Why Ergonomics Matter: Protecting Dentists from Early Retirement

I'm Occupational Physiotherapist Janne Säkkinen. I've been this kind of visiting lecturer from 2017 in this university facility. The Sau and you are and Maria-Liisa Laitala and all those persons asked me, can I have this kind of ergonomic presentations for the dentistry students? And this is the reason why I'm here.

If you have any questions, concerns about the topic, hit me and I will try to answer best I can. And we have a few slides to go through. And this is the first time in English, so don't know how does it goes. But if I say something wrong or bad or if it's really hard to understand, then tell me and I will go to find a better words for it.

So where does the word ergonomics come from? They come from the Greek and ergo meaning for work and nomos meaning for laws. And if we think about the work in total, we need to do it as efficiently as we can. And we need to do also other things that we can be in good shape in the long run that we can go through the whole work years.

And what does these two pictures have in common? Well, what does these have in common? Shit happens. So in everyday activities, you will going to end up in a situation when you are not able to do the stuff so ergonomically.

And when, for example, you go for the gym, you need to push for the higher peaks to get your muscle endurance and total strength way more better. But that is the biggest thing. We cannot get rid of those bad ergonomic postures in the long run. But what we can focus on that you can get used to everything.

So once you started your profession, you start to work with the clients. There will be shaky hands because you need to be really focusing on the task what you are doing. But for example, when you go three years forward, the shakiness of the hands goes away because you know that stuff. So that is the work experience what is affecting on the background.

Also, you start maintaining and getting new techniques how to do the different stuff because once you graduate from the school, you got this driving license that you are able to do the basic stuff. But after that, you will going to start getting experience how to do it efficiently and better in the long run. Also, you are starting the profession where there is plenty of people trying to get to similar school in Finland. You don't need to pay for school in Finland if you go for the university studies.

People really, really, really want to go to different kind of places. But amount of the people what they can take in is limited. So they can really choose the best from the best. That means that if you want to go for the school, you need to be really focused on that topic or that profession.

It tells that there is a self-efficacy on the background. You are willing to do the work to get you through the tests. Also, if we think about everything in life, when we do stuff in a bad posture or something like that, we need to have also good recovery. So if the night sleeps are going bad, if the work-life balance is out of the window, then you will going to end up in having some sort of issues.

So try to focus on that, that you are going to recover from everyday tasks. When I checked the articles from the background, what kind of stuff does make the people in dentistry go for the early retirement? There was this KUPTA article from 2014. In that article, there was mentioned that 60,000 hours in lifetime working in tense and distorted positions.

So you will going to end up in a situation when you need to put yourself in a bad posture on top of the client to get that stuff done. Those kind of stuff happen and you will going to be spending a lot of work in that kind of distorted postures through the whole work career. The biggest factors what causes those early retirements are musculoskeletal disorders. That covers about 30% of the population in that study.

There is also cardiovascular diseases. There is symptoms of the neural tissue. There is tumors and diseases in the neural tissue. If you think about the symptoms of the neural tissue, it has a radiculopathies.

For example, we have a medial nerve. The medial nerve makes the sensation to these areas. So we might have a certain nerve problem. Something is pressing against the medial nerve and that is the situation what we have in the hand.

We might also have carpal tunnel syndrome, nerve injuries and stuff like that. But if we think about the disease in the neural tissue, there is this amnesties and polyneuropathy. Those are the different kind of cases. But we need to really be focusing on the musculoskeletal stuff because if we can get rid of those, we can reduce the risk for the early retirement.

And also, if you start to have some sort of issues in the neural tissue, we need to get them sorted also. More about those articles. What kind of stuff starts to happen when we start to have pains in areas? We start having reduced ROM, range of motion.

So there will be limitations in the shoulder movement because of the pain, for example. Abnormal skin sensations. When there is something pressing against the nerve and the nerve cannot have its own circulation normally, then it starts to have this tingling or burning sensation that starts to come to the area where the nerve is innervating. And also, when the irritation stays for longer, then the abnormal skin sensations might appear.

For example, a typical case in my office. A client comes over to my office and tells that she or he has this carpal tunnel syndrome. And the issue is that it has been present for longer periods. And now when he's walking outside and there is a minor wind going against her body or his body, then the irritated area might feel the wind way more harder.

So the irritation of the nerve is way worse in that kind of situation. Also, reduced compression force of the hand. Lack of cordination. For example, if we think about the nerve roots that come from the cervical spine, the C6 innervates the biceps.

And when the nerve roots start to go for the biceps, there are these motor units in the muscle fibers. If there is a good contraction and good control of the motor units, then the activation of the muscle is good. But if the innervation of the nerve going to the muscle is not activating all of those motor units, then the force, well, then the peak force is reduced. So people go to the gym.

They start working out every new year. And they think that, OK, I'm gaining really much strength in long periods because I can build up the weights that I'm using in different kinds of machines quite rapidly. Typically, in most of the cases, first starts the motor innervation of the muscles going to better. So that is the one that is increasing the maximum output of the muscle.

And when we end up in a situation when we need to build up months of work to get the weights better, then we are working only of the thickness of the muscle and maximum output of the muscle. So motor units start working first and after that comes the total force that the muscle can produce. Also, we might have these stiffness feelings. We might have these cramps.

