effective interventions for cumulative trauma disorders of ... · to prevent or relieve cumulative...

Work 42 (2012) 153–172 153DOI 10.3233/WOR-2012-1341IOS Press

Review Article

Effective interventions for cumulative traumadisorders of the upper extremity in computerusers: Practice models based on systematicreview

Glenn Goodman∗, Laura Kovach, April Fisher, Elizabeth Elsesser, Daniel Bobinski and Jessica HansenCleveland State University, Cleveland, OH, USA

Received 3 March 2010

Accepted 3 June 2010

Abstract. Objective: A systematic review of over 4600 abstracts was performed to address the effectiveness of the currentcumulative trauma disorder (CTD) interventions focused on the upper extremities of computer users.Participants: The researchers were the study participants. They included one Professor of Occupational Therapy and five Mastersof Occupational Therapy Students from a Midwestern University. The Professor of Occupational Therapy has been practicingfor 29 years.Methods: The researchers employed stringent inclusion criteria for this review based on similar systematic review papers. Criteriafor high quality qualitative research were incorporated to include studies other than randomized-controlled trials. This approachconsidered knowledge gained from specific interventions that were studied in greater detail with fewer clients.Results: The results of this study identified 25 articles that met the inclusion criteria. Further review ranked the selected articlesinto high, medium, or low quality based on criteria adapted from other studies. The highest levels of evidence were found foreducation and training in ergonomics, forearm supports, ergonomic keyboards, ergonomic mice, and exercise/rest breaks.Conclusions: Two models of practice were created from this review to assist occupational therapists or other professionals withintervention strategies for computer users with CTDs.

Keywords: Carpal tunnel syndrome, ergonomics, musculoskeletal disorder, repetitive strain injury

1. Introduction

In 2003, two-thirds of U.S. children aged 3 and old-er and in nursery school, 80% of kindergarteners, and97% of students in grades 9–12 used a computer [12].Eighty-five percent of college undergraduate studentsown their own computer and a majority of college

∗Address for correspondence: Glenn Goodman, Cleveland StateUniversity, HS 103, 2121 Euclid Ave., Cleveland, Ohio 44115 USA.Tel.: +1 216 687 2493; Fax: +1 216 687 9316; E-mail: [email protected].

courses require the student to type assignments andhave access to the Internet [18]. The Bureau of LaborStatistics reported in October 2003 that 77 million peo-ple in the U.S. used a computer at work. Computer usehas been linked to an increased exposure to those mus-culoskeletal problems associated with frequent, sus-tained, and repetitive movement [26]. The additionaltime spent in front of a computer over the lifespan hasresulted in an increase in the likelihood of experiencingmusculoskeletal problems.

These problems are also termed as: cumulative trau-ma disorders (CTD),musculoskeletal disorders (MSD),work relatedmusculoskeletal disorders (WRMSD), and

1051-9815/12/$27.50 2012 – IOS Press and the authors. All rights reserved

154 G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users

repetitive strain injuries (RSI). A CTD is a conditionthat develops because the wear and tear of the muscles,tendons and nerve tissues exceeds the ability to healitself. It is not a specific disorder, but rather a collectionof musculoskeletal disorders that are characterized bychronic discomfort, pain and possibly functional im-pairment [26]. Some specific medical disorders underthe umbrella of CTDs that affect the upper extremityinclude: carpal tunnel syndrome, cubital tunnel syn-drome, deQuervain’s Disease and lateral epicondyli-tis. Since symptom exacerbations fluctuate over time,some clients may disregard the development of a CTDuntil the injury becomes chronic, resulting in surgerythat may not alleviate all the symptoms, particularlythe pain [19]. Furthermore, these disorders frequent-ly result in prolonged disability and delayed return towork [7].

According to the U.S. Department of Labor [39]there are several common interventions that can be im-plemented to reduce or relieve CTDs. Neutral pos-tures and positions are encouraged to reduce strain onthe joints and muscles and incorporating frequent ad-justments ensures the position does not remain static.The appropriate placement of the keyboard,mouse, andmonitor with regard to the individual user should alsobe considered. An alternative keyboard and/or mouse,wrist/forearm support, and adjustable chair are sug-gested tools used to facilitate neutral alignment of thejoints. However they are recommended with cautionas there is mixed evidence that injury or discomfortwill be prevented [1,8,9]. Other than ergonomic princi-ples from OSHA [6] there are several other approachesto consider when addressing CTDs in computer userssuch as exercise and stretching, rest breaks, education,primary or secondary prevention, and addressing psy-chosocial concerns. The evidence for the effectivenessof these approaches are also mixed [2,5,7,9]. There arealso many authorities from different disciplines, otherthan occupational therapy, involved in the research andexecution of these ergonomicprinciples. These includebut are not limited to ergonomists (arrangement ofworkstation and application of human movement sciences),physical therapists (exercise and conditioning, appli-cation of movement sciences, physical agent modali-ties) physicians (diagnosis, surgery, medications, otherconservative approaches), psychologists (psychologi-cal factors, stress management), and physiologists (ap-plication of humanmovement sciences). This results inmultifaceted procedures for designing an interventionprogram suitable for computer users.

2. Occupational therapy literature review

The researchers sought to investigate the role of oc-cupational therapists in assisting those who are diag-nosed with or at risk for CTD. There is an increase incomputers users and the number of settings where com-puters are used extensively. Researchers are studyingchildren and college students to collect data about theseat risk populations in order to assess if there is a needfor an earlier prevention strategy for CTD. However,most outcome-related research that focuses on com-puter users is conducted in the workplace, typicallyan office setting where CTD symptoms were alreadypresent. The high costs of healthcare, lost days ofwork,decrease in productivity, and employee turnover havecreated a demand for implementing preventative andrehabilitative interventions in the workplace [39].

The overall goal for occupational therapy in theworkplace is focusing on a holistic prevention of injuryand the advocacy and health and wellness of all peo-ple [21]. There are several areas of occupational ther-apy intervention including: workstation analysis anddesign, computer ergonomics, proper positioning, as-sistive technology, education on prevention, and psy-chosocial issues. The varying quality of literature andthe conflicting information on intervention strategiesfor computer users makes it difficult for the practicingtherapist to determine what evidence to use in interven-tion planning and implementation. A systematic re-view of the literature was deemed appropriate to gatherand synthesize the various interventions and evidencethat supports their use. The question for this researchstudy is: What is the effectiveness of current interven-tions that focus on CTD-related symptoms of the up-per extremities in computer users and how should thesemethods be put into practice?

3. Methods

A team of five researchers from a Master’s of Occu-pational Therapy Program at a public university gath-ered to conduct the systematic review. The researcherswere Master of Occupational Therapy Students super-vised by a faculty member with 15 years of clinicalexperience in hand rehabilitation, ergonomics and as-sistive technology for computer access, and return towork programs. Initially the intention of the team wasto focus the research exclusively on occupational ther-apy intervention outcomes and studies conducted byoccupational therapists. However, after preliminary in-

G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users 155

vestigation, there were limited outcome-related studiesfrom this perspective. The question was subsequentlyaltered by removing occupational therapy as a keywordwhich expanded the areas of research to both clinicaland non-clinical professionals that provided CTD in-terventions with computer users.

Intervention studies were reviewed using an adapt-ed method from a model systematic review on inter-ventions and prevention of musculoskeletal and visu-al disorders of computer users written by Brewer etal. [9]. This article employed stringent criteria for theinclusion articles to meet in order to be evaluated inthe systematic review. The Brewer article excluded allqualitative research and many other studies that werenon-experimental or quasi-experimental in design. Aless rigid method was used in this study to classify thesignificance of the literature on CTD intervention forthis review. This approach was utilized to benefit thepractitioner when considering the variability in clientsand environments and the generalizability of the inter-vention outcomes.

3.1. Databases

Over the course of one year, the following databas-es were searched extensively: Academic Search Com-plete, Alt Health Watch, Cinahl and Cinahl plus fulltext, ERIC, MEDLINE and MEDLINE plus FULLTEXT, NIOSHTIC-2, OT Search, Psychology and Be-havioral Sciences Collection, Science Citation, Sport-Discus with full text and PsychINFO. As articles werecollected, reference lists of those that were systematicreviews were further analyzed for potential articles.

