clinics and hospitals, along with adjustable chairs, beds and slit lamps, there are now a few 3D digital microscopes, like Ngenuity from Alcon and the Artevo 800 from Zeiss.

Both products enable ‘heads up surgery’ which eliminates the need for the surgeon, to hunch over the microscope, gives them greater freedom of movement, and provides the operating theatre team with a real-time clear view of the surgery.

Dr Ilan Sebban switched to the Ngenuity three years ago and, as a high-volume cataract surgeon, noticed an immediate difference.

“When you have a normal microscope, you’re flexing your neck to keep your eyes on the binoculars and if you move, everything becomes blurry.”

He said presbyopia makes things even more difficult because “you’re constantly using your foot pedals to adjust the lens so that you can move up and down through the eyeball”.

Additionally, he said, “If you take your time when you’re operating, you find you become stiff and it’s only when you get up that you realise that you’ve got muscle ache…. Over the long-term, you’re at risk of osteoarthritic issues. I’ve known a number of surgeons who’ve had to stop operating because of damage to the nerves that run from the neck into the arms and because of back pain.

“With the Ngenuity, I’ve got a big screen to look at, so I’m not stooped over, and I wear glasses with different filters in each eye that give me a great depth of vision.

“It’s more ergonomic for my lower back as I’m not having to keep my body in the same position for 10 minutes, so I can retain my flexibility. In essence, I feel better during and after the surgical list by sitting with improved posture, and this may allow me to extend my surgical career.”

Penny Stewart, who leads Alcon’s Surgical Franchise in Australia and New Zealand, said the Ngenuity system is an example of the company’s effort to “intentionally incorporate inclusive design principles to address many needs, including the overall comfort and health of surgeons and their staff ”.

As part of its research and development process, Alcon runs customer focus groups and advisory boards and has employee resource groups (ERGs).

“As an example, we partnered with our Women Innovating Now (WIN) ERG to gather valuable insights around differences in physical height and hand size.

“When viewed as ‘one size fits all’, differences in physical features can unintentionally result in ergonomic disadvantages. Feedback from our WIN ERG, coupled with insights we have gained from surgeons and their teams, led Alcon to adopt a more inclusive product design approach several years ago,” Ms Stewart said.

Ngenuity and hand-activated forceps were the first products impacted by this research.

“We also design some of our surgical instruments for surgeons with different hand sizes, including our Finesse Reflex Handle, built for surgeons with smaller hands.”

Similarly, Zeiss, which as a foundation invests significantly in research and development, has worked closely with doctors and nurses to engineer equipment that is more ergonomically friendly and efficient than traditional equipment. The Artevo 800 digital microscope with a 3D screen, and Lumera 700 are prime examples.

“Lumera 700 can be ceiling mounted. It saves floor space and potentially reduces the risk of falls by minimising the number of obstacles that surgical staff have to move around in the theatre,” said Megane Diforte, Surgical Marketing Manager (Medical Technology Business Group) at Zeiss.

For cataract surgeries, the Callisto markerless alignment screen is mounted onto the arm of the Artevo 800 or Lumera 700 and the data is simultaneously displayed through the eyepiece of the microscope and onto the 3D screen so the surgeon has all the information they need in front of them – assistance functions, phaco values, iOCT images as well as patient information. The assistance functions are completely surgeon-controlled by foot control panel or handgrips.

While these devices are naturally heavy – the Zeiss Artevo microscope weighing in at around 500kg – Ms Diforte says they are surprisingly easy to move.

“The hydraulics dictate the weight – the Artevo has to support an arm with the microscope that hangs over the patient’s head for perfect alignment. However, it also has to be easy to move around so the surgical team can make tiny adjustments to compensate for patient head movements.

“Given the Artevo’s weight, I anticipated it would be difficult to manouvre but I was surprised at how easy it was – it’s as light as a feather.”

Similarly, she said, the new phaco machines are lighter and more compact than previous models and with four wheels, less cumbersome for nursing staff to push around.

“Everything we design is with surgeons and nurses in mind – we think about how they move around the theatre, and we work to make things more efficient for them.”