We might have these tingling and burning and electric shock-like pains. And there was this mass article from 2019 where the number of the participants was 2, 3, 4. And they asked what amount of the pain are the persons feeling. So that is measured in WAS.

Zero, no pain. Ten, the worst pain ever. And also there was this frequency. How many participants answered the pain having similar positions?

And if we think about the male, there is a certain aspect about the painful areas. And here is also what female participants felt the pain and how big pain they felt. The issue with the females is that the soft tissues are way more flexible compared to the men. And if you have really, really, really flexible joints, then you really need to focus on having the mid-posture of the joint because that is the best way to use the joint.

If your fingers are extending really, then you might have some sort of issues in the long run. But we are going to get into that in a bit. So, how does the path of the trouble comes? We start with the repetitive movement.

We start to get the fatigue, we start to get these extreme positions. When the muscles get fatigued, they might also get imbalanced. And if we think about the ways we use the muscle, we have this contraction, we have this static, and we have this eccentric muscle contraction. When we are doing static postures, the muscle is working.

When the vessels try to bring oxygen and nutrients for the muscle to go on with the stuff that it needs to do, then the muscle activity blocks the circulation. Then we start having this milk exit, building up to the muscles, and depending on the capability of the muscle to maintain the milk exit, then we start to feel this fatigue feeling. For a start, if you are able to maintain this kind of posture for 10 minutes, when it really gets fatigued, you need to drop your arm down, and now the circulation can go to the deltoid muscle. When you continue in a similar posture, you are not able to go that amount of the time because there is also this milk exit building up already.

So, when the gap fills up, then you need to stop the movement. Ischemic pain mechanisms, for example, in low back, are really, really frequent in my office. They come from left and right, but we are going to get into those pain mechanisms in a bit. We also get this ischemia, which I have just mentioned, and also triggers.

Typical cases are, for example, a common doctor sends the client to my office and tells that she or he might have some sort of radiculopathy coming from the neck. Irritation in here and stuff like that. Then I check the spurling test. I do the extension, lateral flexion, and rotation.

This is the posture and position when we really shrink down the areas in the cervical spine. So, if that causes the typical pain to the arm, then I know that the neck is in some way related to that client's issue. If I really want to force it, then I put axial pressure downwards because now im really doing the stress to the tissues, and if it shoots down to the arm, then I know something needs to be done with the neck. But if the spurling is negative, then I need to check how is the reflexes, triceps, biceps, brachialis, and the finger flexors.

Then I need to check the myotomes, how the muscles are working coming from the cervical spine, C1, nodding of the head, C2, rotation of the head, C4 diaphragm C5 deltoid C6 biceps C7, triceps, interosseous of the fingers, C8. And if there is nothing lacking, and when I do the certain test for the nerve, for example, if it's radiating somewhere in here, I do the medial nerve pull, and if it's negative also, then I really need to start palpating that client because there might be also these kind of trigger pains. And, for example, if you go for the Google, and you put over there trigger points, you are going to end up in a page when you, for example, well, check that. Go to Google, triggerpoints.

net should be the site. And once you end up in there, find the muscles and go for the infraspinatus. Yeah. And you should find from there the muscles and find the infraspinatus.

Bogduk in 1984 started to inject capsaicin to facet joints, and he started to ask that where does the client feel the facet joint irritation? Then he made a map about it. Then he started to put capsaicin also to the muscles, where the clients tell where the irritations come, and if you think about the amount of the persons that answer it the same way, more the red dots, more the answers pointing to that direction. So triggers are also quite common in normal practice.

And if we think about the pain in the head area, we might have this radiating pain or tingling or numbness or something weird going on. And then we need to really be focusing and thinking what is the area. And if you think about these X marks, those are the places where we need to put, for example, acupuncture needles if we are using that as a part of the treatment. But that comes also.

Triggers and diseases, decreased movement, nerve irritations. 2007 I went to Rovaniemi to have my school for physiotherapy and first time I ran to this topic biopsychosociality. And I thought to myself, I'm never going to use that in my life. That is total crap.

And how wrong I was. For example, let's take a low back client as an example. She or he does their everyday activities, bends forward, he has some sort of sharp pain to the back and it causes everyday activities to go really, really bad. If they start to fear the movement, they are not allowing themselves to go to the forward flexion because they might feel that it might broke something during the next movement.

So he or she prefers to block that movement. Then if she or he goes to Google and starts searching internet about information about the low back they go to the forums and shit happens after that. So they might do the pain catastrophizing. Then might come the anxiety, then comes the sensations, emotions, stress and personality.

And when the client comes to my office and when I start interviewing, he or her I try to find a way what kind of stuff she or he does in free time. Because if they like to do different kind of stuff challenge themselves and stuff like that then I know that self-efficacy would be quite good level in that cases. But if they are only doing stuff what feels comfortable for them they are not pushing themselves In most of the cases if I have that kind of client I always need to be guiding them forward. And it feels stupid but some people need someone to come and take the hand and let's go to this direction.