3.2. Keywords

The primary keywords used in the systematic re-view were taken from the research question. Addition-al terms were added during the review process. Thekeywords used to search for articles of interest includ-ed: carpal tunnel syndrome, CTS, computer use, com-puters, cumulative trauma disorder, CTD, ergonomics,musculoskeletal disorder, MSD, repetitive strain in-jury, and RSI. Topics were further specified using theBoolean AND with alternative keyboard, education, er-gonomicmouse, exercise, forearmboard, health behav-ior, intervention, occupational therapy, prevention, re-habilitation, secondary prevention, stress, workstation,and wellness. Articles were considered appropriate ifthey were published after 1998, in English, and werepeer-reviewed.

Table 1Level 1 exclusion criteria

Questions Excluded

Level 1a1) Was an intervention used No2) Did the intervention involve computer use No

Level 1b3) Was peer reviewed No4) Was written in English No5) Diagnosis or was at risk for CTD No6) Outcome musculoskeletal CTD No7) Baseline data collected (pretest) No

Note. Level 1 – Screening questions and response that would lead toexclusion. If the response matched to any one question it would leadto automatic exclusion and would not be reviewed any further.

Intervention represented any intervention conductedto prevent or relieve cumulative trauma disorders orsymptoms. CTDs, as noted earlier, consist of severaldiagnoses, but for this review the researchers limitedthe disorders to those that only affected the upper ex-tremity. Computer user was defined as any popula-tion who used a computer. The combination of inter-vention and computer use greatly limited the numberof articles in varying populations because most inter-ventions were conducted in a workplace setting withmiddle-aged adults.

3.3. Level 1 review: Selection for relevance

To begin to narrow the 4,686 articles found in thearea of computer use and intervention research, level 1criteria were developed to exclude any non-relevant ar-ticles. Level one was further divided into levels 1a and1b. The abstracts of articles were screened at level 1abased on two criteria (1) intervention was implementedand (2) the population used computers. Those articlesthat did not meet these two criteria were automaticallyexcluded. This resulted in the initial retention of 50articles. The articles were then randomly assigned toa team member to scan the abstract, the article, and toprovide a summary of the article during group meet-ings. Unanimous decisions were made on which arti-cles were to be evaluated using the criteria of level 1b(see Table 1B). The included articles were from peerreviewed journals, were written in English, includeddiagnoses associated with CTD, reported outcomes on-ly related to upper extremity problems, and describedat least some type of baseline data in the methods orresults section.

The articles were randomly and equally dividedamong the 5 different reviewers and scored using level1b criteria. These results were discussed at a series ofteam meetings. The articles were presented to the team


Table 2Level 2 criteria used for quality assessment

Questions1) Was purpose of research clearly stated?2) Was the sample inclusion/exclusion criteria described?3) Is the sample size greater than 30?4) Was the participation rate reported?5) Was there a control group for comparison?6) Was cross contamination reduced?7) Were extraneous/confounding variables identified and analyzed?8) Was random assignment used?9) Were the baseline characteristics of participants/groups presented?10) Was the difference between dropouts and remaining people analyzed?11) Was intervention treatment and implementation described?12) Do the measurement tools have reliability/validity?13) Was the number of days between pre/post stated?14) Were the statistics adequately described?15) Are the limitations of the study identified?16) Are recommendations for further research identified?

by a primary reviewer and the team came to a consen-sus on which articles were retained. In cases when itwas unclear or there was a question whether the articlemet all the criteria, all 5 members read the article andscored it. Of the 50 articles included in level 1b, 25articles were excluded from further evaluation. Theremaining 25 articles were retained and progressed tolevel 2 where data extraction occurred.

3.4. Level 2 review: Criteria used for qualityassessment

The team created sixteen methodological criteria en-titled level 2, (see Table 2) to rate each of the remain-ing articles. The format and the question content wereborrowed from the Brewer et al. article [9], a criticalreview form by Law et al. [20], and from an adaptedchecklist created by Beck as cited in Leedy and Orm-rod [22]. The list of quality assessment questions wasmodified and improved over several group meetings.Upon agreement of a final list, three teammembers thenweighted the questions. The rankings assigned to thequestions were based on the following scale: 1 (some-what necessary), 2 (necessary), and 3 (very necessary).The rankings were tested on seven articles and wererevised and reweighted by the two other researchers toreduce bias. All the articles were then ranked using thefinal list of weighted questions displayed in Table 2.

The articles were split amongst two pairs of re-searchers to rank the evidence and apply the qualityassessment questions. When the answer to the questionwas yes, the rank score was placed in the correspondingquestion box next to the author’s name (see Table 3).If the article did not meet the criteria and the answerwas no it received a zero. If the two researchers did

not agree on the answer, a third reviewer resolved thediscrepancy. The answers were appraised at random asthe data were being entered in the quality ranking ta-ble. The scores were added up and divided by the totalnumber of points and multiplied x 100, to create a per-centage and determine if the quality was low (0–33%),medium (34–66%), or high (67–100%).

3.5. Data extraction

A list of criteria for data extraction was developedby all five researchers and revised upon consultationwith the research advisor to include: attrition, coun-try, and whether the participants where symptomatic ornot. The researchers extracted data from the articlesthey had not previously reviewed at level 2 for qual-ity control. Any discrepancies in ratings or opinionswere discussed and agreed upon unanimously by theteam. After the data were entered in the table, at leasttwo other researchers evaluated if the information wasclear, thorough, and accurate for each article.

The data were convened into two tables: an inter-vention detail table (see Table 4) and a results table(see Table 5). The objective of the two tables was tosummarize the 25 articles included in our systematicreview and to create a user-friendly resource for clin-icians and consumers to reference when looking forspecific study-related information.

4. Results

4.1. Education/ergonomics training

Five articles were rated high in the area of educa-tion and ergonomics training. Bohr [8] showed the


Table 3Quality ranking of articles

Question (see table 2 ) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Total %

Rating Score 3 3 3 2 2 1 2 1 3 1 3 2 1 3 2 1 33 100Author, YearRipat, 2006∗ [31] 3 3 3 2 2 1 2 1 3 1 3 2 1 3 2 1 33 100.00Bernaards, 2008∗ [5] 3 3 3 2 2 1 2 1 3 1 3 0 1 3 2 1 31 93.94Tittiranonda, 1999∗ [37] 3 3 3 2 2 1 2 1 3 1 3 0 1 3 2 1 31 93.94Bohr, 2000∗ [8] 3 3 3 2 2 0 2 1 3 1 3 0 1 3 2 1 30 90.91Greene, 2005∗ [17] 3 3 3 3 2 1 2 1 3 1 3 2 0 3 0 0 30 90.91Rempel, 2006∗ [30] 3 3 3 2 2 1 2 1 3 1 3 0 1 3 2 0 30 90.91Swanson, 2006∗ [35] 3 3 3 2 2 0 2 1 3 0 3 2 1 3 0 1 29 87.88Aaras, 1998/2001∗ ,∗∗ [2,3] 3 3 3 2 2 1 2 1 3 1 3 0 1 3 0 0 28 84.85Aaras, 1999/2002∗ ,∗∗ [1,4] 3 3 3 2 2 1 2 1 3 1 3 0 1 3 0 0 28 84.85Omer, 2003/2004∗ [28] 3 3 3 0 2 0 2 1 3 0 3 2 0 3 2 1 28 84.85Robertson, 2008∗ [32] 3 3 3 2 2 1 0 1 0 0 3 2 1 3 2 0 26 78.79Conlon, 2008∗ [10] 3 3 3 2 0 0 0 0 3 1 3 0 1 3 2 1 25 75.76Stevenson, 2005∗ [34] 3 3 0 2 0 0 2 0 3 0 3 2 1 3 2 1 25 75.76Desai, 2004∗ [13] 3 3 3 2 0 0 0 0 3 0 3 2 1 3 0 0 23 69.70Marcoux, 2000∗ [24] 3 0 3 2 0 0 2 0 3 0 3 0 1 3 2 1 23 69.70Nieuwenhuijsen, 2004∗ [25] 3 0 3 2 0 0 2 0 3 0 3 2 1 3 0 1 23 69.70Fenety, 2002 [14] 3 3 0 0 0 0 0 0 3 0 3 2 1 3 2 0 20 60.61Polvsen, 2008 [29] 3 3 0 2 0 0 0 0 3 0 3 2 1 0 2 1 20 60.61Trujillo, 2006 [38] 3 3 0 0 0 0 0 1 3 0 3 0 1 3 2 1 20 60.61Visschers, 2004 [40] 3 0 3 0 2 0 2 1 0 0 3 0 0 3 2 1 20 60.61Gravina, 2007 [16] 3 0 0 2 0 0 2 0 3 0 3 0 0 3 2 1 19 57.58Goodman, 2005 [15] 3 0 0 2 0 0 0 0 3 1 3 0 0 3 2 1 18 54.55Szeto, 2000 [36] 3 3 0 2 0 0 0 1 0 0 3 0 0 3 2 1 18 54.55Zecevic, 2000 [41] 3 0 0 0 0 0 2 1 3 0 3 2 0 3 0 0 17 51.52Shinn, 2002 [33] 3 3 3 0 0 0 0 0 0 0 3 0 0 0 2 0 14 42.42