NOTHING BEATS EXERCISE

No matter how ergonomically designed surgeons’ chairs, patients’ beds, equipment, and consumables become, there will always be a need for eye care professionals to protect themselves from pain and injury by managing their own physical health.

And movement, physiotherapist Mr Green said, is the answer.

“Exercise is a major barrier for many. And the main barrier to exercise is the barrier we put up in front of ourselves. We need to go out of our way to exercise and get moving.”

He said the main reason why people visit his clinic is for pain – whether that be from trauma, injury, or a condition that has built up over time. And the problem is that when pain isn’t dealt with appropriately, two things can happen.

1. The tissue involved remains weak and ineffective at its job within the body, resulting in furthers issues down the line, and

2. The pain system within the body goes into an overprotection mode – it dials up the tissue sensitivity and gives a pain response that is far greater than what is actually helpful.

“The pain quality starts to change – it might spread to the other side / further down the leg, and move from an acute pull to a crazy burn. And all of a sudden, you get a pain experience that is not totally aligned with the actual damage to the body.

“When people are in pain for a long time the fear of further damage and further injury becomes a reason to not move and exercise, which create a host of downstream issues like muscle weakness and poor fitness. Over time this builds into serious issues like osteoporosis, cardiovascular disease and osteoarthritis.

“So, the message is quite simple: we need to exercise.”

He said the benefits of exercise to offset pain from a sedentary workplace don’t just exist in health sphere.

“It’s clearly demonstrated that people who are pain free are significantly more productive. So, it is in an employer’s or business owner’s best interest to facilitate a pain free workplace.

“Exercise is one of the best things we can encourage to stop pain from starting within our workplaces. General exercise, like walking, running, and swimming are essential. But so too is movement variability, and strengthening exercises.

“If your body has more capacity because it’s strong, you can handle more load and resist stressors that weaken the body… Tendon, muscle, joint, and bone problems all go down when you exercise regularly,” he added.

BACK ON THE GROUND

Pilates, yoga, going to the gym and running were the preferred ways to stay strong, among the eye care professionals interviewed by mivision.

Dr Versace makes a point of running most days and cycles, kayaks, and does yoga on a regular basis. “We need to remain mindful of our posture and I think yoga and pilates are particularly good in this regard,” he said.

For Dr Agarwal, it’s the gym twice a week and Dr Raj favours pilates and running to maintain her health.

“Pilates helps me most with my neck and back. But running is also useful for posture. I used to run marathons and I still run twice a week. I notice that after a long run, when your legs are hurting, you tend to stand up straight.”

Aside from physical health she said, “After a long day, running helps get everything out. So, it’s good for your mental health and your endorphins.”

And then of course, there is the need for sensible shoes – they should become your new ‘best friend’.

Dr Raj switched from heels and a suit to scrubs and good quality runners some time ago and immediately noticed her calf muscles were more relaxed. “When you’re in heels and you’re doing injections or walking the corridors every day to greet patients and take them to your consult room, you get a lot of pain in your calves. So, runners make sense, so much more comfortable, and they only ‘work’ with scrubs,” she said. “I can’t understand why most of the male surgeons are still in suits.”

References
1. Al Taisan, A., Al Qurainees, A.E., AL Sowayigh, O.M., et al., (23 May 2023) Musculoskeletal Pain Among Eye Care Professionals. Cureus 15(5): e39403. doi:10.7759/ cureus.39403.
2. Kent, C., Will ophthalmology cripple you, Review of Ophthalmology (4 Oct 2011) available at (reviewofophthalmology.com/article/will-ophthalmologycripple-you) [accessed 23 June 2023].
3. Centers for Disease Control, Work-Related Musculoskeletal Disorders & Ergonomics (web page) available at cdc. gov/workplacehealthpromotion/health-strategies/ musculoskeletal-disorders/ [accessed 23 June 2023]. 4. Honavar, S.G., Head up, heels down, posture perfect: Ergonomics for an ophthalmologist. Indian J Ophthalmol. 2017 Aug;65(8):647-650. doi: 10.4103/ijo.IJO_711_17. PMID: 28820146; PMCID: PMC5598171.