Well, it's their pain, their story but some persons need some sort of guidance and with the rest of the person you just need to point the direction and they start going to that direction and they are going to get into there. So we need to think about the persons and what they are able to do. Simula had this great paper from 2020 from Southern part of the Finland's population What is the most predictable factors concern about the chronic low back pain? So high BMI, smoking, passive lifestyle low level of education we are not able to effect on the low level of the education in each individual but if we have a chronic pain for example in low back then we need to also tackle the factors on the life life like terms or life factor stuff because if we are not focusing on those we have this chronic back pain and we need to approach it from multiple directions.

2020 these Finnish professor of physiotherapy made this book about the pain mechanism and it was professionals pain book excellent and I wish that I would have ran to that book way more earlier because first time in my profession I started to notice what I need to really focus on the interviewing of the client It was the pain mechanism because when the client tells me how does the pain work then I really know what I need to be focusing on and then I can drop the rest off because the issue is if we think about the orthopedic test for the shoulder or for the neck and stuff like that there is a shit loads of them if we try to do everything in one hour session, we are not going to end up nowhere and from interviewing in certain way we know what kind of pain mechanism client might have then I need to test it then I need to find a solution how can I get the typical pain mechanism from the client because if I can reduce the pain what the client is feeling during the meetup then I know what stuff I need to guide to that person to home and that is my only task, so if there is a certain movement for example for the low back what causes the typical pain I tell the client to do that then I need to start testing how can I change that movement in the way that client is not feeling the typical pain and I just send back home to do that kind of stuff and it is really easy and if you want to have some sort of small brief youtube about it then you can use those QR codes and I will send these lectures also to SAU so he can send these lectures to you so you don't need to be putting these notes up but check those videos because those QR codes will take you directly to these videos but we will going to have minor and short brief about those pain mechanisms if the client comes to my office and she or he tells me that I bruised my ankle and after that the squatting has been bad and she or he tells me that when I have this shoulder length posture and when I go down I feel the pain in upper ankle area so they will go to point of the pain coming into here I say excellent, ok what kind of stuff we need to do with that then I check the ankle, range of motion in there, if there is a clear restriction in upper ankle joint what does the dorsiflexion and plantarflexion of the ankle then I mobilize it open I ask client to do the same squat again if the pain has reduced then I know, ok, what is the favorite band of yours Queen, I will going to go for Google and well, to YouTube, check best song for Queen rounding 3 or 4 minutes then I will going to get the client's cellphone and start doing the video do the video about the song you will need to have this song on the background when you do the ankle mobilization to this direction or she will going to do the movement in my clinic when I film it that she or he can do it correctly and then I take the cellphone back to her or him and that is the way I do it because I am terrible at drawing it is way more easier to do the video and having it a certain way that the person is doing stuff for 3-4 minutes if the music what they like is good it will going to have some sort of mental effect also you can use that also so, they are usually avoiding the painful movement and the anamnesis is short, acute, clear how and when it started and in that kind of cases I attend to do manual therapy and it is my job to follow that and it is my job to find the way to get the pain reduced during the movement and I do different kind of stuff in different kind of clients and once we find the right spot how to do it then we continue with that well, the weather is terrible outside when it gets freezing again and the water comes it will be black ice everywhere and I can't resist this when they fall and hit their hand to the ground and typically in those kind of cases I check the wrist movement like this wrist movement like this, ok, right hand has the pain then I do the painful movement and then I do radial side pressure, ulnar side pressure and when I know that there is 8 bones in the wrist area then I start mobilizing the certain bones to certain direction because the pain goes away or reduces, then I say to client you need to be doing the mobilization to radial side of the wrist so they are going to have this kind of force in hand blocking the bones what they need to be blocking and then they are going to extend elbow upwards easy mobilization and that is the way they are going to get their wrist going normally Inflammatory pain clients typically tell that there is a clear area, what is red and swolled there might be this pulsing sensation when the person goes to rest then the circulation goes over there and it provokes the typical resting pain and when they start doing the minor movements the reds fades away a bit if they take anti-inflammatory medicine for example Burana or something like that if it reduces the symptoms one third or half then we know that ok there is this inflammation going and we need to get that away normally the anamnesis is short, there is a clear region and it is acute and with this kind of clients we need to be really telling that ok it is normal the body has the inflammation, it goes away so we need to reduce the cataphrasizing and avoiding negativity with that kind of clients and also try to tell how to use the medication the right way also we have these persons that have these pains going everywhere they might have one day the pain in the right wrist next it might be at the left ankle right hip, left knee, it goes everywhere and in that kind of factors I usually start thinking that is there this minor inflammation going all the time in the body and those cells just go to certain area and during that the person starts to feel the pain over there and in that kind of cases we really need to be talking about the nutrition factors on the background because they tend to eat like shit and if you really want to focus on the mechanism how different kind of natural stuff what we can eat can reduce the inflammation and how they do it Hankisson sisters made excellent article in 2012 and it's really good because it talks about the mechanism when and how for example turmeric or ginger and stuff like that work to block the inflammation in the body it's really good to read ischemic pain and this comes from left and right for example concerning about the back pain when you see the person that goes to the bigger market they have these trolleys in front of them and they start walking in the supermarket and when they continue and continue for example if there is a better half also that you need to walk behind and go from every aisle to every aisle they start leaning forward and if you check them and frequently see those person they start this sweat coming from the head and they face that it's really getting frustrating to the low back because they want to lean more and more and more forward issue with the ischemic low back pain is that when the glutes are working hard when the low back muscles are working hard when the back extensors are working hard there is this static contraction in the muscle all the time so milk exit start to build up more the milk exit there will be, the more fatigued it will be and once those person sit down for a bit and lean forward and try to relax their back it will going to melt away a bit about the pain but once they stand up and start going the muscles tense up and after that the shit hits the fan so more fatigue they will going to get the more pain they will going to have if we think about the glutes