∗Articles considered to be of high quality after systemic review.∗∗These articles were based on the same study.

perception of health status increased with the partici-patory group after a two-hour education meeting withactive learning, discussion, problem-solving, and theapplication of ergonomic principles with assistance totheir own workstations. Self report of pain and dis-comfort decreased with the intervention groups and theevidence found that the traditional educationwas effec-tive with or without the participatory element. Therewas no indication that discomfort or pain was relatedto worker area configuration or worker posture priorto the intervention. However, these results cannot beattributed to the intervention, alone.

Marcoux et al. [24] evaluated an intervention withfunctional work applications and a multi-method edu-cational program consisting of: seven 45-minute work-shops. The sessions focused on posture principles,good body mechanics, workstation adjustment, postu-ral hints via email reminders, informational booklets,posters displaying positive postural behaviors, and akeyboard template with stretch exercises and stress re-lieving activities. The results showed an increase inoverall knowledge of CTD and a significant increase inself-reported hand/wrist and neck/shoulder postures. A2008 study by Bernaards et al. [5] demonstrated that an

interactivework groupwith a focus on behavior changewas successful in reducing keyboard tilt, improvingdesk and keyboard height, and reducing the number ofworkers with raised shoulders. Greene et al. [17] stud-ied an intervention using educational interactions, dis-cussions, problem-based activities for workstation ad-justments, and prevention strategies that reduced CTDrisk factor for those at higher risk. There was also in-creased knowledge, self-efficacy, and belief in the ben-eficial effects of changing one’s workstation. Behav-iors of the intervention group were significant in thatchangeswere made to workstations, work organization,and exercise practices.

A study by Robertson et al. [32] showed that by rear-ranging the desktop into a semi-circular shape with anadjustable chair and storage area component, there wasa significant reduction in reportedWMSDs of the train-ing group. Less discomfort was reported for the work-station and training group compared to the workstation-only group. Shoulder, wrist, hand, and finger discom-fort was significantly reduced between the workstationand training and the workstation-only group. Whencompared to the control group, intervention groupsshowed a significant difference in job control, collab-


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adju

stab

lest

orag

ean

dpa

perm

anag

emen

tto

olan

dan

adju

stab

lech

air;

I3:

Flex

ible

wor

kspa

ce+

ergo

nom

ics

trai

ning

;C

:No

inte

rven

tion

Qua

si-e

xper

imen

tal,

non-

rand

omiz

ed,

3-w

ave

long

itudi

nal

A&

SO

ffice

wor

kers

I1=

121*

I2=

91*

I3=

31*

C=

45*

I=

6m

O=

8m

Uni

ted

Stat

es/

Offi

ce

Erg

onom

icm

ouse

Aar

as,

1999

/200

2Erg

onom

ics

Hig

hI:

An

Ani

rm

ouse

that

plac

esth

efo

rear

min

am

ore

neut

ralp

osi-

tion

was

used

during

daily

wor

kac

tiviti

es.

C:U

sed

atrad

ition

alm

ouse

and

rece

ived

the

Ani

rm

ouse

6m

onth

sla

ter

Pros

pect

ive

para

llel

grou

pde

sign

SV

DU

oper

ator

sSt

udy

1:I=

32C

=35

Stud

y2:

I=

19C

=13

I:1

+y

O:3

yN

orw

ay/

Offi

ce

Erg

onom

icM

ouse

/Fo

rear

mSu

ppor

t

Rem

pel,

2006

Occ

upat

iona

lH

ealth

Hig

hI1

:Erg

onom

ics

trai

ning

cons

istin

gof

conv

entio

nalw

orks

tatio

nre

com

men

datio

ns;I

2:Tra

inin

g+

Log

itech

Tra

ckba

llm

ouse

;I3:

Tra

inin

g+

Fore

arm

supp

ort;

I4:Tra

inin

g+

Log

itech

Tra

ckba

llm

ouse

+Fo

rear

msu

ppor

t

RC

TA

I1:4

6I2

:45

*I3

:46

I4:46

*

I/O

:1y

Uni

ted

Stat

es/

Com

pute

rW

orke

rs

Erg

onom

icm

ouse

/Fo

rear

mSu

ppor

t

Con

lon,

2008

Erg

onom

ics

Hig

hI1

:C

onve

ntio

nal

Inte

llim

ouse

mou

se;

I2:

Alte

rnat

ive

Ren

ais-

sanc

e(3

MC

orp)

mou

se;I

3:B

utte

rflyb

oard

(Met

amor

phas

isD

e-si

gnan

dD

evel

opm

ent)

Fore

arm

supp

ortb

oard

;I4:

Ren

aiss

ance

mou

sean

dB

utte

rflyb

oard

RC

TO

ffice

wor

kers

I1=

52I2

=52

I3=

51I4

=51

I/O

:1y

Uni

ted

Stat

es/

Offi

ce

Fore

arm

Supp

ort

Aar

as,

1998

/200

1Erg

onom

ics

Hig

hTo

allo

ww

orke

rsto

plac

efo

rear

ms

onth

eta

ble

top

during

typ-

ing

activ

ities

partic

ipan

tsw

ere

assi

gned

toei

ther

I1:

Cra

nk-

adju

stab

lehe

ight

tabl

eor

I2:A

djus

tabl

ele

ghe

ight

tabl

e

Pros

pect

ive,

para

llel

grou

pde

sign

A&

SV

DU

oper

ator

sI1

=27

*I2

=44

*C

=36

*

I/O

:6y

Nor

way

/O

ffice

Exe

rcis

eFe

nety

,20

02PT

Med

ium

Rev

ised

vers

ion

ofth

eD

atas

pan

Erg

onom

icSk

ills

Tra

inin

gpr

o-gr

amw

asin

trod

uced

and

exer

cise

sw

ere

dem

onst

rate

dan

dpr

ac-

ticed

,pa

rtic

ipan

tsw

ere

toco

mpl

ete

one

desk

exer

cise

ever

y30

min

.

Rep

eate

dM

easu

res

Pret

est/P

ostte

stA

VD

Uop

erat

ors

I=

11I:

6–10

dO

:1y

Uni

ted

Stat

es/

Offi

ce

Exe

rcis

e/Pr

imar

yEdu

catio

n

Des

ai,

2004

OT

Hig

hPa

rtic

ipan

tsw

ere

tota

ke<

2m

inm

icro

brea

ksan

dch

ange

mus

cle

grou

psas

need

ed,ta

kean

othe

rre

stbr

eak

ever

y30

–60

min

san

dge

tup

and

mov

e,an

dex

erci

seev

ery

1–2

hsus

ing

ach

artw

ithex

erci

ses

forth

efo

rth

ene

ck,s

houl

der,

wrist

,etc

.

Pret

est/P

ostte

stA

Offi

cew

orke

rsI=

100

I/O

:15

dIn

dia/

Offi

ce

Exe

rcis

e/Tra

inin

gO

mer

,20

03/2

004

Reh

ab

Hig

hA

llat

tend

eda

1h

educ

atio

nin

clud

ing

ergo

nom

ics,

body

me-

chan

ics,

exer

cise

and

heal

thpr

oble

ms

ofco

mpu

ter

oper

ator

s.I:

rece

ived

mob

iliza

tion,

stre

tch,

stre

ngth

enin

g,an

dre

laxa

tion

exer

cise

sto

beco

mpl

eted

for1

h-3x

/win

the

wor

kpla

cese

tting

.