low back muscles and back extensors in most of the cases we just need to reduce the ischemic state in those tissues or if it's for example deltoid area we just need to get rid of the ischemic mechanism in there and typically everything that promotes circulation is good for those for example warm packages, good exercises massage and stuff like that and if I have this ischemic pain mechanism in my office for example forward bend is really restricted then I check the glutes, then I check the low back muscles then I check the back erector then I do minor massage for those and do the same flexion again because if they are able to go further with less pain, okay, whats the favourite band let's have massage instructions for you for the whole typically in those cases the symptoms melts away to the half or in some cases completely gone but for example if only the massaging takes away the issue for example 50% and it remains the same then we need to have a different kind of approach we attend to have the posterior supported with the muscles that has really much force so in those kind of cases the glutes low back muscles and the back erectors are doing really much of the work so we just need to activate the opposite muscles and if we think of the reciprocal inhibition, when the bicep contracts always there is a tricep relaxation and with the low back pain clients we need to activate the hip flexors the abdominis muscles to get relaxing innervation to the back muscles and we just need to focus on the belly muscles and we get the rest 50% away and this is really really common in anamnesis there might be issues present for longer times, perhaps in years and they start affecting more and more everyday activities and what should be done exercise, strength, endurance, patient education and also those facilitating factors sports, heat and massage because they need to just get those tissues relaxed and after that it starts easing up and let's go for the nerve pains in extremities when the client comes to the office then they tell that they have this issue present we can think about innervation of the nerves concern about the level of the spine for example cervical, lumbar or stuff like that and we can also think about the dermatomic areas concerning about one single nerve what is innervating that area, but when a client comes and says I have this low back pain what starts radiating down to the glutes area going down to the thigh and calf I just ask is it at the 5th toe is it at the big toe or where does it go and it tells me that I need to be focusing on the low back area there is typically radiation, tingling, numbness burning or piercing feelings present if we think about the nerves, we have these and the meridians are meant to preserve life if we think about touching the heated surfaces or if we think about that we are touching sharp needles then we need to have these reflectory movements when we need to pull the hand away from the heat source or needle if we touch something then innervation comes to the central spine and after that it shoots back that we pull our hand away typically when the nerves are contributed to the symptoms they have these really extreme feelings but we also might have these different kind of feelings in the dermatome area for example non-myelin sheathed nerves they are giving the feedback to the brain about the pressure changes and vibrations and stuff like that so if the client tells me that she or he has this melial nerve issue present but the person tells me that it's like warm water or it's like something pouring something in that area then I know it might be those nerves that are not myelin sheathed so the sensations that come from that are different so if we have a sharp pain this electric kind of feeling then we think that it's the nerve that has these myelin sheaths on when we have these mild sensations that come and go not that rapidly then we need to think that it's those nerves that are innervated non-myelin sheaths that are causing the issue and also we have these pain specific C-fibers in our body issue with the C-fibers is that for example if I broke my arm with those slippery weathers over there I have a cast on top of my hand the cast is making pressure to somewhere in my body and I don't go and fix my cast the C-specific fibers start making innervation from the cast pressure and also there is tissues and nerves what makes this innervation for my brain about the cast presence and because of those C-fibers are polymodal they might take the role of different kind of nerves so when they get the cast away then the normal tissues what are giving the sensation about the pressure of the cast goes away but after that the C-fibers continues giving that feedback and then we have these really bad pains and really difficult pains because then the body is doing the pain by itself because those C-fibers do have these polymodal capabilities and they start doing that and those are really tricky so thinking about the ghost pains and stuff like that that might be the factor on the background we need to take load of the nerves we need to get supports or taping and stuff like that there might be accidents or surgery or injuries in the background and sometimes symptoms may be present for longer periods and also as I mentioned about those triggers if there is no clear findings when we test the nerves and stuff concerning about the nerve mobility then we need to think about the triggers Descartes 2016-2017 made this nociception model what has the idea on the background that when we got this sharp needle over here the nerve innervates, goes to the central spine then goes to the brain and brain interrupts what has been felt in what area nociplastic pain is that we have these innervations but the body is making those innervations to go way more worse if we think about the situation when we are driving or going outside and if we feel ourselves threatened or if somebody else goes to a threatened situation then the adrenaline kicks in our heart feels that it's pumping out of the chest we get this really informative sense that we can see everything we can smell everything because it's meant to be that we need to preserve the life so we need to run or fight and during that kind of cases the body is really really alarmed if we think about the cortisols it has similar effect but the cortisol levels rise in longer periods so it's really difficult to find out what was the feelings today compared to 6 months backwards during those situations if we have this nociplastic pain then the area might vary so client might tell that it's whole lower body or upper body or half of the body and the pain goes up and down and client is quite frustrated about what we need to do about that and in those kind of cases then we need to think about recovery and overall how the person is preserving his life or her life because if there is really stressful factors in every direction if there is a lack of sleep then we know that the body is really focused on every sensation because the body is really alerted concerning about the cortisol and that kind of clients also comes to the office but if we think that I need to check every joint in the lower extremities I just check one or two because there is no difficulties with the range of motion or with the joint functions then we need to start talking more because I'm a manual therapist so I need to check something so I check something but I know that there is no answer in here so I just need to continue by talking and that kind of stuff also comes and I'm frustrated that persons are not well there is shit loads of information but I wanted to make it a bit more easier so if you have carpal tunnel syndrome if you have ulnar nerve or radial nerve issues then there is a test how to do the test how to get rid of that irritation and its public to everybody and if the client tells that she or he has some sort of issue you can say ok go to my youtube and there will be good information so as I mentioned previously in 1948 started to do those injections to facet joints and as we can see the radiating area comes to certain area she or he has this radiating well some sort of pain in certain areas then I need to check is the facet going normally in there we have also this yeah let's do this kind of stuff get good posture when you are sitting there place your index finger back of the skull in some cases there is this bony bump but some persons have it some doesn't go downwards and you are going to feel this U shaped structure and when you go down at the middle you are going to end up running to cervical number 2 and then go up and go over here now the index finger should be quite close to our upper neck muscles close your eyes and then think that you want to move your eyes in a big circle against the clock and do the big circle in clockwise counterclockwise and clockwise and think do you have any movement or muscle tension against the index finger when you think about moving the eyes and do the lateral movement and do the movement up and down because when the eyes start to move then the proprioceptics of the upper neck should start moving also so you should feel the contraction of the muscles do you feel it when you move your eyes there should be connection and when we think about that we are getting the certain kind of postures and for example eyesight if we need to be checking above the horizontal plane of our eyes it's really fatiguing and when we check up we attempt to also activate upper neck muscles so we attempt to do this kind of stuff so usually keep the subject lower to the horizontal plane and also the upper neck affects our jaw movement so think about when you go to this kind of posture you are going to be sitting in front of the chair tilt your chin forward and go to back posture like this and have your neck like this and then think about the jaw movement when you open up fully I've been told that you need to get three fingers in vertical plane between your teeth and it's good range of motion but if we end up putting our clients in a situation when the neck is retracted well protracted in this case then think about the mouth movement and then go really upwards and then open up the mouth is there wider range of motion when you have this good posture when you open up the mouth because in this posture the movement of the jaw should feel really really tight and stiff and in this it would feel way more better and when you move your jaw your upper neck also moves so here is a video about that check that area in the video there is this tilt of movement when she opens the mouth so if neck is really tight in this direction it cannot go further and if it's restricting the jaw movement then we need to sort out the upper neck area and I'm in lucky position because the few of the dentists here in Oulu sends me these clients who have these TMD issues because I'm really glad to work with that kind of clients they might have this tingling or something sensation or they might have this locking in the jaw joint or stuff like that and they just tell the client book time for me and they are going to come over here they are really really nice to work with but I cannot only be focusing on the jaw because I need to focus on the upper neck area also in most of the cases they are really related and if you want to have one test what really easily checks the upper neck movement then it's this you are going to force your client's head chin to the chest and then you are going to do rotation to both sides if the jaw can go towards the armpit the upper neck movement is excellent but I've ran into situation when the client comes to office she or he has this jaw issue and when I check this the limitation is really really clear and opposite side movement is really really good so in that kind of cases I know that I need to be working also with the upper neck area so craniocervical flexion test and rotation, use that if you think there might be something contributing to the client's issue with the upper neck and there is this articles that what kind of stuff comes together and when you have this upper neck issues and when you have this jaw issues they typically walk the same paths other contributing factors we cannot get rid of the age so every year we get this one year more and that is how it goes lung elasticity goes down so it affects on ventilation capacity stroke volume and the heart and the maximum heart rate goes down one hit per year peripheral vascular resistance goes heavier aerobic and anaerobic endurance weakens by 5-10% over 10 years with in principle 1% per year so there is no load if we think about the muscle cells the fast cells goes out of the window first so if we think about the muscle we need to do fast movements also when we do the resistance training we need to also get those muscles recruited and stiffness of the agonist and antagonist also starts building up when we go older and that is how it goes. But keep picturing this, so use your aerobic capabilities and do something what requires strength and you will be good in the long run if we think about the work and the maximum what it can be concerning about the work for example if the lateral rise of my shoulder is 10 kilos then the maximum weight what I am able to do in lateral rise would be 10% from the 10 kilos so 1 kilo and in that kind of cases the muscle activation needed in the work is low enough so it won't cause any issues if we think about the aerobic stuff then it should be half of the total capacity and typically when I have this client what works in the industry or they build stuff well the stuff what is concerned to be heavy they always tell me that I don't need to train on my free time because the work is so heavy and I really fed up to that point and I started to search an article giving backup for my advice in Danish population there was this study concerning about the heavy workers and does the heavy work prevent from cardiovascular diseases and the number in that study was 233 000 so shit loads of persons and the most thing what effects on the cardiovascular diseases are the activities what you do at your free time so shit happens and in heavy stuff the issue is that when they are not taking care of their selves they end up having this normal decline of the aerobic and muscular strength but if the work needs to have some sort of level then at some point we end up having situation and same comes for the policeman same comes for fire fighters because if you get fatigued you start getting errors in your job and if the laziest or if the worst person in the whole group is the last when you need to go for the fire building you are not feeling yourself safe so they need to have certain level of capabilities what they can do you don't want to be the worst of the bunch in those kind of cases and does the exercise make our muscle mass go better? I'm not telling that you need to all start doing this triathlete sports swimming and biking and running no way but if you do some sort of stuff what maintains your good muscular health then it's going to be preserved in long run there is a 70 years old triathlete and there is a 74 years old sedentary man and if I would be needing to choose from one of these I would go 10 out of 10 with this because those muscles can do these fast movements so when the person starts falling he or she can do the movement but with those there is not that much of the fast muscle cells let's start with the chair selection these are terrible stuff seriously they just made the chair what most of the people if you are shorter or longer these chairs are terrible when you go for the place where you start doing your work you always add stuff suitable for you because no one else is going to do that if we think about the height of the chair if we are using these kind of chairs we need to get our kneecaps safe so the height of the chair comes from the height of the tibia and fibulai when there is a 90 degree angle at the kneecap then there is nothing blocking the circulation and then the seating posture would be quite good if we think about the support underneath the thighs we need to get the support area wide as possible so there is usually this kind of seat depth adjustment also for that kind of situation and there is also this angle because if the angle is pointing from back to upwards then you are going to start feeling the pressure in the kneecaps, and thats not good. so 90 degree kneecap always pressure from the thighs and get the support area way more bigger if we think about the posture in the work if we do the regular stuff when we have our elbows close to the body then it is quite efficient for the body and when we do the regular stuff in here it should be quite fine.