Bef

ore

&A

fter

SC

ompu

terw

orke

rsI=

25C

=25

I/O

:5x/

wfo

r2

mTur

key/

Offi

ce


Tabl

e4,

cont

inue

d

Inte

rven

tion

type

Firs

taut

hor,

year

/di

scip

line

Qua

lity

Inte

rven

tion

deta

ilsSt

udy

Des

ign

Popu

latio

n(A

/S)an

dfin

alsa

mpl

esi

zeLen

gth

ofin

terv

entio

n/ob

serv

atio

n

Cou

ntry

/en

viro

nmen

t

Key

boar

dR

ipat

,20

06O

TH

igh

I1:M

icro

soft

Nat

ural

Mul

timed

iaK

eybo

ard;

I2:M

odifi

edve

rsio

nM

icro

soft

Nat

ural

Lig

htTo

uch

desi

gned

tore

duce

activ

atio

nfo

rce,

vibr

atio

n,an

dke

ytrav

el.

Pros

pect

ive

RC

TS

Offi

cew

orke

rsI1

=41

I2=

24

I:24

wO

:26

wC

anad

a/O

ffice

Key

boar

dSt

even

son,

2003

PTH

igh

Subj

ects

used

anEas

yM

otio

nC

PMke

yboa

rdpl

atfo

rmdu

ring

daily

keyb

oard

ing

task

sPr

ospe

ctiv

eC

ase

Rep

ort

1S

Wor

ker

1A

Wor

ker2

I1:1

0m

inI2

:20

min

O:6

w

Uni

ted

Stat

es/

Clin

ic

Key

boar

dSw

anso

n,20

06N

IOSH

Hig

hI:

Non

-adj

usta

ble

alte

rnat

ive

keyb

oard

with

halv

esat

fixed

angl

esto

beus

edat

thei

rw

orks

iteC

:Sta

ndar

dke

yboa

rdLon

gitu

dina

lPr

etes

t/Pos

ttest

A&

SO

ffice

wor

kers

I=

94C

=95

I/O

:12

mni

ted

Stat

es/

Offi

ce

Key

boar

dTitt

itran

onda

,19

99Erg

onom

ics/

Phys

icia

ns

Hig

hA

llre

ceiv

ed1

her

gono

mic

trai

ning

and

aw

orks

tatio

nad

just

men

t;I1

:A

pple

Adj

usta

ble

Key

boar

d;I2

:C

omfo

rtK

eybo

ard

Syst

em;I

3:M

icro

soft

Nat

ural

Key

boar

d

RC

TA

Offi

cew

orke

rsI1

=19

I2=

11*

I3=

19C

=20

I/O

:6m

Uni

ted

Stat

es/

Offi

ce

Key

boar

dSz

eto,

2000

Occ

upat

iona

lR

ehab

Med

ium

Com

pariso

nof

ast

anda

rdke

yboa

rdan

dth

eM

icro

soft

Nat

-ur

alke

yboa

rdon

typi

ngta

sks

perf

orm

edfo

r30

min

with

a10

min

rest

period

.

sing

leca

sese

ries

orbe

fore

/after

ASt

uden

tsI=

10I/O

:120

min

Hon

gK

ong/

Lab

orat

ory

Key

boar

dZec

evic

,20

00PT

Med

ium

Ten

hour

sof

trai

ning

onan

adju

stab

leO

PEN

(15◦

split

setti

ng&

42◦

dem

iboa

rdla

tera

linc

linat

ion)

keyb

oard

and

aFI

XED

keyb

oard

(12◦

split

setti

ng&

10◦

late

ralin

cli-

natio

n)an

da

com

pariso

nof

the

keyb

oard

sw

itha

cont

rol

keyb

oard

onse

ttyp

ing

text

s.

1gr

oup-

all

inte

rven

tions

(wer

era

ndom

ized

)

AO

ffice

wor

kers

I=

16I/O

:2–3

wC

anad

a/O

ffice

Res

tBre

akSo

ftw

are

Tru

jillo

,20

06O

TM

ediu

mA

utom

ated

‘Sto

pan

dSt

retc

h’co

mpu

terpr

ogra

mw

ithau

-di

oan

dvi

sual

rem

inde

rsto

stop

wor

kan

dst

retc

han

dan

inst

ruct

iona

lre

view

onC

TD

relie

f.

Non

-exp

erim

enta

lA

&S

Offi

cew

orke

rsI=

19I:

29d

O:1

mU

nite

dSt

ates

/O

ffice

Res

tBre

aks

Vis

sche

rs,

2004

Hea

lthEdu

catio

n/Exp

erim

enta

lPs

ycho

logy

Med

ium

Com

mun

icat

ion

Hum

anIn

foPr

oces

s(C

-HIP

)w

aste

sted

usin

g:w

arni

ngon

com

pute

rsc

reen

,w

arni

ngon

aw

all,

aned

ucat

iona

lbr

ochu

re,

ane

utra

lin

terr

uptio

non

com

psc

reen

,orno

cue

One

fact

oria

lbe

twee

nsu

bjec

tsde

sign

ASt

uden

tsI=

125

I/O

:<1

hN

ethe

rlan

ds/

Lab

orat

ory

Res

tBre

aks/

Exe

rcis

ePo

vlse

n,20

08O

T/M

DM

ediu

mI:

cons

iste

dof

1:1

sess

ions

with

anO

T,am

anua

linc

ludi

nga

HEP,

(pha

se1)

redu

cing

caffei

ne/ni

cotin

ean

din

crea

selig

htae

robi

cex

erci

ses,

(pha

se2)

stre

ngth

enin

gpr

ogra

m,

and

(fina

lpha

se)i

mpl

emen

ting

ane

whe

alth

ylif

esty

lean

dap

plyi

nger

gono

mic

prin

cipl

esda

ily.

Bef

ore

and

After

Cas

est

udy

SO

ffice

wor

kers

I=

3I/O

:Ia

(4x

1h)

and

Ib(1

3x1

h)=

6m

Ic(1

0x1

h)=

5m

Uni

ted

Kin

g-do

m/

Lab

orat

ory

I=

Inte

rven

tion;

y=

year

;m=

mon

th;h

=ho

ur;m

in=

min

ute;

A=

Asy

mpt

omat

ic;S

=Sy

mpt

omat

ic;*

=>

than

10%

chan

gein

sam

ple

size

.


Tabl

e5

Stud

yPu

rpos

e,O

utco

me

Mea

sure

s,St

atis

tical

Ana

lysi

san

dR

esul

tsfo

rA

llA

rtic

les

Sele

cted

forR

evie

w

Firs

taut

hor

Res

earc

hqu

estio

nsan

d/or

hypo

thes

esO

utco

me

mea

sure

sSt

atis

tical

test

Res

ults

inte

rpre

tatio

n

Rip

atTo

inve

stig

ate

whe

ther

alte

rnat

est

yle

keyb

oard

sw

ere

effe

ctiv

ein

redu

cing

sym

ptom

seve

rity

and

impr

ovin

gfu

nctio

nal

stat

usfo

rin

divi

dual

sw

hoex

perien

ceW

RU

ED

sym

ptom

s.

Job

cont

entqu

estio

nnai

re;Sy

mp-

tom

Seve

rity

Scal

e(S

SS);

Func

-tio

nal

Stat

usSc

ale

(FSS

);Q

ue-

bec

Use

rof

Eva

luat

ion

Satis

fac-

tion

with

Ass

istiv

eTe

chno

logy

(QU

EST

);m

anua

lmus

cle

test

ing;

Phal

en’s

test

;Sem

mes

-Wei

nste

inm

onofi

lam

ents

;typ

ing

spee

dca

paci

ty

Split

-uni

tre

peat

edm

easu

res

AN

OVA

;McN

emar

Test

;Lea

stSq

uare

Mea

ns;

Des

crip

tive

Stat

istic

s

Asi

gnifi

cant

redu

ctio

nin

sym

ptom

sw

assh

owed

be-

twee

nbe

fore

Ian

dat

2w

eeks

(p<

0.00

1)an

dbe

-tw

een

2–12

wee

ks(p

<0.

001)

at12

–24

wee

ksth

ere

sults

wer

em

aint

aine

dbu

tw

ere

notsi

gnifi

cant

.A

sign

ifica

ntim

prov

emen

tin

the

Phal

en’s

Test

was

seen

for

I1(p

<0.

025)

and

I2(p

<0.

05).

Asi

gnifi

cant

incr

ease

infu

nctio

n-ty

ping

was

show

nfo

rbo

thI’s

befo

reIan

daf

ter12

wee

ks(p

<0.

001)

.Sa

tisfa

ctio

nw

ithke

yboa

rdw

assi

gnifi

cant

at12

wee

ks(p

<0.

001)

and

mai

ntai

ned

asl

ight

impr

ovem

enta

fter

24w

eeks

.

Ber

naar

dsTo

inve

stig

ate

the

effe

ctiv

enes

sof

agr

oup-

base

din

tera

ctiv

ew

ork

styl

ein

terv

entio

nin

chan

ging

wor

kst

yle

beha

vior

and

aco

mbi

ned

wor

kst

yle/

phys

ical

activ

itygr

oup

onre

cove

ryfr

omne

ck/

UE

sym

ptom

sre

late

dto

com

pute

rus

e.H

1:I2

wou

ldbe

mor

eef

fect

ive

than

I1or

Con

impr

ovin

gw

ork

styl

ebe

havi

ors

and

redu

cing

sym

ptom

s.

Rec

over

yof

neck

/UE

sym

ptom

svi

aa

7-po

intVA

S;Pa

inan

dD

is-

abili

tyvi

aan

11-p

oint

num

eric

alsc

ale;

Que

stio

nnai

re

Mul

tilev

elan

alys

es(M

Lw

iNve

rsio

n2.

02)

I1an

dI2

redu

ced

the

keyb

oard

tilt,

incr

ease

dus

eof

the

rest

brea

kre

min

der

softw

are,

and

incr

ease

dth

enu

mbe

rof

rest

brea

kspe

rho

ur.

The

rew

asno

dif-

fere

nce

betw

een

wor

kar

eaco

nfigu

ratio

nan

dpo

stur

esbe

twee

nth

egr

oups

.

Titt

itran

onda

Tode

term

ine

ifco

mpu

ter

user

sw

itha

MSD

can

bene

fitfr

omlo

ng-ter

mus

eof

anal

tern

ativ

eke

y-bo

ard.

Are

ther

ecl

inic

alim

prov

emen

tsin

clin

-ic

alsy

mpt

oms

and

UE

func

tion

ifan

alte

rnat

ive

keyb

oard

isus

edin

com

pariso

nto

atrad

ition

alke

yboa

rd?

Stan

dard

ized

med

ical

exam

;se

lf-

adm

inis

tere

dqu

estio

nnai

re;

10-

cmVA

Sfo

rsy

mpt

oms,

keyb

oard

com

pariso

nsvi

aa

11-p

oint

VA

Ssc

ale;

Psyc

hoso

cial

item

sus

ing

the

Job

Con

tent

Inst

rum

ent(J

CI)

and

Wor

kIn

terp

erso

nalR

elat

ion-

ship

sIn

vent

ory

(WIR

I);

keyi

ngac

tivity

usin

gth

eO

dom

eter

Ob-

serv

erSo

ftw

are

Kru

skal

lWal

liste

st;p

osth

ocD

unne

tt’s

one-

side

dte

st;

Rep

eate

dm

easu

res

AN

OVA

;po

stho

cTuk

ey-K

ram

erte

st;S

pear

man

corr

elat

ion

coef

ficie

nt;Tw

o-w

ayA

NO

VA

I3sh

owed

mos

tim

prov

emen

tin

over

allpa

in,sy

mp-

tom

seve

rity

,an

dfu

nctio

nalst

atus

at6

mon

ths

(P<

0.05

).In

I3pa

inse

verity

was

redu

ced

mor

efo

rth

ose

with

tend

oniti

sw

hen

com

pare

dto

CTS

(P<

0.05

).K

eybo

ard

satis

fact

ion

was

corr

elat

edw

itha

decr

ease

inov

eral

lpai

n(P

<0.

01)

Boh

rTo

inve

stig

ate

theef

ficac

yof

offic

eer

gono

mic

sed

-uc

atio

npr

ogra

ms

inre

duci

ngw

orke

rdi

scom

fort,

awkw

ard

wor

kpo

stur

esan

din

prev

entin

gm

us-

culo

skel

etal

inju

ries

byfa

cilit

atin

gw

orke

rad

just

-m

ents

inth

eirw

ork

area

.

Self-r

epor

tsur

vey

(31

item

s);O

b-se

rvat

ion

chec

klis

t:w

ork

confi

g-ur

atio

nan

dpo

stur

es

AN

OVA

;APG

AR

scor

es;

Ana

lysi

sof

Cov

aria

nce

I2pe

rcei

ved

thei

rhe

alth

stat

usto

besi

gnifi

cant

lybe

t-te

rth

anC

(p<

0.01

).C

repo

rted

ahi

gher

freq

uen-

cyof

uppe

rbo

dypa

inan

ddi

scom

fort

thro

ugho

utth

est

udy

than

I1or

I2(p

<0.

01).

The

rew

asno

differ

-en

cebe

twee

nI1

orI2

.D

ecre

ase

inst

ress

betw

een

the

Can

dI1

and

I2(p

=0.

01).

The

rew

ere

nosi

gnifi

cant

differ

ence

sin

wor

ksta

tion

adju

stm

entq

uest

ions

.

Gre

ene

H1:

Do

risk

expo

sure

and

rela

ted

wor

kbe

havi

ors

chan

gefo

llow

ing

anA

ET

prog

ram

?H

2:D

oesth

ein

tens

ity,f

requ

ency

,ordu

ratio

nof

mus

culo

skel

-et

alsy

mpt

omsch

ange

imm

edia

tely

post

-int

erve

ntio

nan

dat

1-ye

arpo

stfo

llow

ing

anA

ET

prog

ram

?H

3:D

ow

ork

self-e

ffica

cyan

dou

tcom

eex

pect

a-tio

nsch

ange

imm

edia

tely

post

-int

erve

ntio

nan

dat

1-ye

arpo

stfo

llow

ing

AET?

Rap

idU

pper

Lim

bA

sses

smen

t(R

ULA

);Su

rvey

mod

ified

byN

IOSH

form

uscu

losk

elet

alsy

mpt

oms;

T/F

inst

rum

ent

ergo

nom

ickn

owle

dge/

belie

fs;

3se

lf-e

ffica

cyite

mson

asc

ale

of1–

6.

AN

CO

VA

;C

hi-s

quar

ean

aly-

sis;

Paired

t-te

st;

Wilc

oxon

-si

gned

rank

ste

stD

escr

iptiv

eSt

atis

tics

H1:

The

rew

asa

sign

ifica

ntde

crea

sein

fact

orex

po-

sure

for

Ico

mpa

red

toC

(p<

0.01

).W

ork-

rela

ted

beha

vior

ssh

owed

that

asi

gnifi

cant

lygr

eate

rpr

opor

-tio

nof

partic

ipan

tsin

the

Igr

oup

had

mad

ech

ange

sto

thei

rw

orks

tatio

n,w

ork

orga

niza

tion,

and

exer

cise

prac

tices

(p<

0.05

).H

2:R

educ

edup

perba

ckin

ten-

sity

(p<

0.05

),pa

infr

eque

ncy

(p<

0.01

),an

dpa

indu

ratio

n(p

<0.

01).

The

rew

asno

differ

ence

forU

E


Tabl

e5,

cont

inue

d

Firs

taut

hor

Res

earc

hqu

estio

nsan

d/or

hypo

thes

esO

utco

me

mea

sure

sSt

atis

tical

test

Res

ults

inte

rpre

tatio

n

pain

inbo

thgr

oups

.A

t1

year

follo

wup

,U

Esy

mp-

tom

sw

ere

repo

rted

less

atbo

rder

line

sign

ifica

nce

(p0.