If we need to apply force to it then we need to drop the elbow downwards because now we can activate the big muscle in the back area so if you need to do something that requires force stand up and do it underneath the elbow line because now you are able to use way more force and if you need to do really detailed work you need to have good visuals then have elbows supported at somewhere so now your shoulders can relax they are not doing the static posture and for example if you are doing adjustments for the night pressures and stuff like that it is really good to do in here because you can do it precisely you don't need to shrunk your shoulders to maintain the posture because this would be terrible so in precise work always try to find a way to support your elbows it is way more easier that way. Think about the active and passive sitting because when we are sitting in this kind of posture this is considered to be passive sitting so I don't need to be using my muscle to maintain the posture when we go for the saddle chair that is meant to be active sitting so in that kind of cases you are using your belly muscles to maintain a good erected posture but in those kind of cases you want to have the seat feeling comfortable against your glutes because if there are these sitting bones in the gluteal area if they are pressed way too hard against the saddle chair sitting part, then you are going to start to get this compression and you will start to get this discomfort so try to get the saddle chair this adjustment that it is comfortable against your pelvis because there is different kind of pelvis in every person and also if there is a wider and narrower seating position in the saddle chair adjust it also because there are chairs where there is this saddle chair adjustment also there is this kind of adjustment if there is a backrest in the saddle chair it is meant to use that when you are sitting down the backrest is not there so if you have this lumpy or low back then the backrest should be in there so if you need to maintain that posture for the longer periods then you are able to use the backrest and typically you are not using the backrest and that is active seating in both I have videos how to adjust the saddle chair how to adjust the normal office chair try to find the ways what kind of tasks are you able to do in different kind of postures for example normal checkups are you able to do those normal checkups for example in standing position when you need to do the heavier work go underneath the elbow when you need to do precise stuff and try to find a way to postures change during the workday so you are not sitting 8 hours in passive sitting because that is the worst pay attention to the colleagues Shit it happens if you are 2 meters long and you have this partner that is 150 so there is ergonomic issues present so try to cope with that also remember that those colleagues will be by your side years to come approach angle and the customer guidance if it is easier to see the visuals in the mouth then rotate their head and extend their head but remember if you brought root to the neck then you might have jaw limitations concerned about the neck placement and placement of the work tools try to find different ways to put them so you are going to get minor movement in everyday activities Pedals if you are going to do external rotation you are going to use the RPM or the function of the pedal via that if you need to do this kind of tax what requires certain kind of RPM you just place the pedal over there and push it forward so the weight underneath the heel bone will make the pedal go to certain RPM if you need to go for the longer periods in certain RPM there is no point to do the external rotation because if you roll the pedal like this and put your leg forward then it is way more easier to do the similar RPM for the longer periods try it, if it feels like shit then continue, but if its worth trying or worth applying, then go for it If we think about the muscle contraction, and we have this Supraspinatus muscle it has been measured that after 30 or 45 degrees the supraspinatus muscle is really contracted and the issue is that the acromion the bony prominent lateral part of the shoulders the supraspinatus comes underneath it so if we end up in a situation where we need to do a lot of work in this kind of postures, then the deltoid muscle comes to also to assist if we need to do a lot of work in this kind of postures then we need to think about the height how we are possessing our self concerning about the client if we can drop the elbows down by lowering the client always lower it but sometimes you will end up in a situation when you need to really be at the top of the client to get clear visuals and do the work if you start to have shoulder issues get massage or lacrosse or fascia ball place it over here and start massaging because if it eases the pain during the abduction movement then you are going good then about the inhalation let's get this kind of posture so you are doing precise work top of the client so seat at the front of the chair then bend forward and be like this try it get this posture and do the inhaling from your nose and exhale through your mouth and think about how much lung capacity are you able to use in that kind of posture and then get yourself upright and then do the inhaling and the exhaling again and think about the maximum amount of air that you can get inside of your body in that kind of posture, where there any differences as mentioned previously the diaphragm comes from C4 the C4 innervates the muscle when we are leaning forward the diaphragm muscle is a big muscle underneath our chest and when it activates, it pushes your chest downwards so we can get the lower parts of the chest to be filled up during the inhaling this muscle goes downward so we can get the lungs filled up and when we put for example those lungs in here those are the areas that we need to fill up but in case if we are bending forward we are not able to use the diaphragm so in that kind of cases we are using the lungs capacity from the up- and from the middle portion and if we think about the change of the carbon dioxide to oxygen then the exchange is not that efficient so only way how we can get the certain amount of the circulation and certain amount of the oxygen going