058)

.H

3:The

rew

ere

nosi

gnifi

cant

differ

ence

sbe

twee

nim

med

iate

lyfo

llow

ing

and

post

-int

erve

ntio

n1

year

forse

lf-e

ffica

cyan

dou

tcom

eex

pect

atio

ns.

Rem

pel

Tode

term

ine

whe

ther

afo

rear

mbo

ard

and/

ora

trac

kbal

lm

ouse

wou

ldre

duce

the

pain

seve

rity

and

the

deve

lopm

entof

inci

dent

mus

culo

skel

etal

diso

rder

s.

Wee

kly

pain

seve

rity

;Ph

ysic

alExa

m;Q

uest

ionn

aire

;W

eekl

ySu

rvey

s

Cox

prop

ortio

nalh

azar

dm

od-

els;

Lin

earR

egre

ssio

nM

odel

sFo

rear

mbo

ard

decr

ease

dne

ck/s

houl

der

pain

(p=

0.01

)an

dRU

Epa

in(p

=0.

002)

.The

effe

cts

ofth

etrac

kbal

lin

terv

entio

nw

ere

nots

igni

fican

t.

Swan

son

Tote

stpa

thw

ays

betw

een

phys

ical

,w

ork

orga

-ni

zatio

n/ps

ycho

soci

al,st

ress

and

mus

culo

skel

etal

sym

ptom

sfa

ctor

spo

stul

ated

bySa

uter

and

Swan

-so

n’s

ecol

ogic

alm

odel

ofm

uscu

losk

elet

aldi

sor-

ders

atw

ork.

H1:

The

effe

ctof

keyb

oard

cond

itio

n(a

ltern

ativ

evs

.co

nven

tiona

l)on

mus

culo

skel

etal

sym

ptom

s,be

ing

that

partic

ipan

tsin

the

two

key-

boar

dco

nditi

onsw

ould

show

adi

ffer

entp

atte

rnof

mus

culo

skel

etal

sym

ptom

repo

rtin

gov

erth

eye

ar.

Psyc

hoso

cial

surv

eysco

nsis

ting

ofth

eN

IOSH

Job

Stre

ssQ

uest

i-on

naire

(JSQ

);U

nive

rsity

ofW

isco

nsin

Offi

ceW

orke

rSu

rvey

;sh

orte

ned

vers

ion

ofth

eN

IOSH

mus

culo

skel

etal

sym

ptom

surv

ey

Des

crip

tive

Stat

istic

s;C

ronb

ach’

sal

phas

;Mul

tiple

Reg

ress

ion

Ana

lyse

s

The

keyb

oard

cond

ition

was

sign

ifica

ntly

rela

ted

tom

uscu

losk

elet

alsy

mpt

oms

inth

eL

shou

lder

(p<

0.05

)an

dne

arsi

gnifi

canc

ein

the

Lha

nd(p

=0.

07).

The

differ

ence

betw

een

base

line

and

scor

es@

1y

indi

cate

dfe

wer

partic

ipan

tsre

ported

sym

ptom

sin

the

Igr

oup

than

the

Cgr

oup.

Aar

asSt

udy

1:W

illpa

inde

velo

pmen

tbe

redu

ced

ifus

-in

ga

mou

sew

itha

mor

ene

utra

lpo

sitio

nof

the

wrist

than

ifus

ing

atrad

ition

alm

ouse

with

am

ore

pron

ated

fore

arm

?St

udy

2:W

illsi

gnifi

cant

re-

duct

ion

inpa

inle

velo

fth

eup

perpa

rtof

the

body

repo

rted

afte

r1

year

still

bepr

esen

taf

ter3

year

s,w

hen

usin

ga

mou

seal

low

ing

anal

mos

tne

utra

lpo

sitio

nof

the

fore

arm

and

wrist

?

100

mm

VA

Spa

in;Q

uest

ionn

aire

Paired

t-te

st;M

ante

l-H

aens

zel

test

Stud

y1:

Pain

inte

nsity

impr

ovem

ents

wer

esi

gnifi

cant

fort

hew

rist

/han

d,fo

rear

m,s

houl

deran

dne

ck(p

>=

0.00

9).

Stud

y2:

The

pain

redu

ctio

npe

rsis

ted

for

2.5

year

sfo

ral

lupp

erbo

dypa

rts

(p<

0.00

1).

Om

erIn

vest

igat

eth

eef

ficac

yof

prev

enta

tive

educ

atio

nan

dex

erci

sepr

ogra

ms

inth

etrea

tmen

tof

CTD

.W

hati

sth

eef

fect

iven

essof

exer

cise

and

educ

atio

non

pain

,fun

ctio

nalst

atus

,and

depr

essi

on?

Num

eric

Rat

ing

Scal

e(N

RS)

and

Pain

Dis

abili

tyIn

dex

(PD

I);

Tired

ness

Scal

e(T

S);B

eck

Dep

ress

ion

Scal

e

T-te

sts,

Man

n-W

hitn

eyU

test

,W

ilcox

onte

st,P

ears

onan

dSp

earm

anco

rrel

atio

nte

sts

The

Igro

upex

perien

ced

asi

gnifi

cant

impr

ovem

enti

nN

RS

(p<

0.00

1),Pa

inD

isab

ility

Inde

x(p

<0.

05)

and

Bec

kde

pres

sion

scal

e(p

<0.

05).

The

rew

asno

differ

ence

betw

een

TS

scor

es.

Rob

erts

onH

1:W

asno

ttes

tabl

eH

2:D

ecre

ase

inW

MSD

forI2

vs.C

.H3:

Red

uced

WM

SDre

ports

with

I3vs

.I2

.H

4:Ps

ycho

soci

alfa

ctor

s/W

orks

pace

Satis

fact

ion

will

incr

ease

forI3

vs.C

.H5:

Gro

upPe

rfor

man

cean

dB

PAw

illin

crea

sein

I2an

dm

ore

forI3

vs.C

.

Wor

kpla

ceen

viro

nmen

tele

ctro

n-ic

surv

eys;

Erg

onom

icskn

owl-

edge

test

s;an

dB

usin

ess

Proc

ess

Ana

lysi

s

Rep

eate

d-m

easu

res

AN

OVA

;G

ener

alLin

earM

odel

sin

SPSS

15.0

;Mul

tiple

Reg

ress

ion;

Bon

ferr

oni;

post

-hoc

anal

yses

H2:

Yes

,the

reis

adi

ffer

ence

buti

twas

nots

igni

fican

t(p

=0.

08)

H3:

Diffe

renc

ebe

twee

n2

grou

psw

ithsh

ould

er,w

rist

/han

d,&

finge

rs(p

<0.

00).

H4:

No

differ

ence

betw

een

I3an

dI2

butth

ere

isw

hen

both

com

pare

dto

C(p

<0.

05).

H5:

Red

uctio

nin

proc

ess

time

only

com

pare

dto

I2.

Con

lon

Tode

term

ine

the

effe

cts

ofan

alte

rnat

ive

mou

sean

d/or

fore

arm

supp

ortb

oard

onth

ech

ange

inU

Edi

scom

fort

scor

esan

dth

ede

velo

pmen

tofi

ncid

ent

mus

culo

skel

etal

disc

omfo

rt

Hea

lthqu

estio

nnai

re;W

eekl

ydi

s-co

mfo

rtsu

rvey

s;Ph

ysic

alex

ami-

natio

n;Exi

tque

stio

nnai

re

Cox

prop

ortio

nalha

zard

sm

odel

;Gen

eral

Lin

earM

odel

sFo

rear

msu

ppor

tres

ulte

din

redu

ced

RU

Edi

scom

fort

inI3

and

I4co

mpa

red

toI1

and

I2(p

<0.

05).

Er-

gono

mic

mou

sesh

owed

nosi

gnifi

canc

eon

RU

Em

us-

culo

skel

etal

diso

rder

sco

mpa

red

toot

hers

.


Tabl

e5,

cont

inue

d

Firs

taut

hor

Res

earc

hqu

estio

nsan

d/or

hypo

thes

esO

utco

me

mea

sure

sSt

atis

tical

test

Res

ults

inte

rpre

tatio

n

Stev

enso

nD

oes

cont

inuo

uspa

ssiv

em

otio

nde

liver

edby

anEas

yM

otio

nC

PMK

eybo

ard

Plat

form

during

key-

boar

ding

task

sim

prov

eha

ndbl

ood

flow

and

wrist

func

tion?

Car

palT

unne

l(M

edia

nN

erve

)Fu

nctio

nD

isab

ility

Form

;D

uple

xD

oppl

erU

ltras

ound

;se

lf-a

dmin

iste

red

ques

tionn

aire

Cod

ing

Apa

rtic

ipan

tsho

wed

anin

crea

sein

both

radi

alan

dul

nar

bloo

dflo

wve

loci

ty.

Spar

ticip

ant

show

edin

crea

sein

over

allbl

ood

flow

exce

ptpr

e-ul

nar

atba

selin

ean

dfin

al.A

nin

crea

sein

func

tiona

lsta

tus

and

sym

ptom

seve

rity

.B

oth

subj

ects

show

edan

incr

ease

inW

PMw

hile

typi

ng.

Des

aiTo

stud

yth

eef

fect

iven

ess

ofin

terv

entio

nw

ither

gono

mic

mod

ifica

tions

and

rout

ine

exer

cise

regi

me

during

wor

kho

urs.

Que

stio

nnai

re;VA

Sfo

rpa

in;

Func

tiona

lAss

essm

entS

cale

(FA

S)

Paired

t-te

sts

Post

inte

rven

tion

ther

ew

asa

decr

ease

inth

epa

inre

ported

atth

esh

ould

er,

back

,an

dne

ck.

Mea

nVA

San

dM

ean

FAS

wer

esi

gnifi

cant

atth

ew

rist

site

(p=

0.00

5).

Wor

ksta

tion

mod

ifica

tion

alon

gw

ither

gono

mic

guid

elin

esco

mbi

ned

with

variou

sex

erci

sesw

ere

effe

ctiv

ein

redu

cing

the

pain

,aw

k-w

ard

and

stat

icpo

stur

e,de

crea

sere

petit

ive

mot

ion

and

redu

cech

ance

sto

deve

lop

CTD

s.

Mar

coux

/N

ieuw

enhu

ijsen

Tode

term

ine

the

effe

ctiv

enes

sof

aned

ucat

iona

lin

-te

rven

tion

desi

gned

toin

crea

sekn

owle

dge

ofrisk

fact

ors

for

CTD

asw

ellas

redu

cerisk

ybe

havi

ors

amon

gof

fice

wor

kers

.

10-m

ultip

lech

oice

ques

tionn

aire

Des

crip

tive

Stat

istic

s,C

hi-

squa

rean

alys

isR

epor

ted

use

ofm

ore

appr

opriat

epo

stur

esfo

rth

eha

nd/w

rist

and

neck

/sho

ulde

rs,

incr

ease

dkn

owl-

edge

ofrisk

san

dpr

even

tativ

em

easu

res

rela

ted

toC

TD

(p<

0.05

).

Fene

tyD

oes

doin

gre

gula

rsh

ortt

erm

exer

cise

(<10

days

)at

aw

orks

tatio

nde

crea

seM

SDan

din

crea

seIn

Cha

irM

ovem

ent(

ICM

)?H

1:The

rew

illbe

anin

crea

sein

ICM

.H

2:The

rew

illbe

noin

crea

sein

MSD

over

time.

H3:

The

will

bea

decr

ease

inw

hole

body

MSD

.

Bod

yPa

rtD

isco

mfo

rtSc

ale

(BPD

S)an

dB

ody

Map

;IC

Mvi

aa

VER

G(V

isio

nEng

inee

ring

Res

earc

hG

roup

)pr

essu

re-

sens

itive

mat

AN

OVA

,Tw

o-w

ayre

peat

edm

easu

reH

1an

dH

3:M

SDw

ere

decr

ease

dan

dIC

Mw

asin

crea

sed

with

thesh

ort-te

rmex

erci

ses(p

<0.

01).

H2:

Not

stat

istic

ally

sign

ifica

nt.

Povl

sen

Topr

esen

tase

ries

ofca

sere

portson

the

asse

ssm

ent

and

trea

tmen

tof

indi

vidu

als

who

perf

orm

keyb

oard

and

high

inte

nsity

mou

se-b

ased

wor

kbu

twan

ted

tore

mai

nat

wor

kdu

ring

thei

r6

mon

thtrea

tmen

tan

dfo

llow

uppe

riod

.D

oesa

cons

erva

tivetrea

tmen

tpro

-gr

amde

crea

sesi

gns/

sym

ptom

s(p

ain)

ofW

RU

LD

whi

leth

epa

rtic

ipan

tco

ntin

ues

tow

ork?

VA

Sfo

rpa

in;

“Typ

ing

capa

city

cycl

e”;

RO

M;

adap

ted

Func

tiona

lG

rad-

ing

Scal

e

Des

crip

tive

Stat

istic

sA

llw

ereab

leto

wor

kan

dat

tend

outp

atie

ntth

erap

yan

dat

the

end

ofth

etrea

tmen

t,al

lrep

orte

dre

stin

gpa

inle

vels

atVA

S0

and

incr

ease

dpr

oduc

tivity

mea

sure

dby

the

“typ

ing

capa

city

test

”fr

om48

–12

9%.

Tru

jillo

Iden

tify

poss

ible

met

hods

used

inre

lievi

ngC

TD

,co

llect

data

from

com

pute

rw

orks

tatio

nus

ers

and

thei

rre

spon

seto

stop

and

stre

tch,

and

tode

term

ine

the

effe

ctiv

enes

sof

the

softw

are

and

inth

eam

ount

/re

gula

rity

ofits

use.

Que

stio

nnai

reC

ross

-tab

ulat

ion;

Des

crip

tive

Stat

istic

s10

/19

user

sno

ticed

adi

ffer

ence

insy

mpt

oms.

12/1

9ha

da

posi

tive

effe

cton

thei

rpr

oduc

tivity

.A

llus

ers

stat

edit

was

easy

tofo

llow

and

foun

dit

help

ful.

18/1

9w

ere

satis

fied

with

prog

ram

and

wou

ldre

com

men

dit

toot

hers

.Ave

rage

num

ber

oftim

es/d

aypa

rtic

ipan

tus

edpr

ogra

m:

7-1x

/day

,6-

2x/d

ay,5

-3x/

day,

and

1-4x

/day

.

Vis

sche

rsH

1:Is

the

war

ning

mor

eef

fect

ive

than

educ

atio

nal

broc

hure

s?H

2:Is

thew

arni

ngm

oreef

fect

ive

ifth

eyin

terr

uptth

ew

ork?

H3:

Doe

sus

eof

the

C-H

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oration and communication, communicating corporateculture, office ergonomics climate, and business pro-cess analysis. The annual cost savings for the partic-ipants in the intervention groups was $7,500 for theworkstation only group and $15,000 for the workstationand training group.

4.2. Forearm supports

Three articles were ranked as having high quality ev-idencewith forearmboard/support interventions. Rem-pel et al. [30] showed that a forearm support could re-duce pain associated with a neck/shoulder disorder by50% and reduce left upper extremity disorder hazardrates atmarginal significance. Conlon et al. [10] showedthat a forearm support board could reduce discomfortof the right upper extremity. Aaras and Walsoe [2,3]showed that use of a workstation adjustment to allowthe forearm and hand to be supported on the tabletopresulted in significant reduction of pain in the neck andshoulder region. Pain in the forearm and hand showedno significant change after two years, and actually in-creased after six years of intervention.