to our system then we need to elevate the heart rate then we need to elevate the frequency of inhaling and exhaling and then the body goes to a bit more alerted state so if you find yourself doing this kind of posture all the time and if you are a bit dizzy or something like that try to get the posture way more better because during that posture you are able to use the lung capacity way more better it's sad because this software was in microsoft store for $15 and I bought a new laptop I tried to get to microsoft store and buy this and log in to my account so I can download it again and it was not available so as long as I have this laptop I am able to use it but if I want to get a new version of the SNTR then I need to pay these monthly fees and it's stupid but if you want to prevent it, here is this psychotec body so for example in here you can place the markers like this you can get the skin away and you can get the certain muscles away and it's way more easier to show the client what you are doing for example if I show stuff from here but the issue in this is that when I get the digestion, circulation, lymph and nerves away I end up only having the cartilage and the muscles when I go over here and I point this one this is the only way where I can do this kind of movement but when I am at the normal vision when I do this movement it only rotates in this way and this is freeware so bookmark this to your laptop what you need to use at work if you don't have any and when I do my videos to YouTube I would love to have some sort of presentation because the only way where I can do it safely is to use the Wikipedia's common law pictures and stuff like that and you have seen them everywhere and I used to play with the Legos a lot if you have a 3D dimensional site about the issue or stuff that I am talking about this would be good but I sent 2 or 3 emails to that company can I use your software as a presentation in my YouTube videos and they didn't reply so I went to here and again law text not good with that so I copy pasted it to ChatGPT and asked it am I able to use this stuff in internet and it told me no you need to be subscribed user of that program to show it in internet and it was expensive also so it's good for my client work, but its not good for my videos if you find any please let me know so anyways as we can see here is the neck posture and the spinal stress so when we lean forward with our neck the weight of the head is 8% from the body weight so when the level goes further the resistance what required to do from the muscles is way more bigger but if we think about the neck posture does it correlate with the neck pain no it doesn't in a big picture what correlates with the neck pain is a physical passivity so if some teenagers or if you find yourself checking your cell phone in this kind of posture, no worries, its not causing you pain as long as you will be active in your free time elements related to vision so when the distance to destination is bad or if it's not lighted properly then we are attending to do this kind of movement so when you do precise work light it up because you need to have good clear vision think about also the spotlight and shade the color of the light might also feel a bit awkward these lights in here should be around 5000 Kelvin but if the Kelvin is lower then the light appears to be a bit more yellowish or different color so aim to focus to have the neutral light and always when you are using those those stuff that you put, loops, yeah then the magnification will make it easier but always think that you need to light the mouth properly and then when you start doing your profession in normal way try to find the loops that are good for you because it will make your life way more easier so good light light the object well because if you don't head forward and color of the light is important also about the upper extremity if we think about the factors what makes the risk of work related issues concern about the upper extremity way more worse is the static muscle work, so longer periods in same posture shaking of the object but not in your case because if the shaking of the object is the issue then the shaking of the object needs to be way more bigger so your tools are not doing that tools what they use for example in construction yards those are the shakes what cause the issues and abnormal wrist positions so from these you got to static work and in some cases abnormal wrist positions how to prevent those to have those pauses think about the tool handles and think about the stretching if you find yourself working in this kind of posture with your wrist for longer periods is the handle bad or can you do it in more neutral way because more neutral the wrist is less issues you will going to have, issue is that when the medial nerve comes over here underneath the transversus ligaments then compression starts to build in then you are going to have these numbing and tingling in the upper lid area if you need to stretch these structures then place your fingers going downwards then extend your elbow and this is really easy way to get these areas stretched if you need to be having stretches to this upper part and if the movement of the arm is not good if the movement is good at the wrist try to do stretching like this pull your wrist against you and if you feel more pain at the wrist then the issue is that the joints are flexible if you want to increase the stretch in there put your fingers like this grab a fist and then start doing this kind of movement so the tension comes way more faster because these muscles are stretched out from this posture and also if you start to have these tennis elbow issues then there is a video for that how to do the maintenance in here because typically in tennis elbow cases there is this ischemic pain mechanism on the background what we need to just sort out when we bend our fingers, that is normal range of moment to finger but when we start extending our joints then you are going to have finger in that kind of placement that if you are pinching the stuff like that you might have issues in that joint in the long run because the finger joints are not to be used in extension they are meant to be used in flexion wide range of motion also in the finger joints always focus on the flexion grip because if you go for the extension you are going to end up having situations because if you start to have osteoarthritis in the joints of the fingers then you are going to have the resting pain during the night and issues from that and if you think about the joint and its angles, elobow close to the body and in this vertical line keep it close because if you go way more further then you need to use way more force to maintain that posture in abduction movement try to relay quite close to the body and with the use of the force use the 90 degree if you need to have more force get it to higher degrees wrist angles in this way and also in this plane keep it in the middle and concerning about the supination and pronation supination is way more harder for the hand to maintain so aim for the pronation because its way more easier for that and what should be done in the big picture here is an example from the low back pain so ergonomic interventions at workplace are ineffective and im doing it right away so enjoy but when you know the pain mechanism you know how to treat yourself when you know the principles how to get those stuff adjusted then you are able to adjust them when you know what to notice concerning about the work you are going to get less issue for hand osteoarthritis and stuff like that and that's the way it goes but if we think about the low back pain about insole then there is not that much of the evidence in there either but when we check for the exercise and education it has moderate quality so this is the reason why I am doing this education for you and if we check about association between lifetime musculoskeletal pains in big population being physically active is associated with the lower risk of having musculoskeletal pain in my case I prefer to bike everywhere because Oulu is biking city so bike roads are everywhere you just need to have spikes during this kind of time of the year in my case I prefer to go to gym on Mondays and Fridays and I don't lift weights because I hate it so I thought myself that I am going to go over the gym and do my fairytale gym so I do squats, I do pushups I do belly, I do back, I do something pulling and that's it and if I have some sort of excuses at the morning shit and go over there and do your task and I am going to go over there and do my task no questions asked after that so aerobic endurance comes from the biking and also the gym comes from Mondays and Fridays and what is good think about the persons what you don't end up having time in your daily activities or weekly activities I had this excellent friend of mine during the studies and I told him that do you want to come and wrestle with me and he told me ok, if we think about so starting something martial arts related, i tell, okay, excellent you need to come to our class and he came so every Tuesday and every Thursday I know that he is going to be at the same place so we can have a chat we can catch up because we don't end up having those talks in everyday activities because he has work in different place, he lives in a different place but i know that every Tuesday, Thursday I am going to see Joni, excellent and when I can take my pressure away with him hit him and kick him and wrestle with him it's excellent and we are having good time but that is the only way how I can keep that person in my life and because he is that good of a person I really want to go for my training because I want to see him and if I don't see him I get sad, so i get social I get mental, I get my physical activities from that so try to find the ways how to incorporate your stuff that you are liking with the best friends of yours because that is the glue that is going to keep you in there so concern about the work try to always maintain the electric posture but you know that you are going to end up in a shitty situation when you need to be working in different kind of postures, no worries, you will get used to it use the adjustable chair and always adjust it because no one else is not going to come and adjust it for you work close to your body because the levels are quite minimal during that so it would be quite easy for you minimize the external wrist movements and try to find the ways how to get fingers from extended postures because they are meant to be working in flexion alternative work position, sitting, standing and always try to find the ways what kind of job tasks are you able to do in different kind of postures because when you find that it will be way more easier to maintain in the long run consider horizontal positioning of the patient so fix their head and pull their head and turn it so it will be easier for you because they don't get these musculoskeletal issues you are the person who has, so try to get it eased, first and foremost correct ergonomics problems in the operatory so use the furniture and the adjustments of those if you have issues get them sorted when you start to have these first issues typical when client comes to my office is the situation when they start to have that amount of the severe of the night pain that it's blocking the night sleep I would gladly be in assist way more earlier so we need to get the nights better and once we get the nights better then we need to focus on the everyday tasks or stop concerning about the work major trigger points should be resolved and specific strength training in your case would be shoulders and the back so get your upper back working something what pulls you is excellent for your counter movement be patient most of the commit regimen prevention strategies and if you have task what requires a lot of static work then do some sort of stretching or some sort of massaging those so you don't get the situation when you have this ischemic pain if you want to have some sort of guidance to your clients here is a video we made with Anni about bruxism here is the massage masticatory muscles easy instructions for clients to follow and sometimes there might be some sort of radiating pain in the face area and it's also covered in there final questions do you have a way how to test the neurodynamics of the trigeminus nerve check for example if the client has one sided issue is there a way how to provoke or try to get it relaxed or test the sides of the trigeminus nerve how well the neurodynamics work it's like doing this and this yeah, mouth nerves yeah.