4.3. Ergonomic keyboards

A total of four articles attained the high quality ratingin the area of ergonomic keyboards. Ripat et al. [31]showed participants using the Microsoft Natural Multi-media Keyboard and the research-adapted LightTouchversion, had improvements in Phalen’s test results. Af-ter 12 weeks of use, all participants regained their pre-study typing speed and accuracy. There was a decreasein symptoms between baseline and 12 weeks and base-line and 24 weeks with use of either ergonomic key-board. The users experienced an increase in typingability between baseline and 24 weeks, as well. Post-intervention, 93% of users wanted to keep the alter-native keyboard. Swanson and Sauter [35] showed areduction in keyboard-related muscle symptoms of theleft shoulder and a near significant reduction for simi-lar symptoms of the left hand. Overall, the ergonomickeyboard users reported fewer symptoms compared tothe control group. The use of an ergonomickeyboard inthe workplace was related to an increase in co-workersupport. Tittiranonda, Rempel, Armstrong, and Buras-tero [37] showed that although there was no improve-ment in clinical findings of tendonitis and carpal tunnelsyndrome of the alternative keyboard users comparedto standard users, there was a correlation between theimprovement of pain severity and greater satisfaction

with the keyboards. Use of the Microsoft Natural Key-board after six months showed a trend toward greaterimprovement in pain severity. Stevenson, Blake, Dou-glas, and Kercheval [34] evaluated the use of an Easy-Motion Continuous Passive Motion device under thekeyboard, which had implications for increasing bloodflow to the hand for both asymptomatic and symptomat-ic keyboarders. The symptomatic participant showedan increase in words per minute, a decrease in symp-toms, and an increase in overall upper extremity func-tion.

4.4. Ergonomic mice

Three articles were ranked high for conclusions re-garding usage of an ergonomic mouse. Conlon etal. [10] reported that theRenaissanceMouse,developedby the 3M Corp, had a protective but not significanteffect on decreasing right upper extremity discomfort,intensity, and pain. Rempel et al. [30] found no signif-icant benefits with use of a trackball mouse after oneyear follow-up. Aaras, Daindoff, Ro, and Thoresen [1]showed that after 36 months, participants who used anAnir mouse, which reduces the amount of wrist exten-sion and forearm pronation, had a significantly lowerpain level at the shoulder, forearm, wrist and hand thanbefore the intervention.

4.5. Exercise/rest breaks

Omer et al. [28] demonstrated that mobilization,stretching, strengthening, and relaxation exercises forone hour 3 times per week, decreased pain and depres-sion for computer users with a CTD, after 2 months.Desai and Shah [13] showed that work station mod-ifications using ergonomic guidelines combined withvarious exercises of the neck, shoulders and wrists, anda 2-minute rest break were effective in reducing thepain, awkward and static postures, and repetitive mo-tions in computer users. Both studies recommendedbreaks be incorporated into one’s daily work scheduleon an hourly basis. Bernaards et al. [5] reported theuse of breaks and exercise reminder software increasedin the intervention groups. However this finding didnot confirm the groups were more likely to actuallyact upon the reminders when compared to the controlgroup.

5. Discussion

The primary goal of this systematic review was toseek the most effective and current interventions for


Fig. 1. Model of intervention for computer users with symptoms of CTD.

CTD limited to the upper extremities of computer usersand to determine how these methods would best be putinto practice. The literature explained there is no sin-gle intervention method or profession that effectivelyreduces CTD symptoms and upper extremity discom-fort of computer users. Instead, it was concluded that acombination of various intervention methods and pro-fessionals are often required to address the symptomsof CTD. Our review and rating system reduced bias andallowed us to more objectively discern the high qualityfrom the low quality literature. We utilized this knowl-edge to develop a model of best practice including oc-cupational therapy principles at each level and encour-

aging use of a holistic approach for CTD interventionplanning and treatment.

The model was divided into two sub-models, one forasymptomatic computer users and one for the symp-tomatic population. Both models begin with the mostcost effective approaches and progressively increase inexpense, as the earlier intervention levels require ad-ditional strategies and supports. When taking into ac-count which health care professionals to aid in pro-gram conception and implementation it is important toconsider occupational therapists. Dale [11] stated thatoccupational therapists play a significant role in treat-ment intervention for CTDs by providing prevention


Fig. 2. Model of intervention for computer users with no CTD symptoms (prevention).

and education interventions, which can help decreasethe financial and human costs of CTDs. This modelwas designed to advise practicing therapists on findingsthat may guide and impact their rehabilitation methods.

The model for clients currently experiencing CTDsymptoms specifically focuses on relieving pain anddecreasing symptoms. It is organized in a downwardchain. Level one includes intervention methods forlarge populations. The second level includes instruc-tion in proper exercise and rest breaks. The third lev-el includes more specific, individualized interventionmethods the symptomatic model focuses on educationand work station adjustments to decrease shoulder painand forearm/wrist pain (see AppendixA). For example,when workingwith a client who displays upper extrem-ity pain, a healthcare professional could begin with theintervention method of a two hour education session ofactive learning that incorporates problem solving anddiscussion as well as workstation adjustments [8]. Atlevel two, the model focuses on upper extremity exer-cises and rest breaks, resulting in a recommendationto incorporate upper extremity exercise into their workor daily routine. A healthcare professional would ap-ply this level of the model by having a client completestretching, range of motion, strengthening, and pos-ture exercises involving the shoulders and wrists for 3days a week, for one hour to decrease their CTD symp-toms [28]. At level three, the model focuses on specif-ic ergonomic interventions such as an alternative key-board, mouse or forearm support. If a client continuesto experience pain and other CTD symptoms a therapistmight suggest the client use a specific piece of adaptive

equipment that can help decrease these symptoms. Forexample, Conlon et al. [10] found that a large butterflyshaped forearm support attached to the computer deskdecreased upper extremity pain (see Appendix B).

Many of the interventions used for symptomaticclients can also be used as a preventative measure. Theasymptomatic sub-model focuses on research conduct-ed with participants who have no symptoms with thegoal of CTD symptom prevention. The arrangementoccurs in a linear progression to leave specific optionsfor each individual, in addition to the levels presentedwithin the symptomatic sub-model. The most gener-al method of implementation of the model would beto use education and workstation adjustment to pre-vent a CTD and then progress to using exercise/restbreaks and finally specific ergonomic equipment (seeAppendix C).

As the literature contained a variety of methods usedby researchers and health practitioners to address thepopulation of computer users, so too does our model.We suggest the levels of our models are complimen-tary, and that interventions should begin with the firstlevel and continue downward or outward. Since the ev-idence, treatment methods, and interventions for CTDin computer users varies, our model is a collection ofwhat we know now and should be utilized as an initialstarting point for intervention. There may be specificinstances where modifications to this linear approachare required. Our model aims to assist healthcare pro-fessionals, working with computer users, in accessingevidence for a variety of intervention types in manage-able manner, so that the particular needs of the comput-


er user population can be met. We acknowledge thatmany issues affecting high end computer users are notaddressed in these models. Examples of this includeworkplace psychological stressors, stressors in an in-dividual’s personal life, the overall workplace environ-ment (such as additional tasks and responsibilities notrelated to computer use), and the social environment.More research is needed to address these important ad-ditional considerations. Therapists should understandthat these models were constructed based on existingevidence.

Our systematic review results also consisted of a sev-eral professionals working together to prevent and de-crease the symptoms of CTDs. When exploring appro-priate accommodations for a client, the decisionmakingprocess for treatment must be evaluated on a case-by-case basis [23]. The symptoms, limitations, and abil-ities are unique to each individual and are consideredessential in order to assist the client in meeting theirrole demands and environmental expectations. Therole of the occupational therapist is to enhance well-being and quality of life of all persons who use comput-ers by structuring the work environment and job tasksto increase awareness, prevent injury, and ensure theirsafety and maximal productivity [21]. With respectto computer use and the prevention and treatment ofCTDs, occupational therapy practitioners should con-sider a holistic perspective in the evaluation of thework-er’s functional performance and consider the person,the task, and the environment when implementing in-terventions [26]. Our model for best practice can bea useful tool to help an occupational therapist decidewhat intervention to recommend or implement that willbe most cost efficient, beneficial, and holistic for thecomputer user.

6. Limitations and need for further research

There are several limitations to our methods and out-comes. Primarily, our research team consisted of onediscipline, occupational therapy. Professional bias mayhave influenced our decision-making during the inclu-sion/exclusion process and rating of the articles for oursystematic review. The student reviewers were alsonovices to research and were not yet licensed practi-tioners. However, they were closely supervised andmentored by a faculty member with several years ofexperience in practice directly and indirectly related toCTD’s, and with training, knowledge, and experiencein research.

The topic is broad in scope. We only had one yearin which to conduct our literature review and write ourpaper. Though we did use a variety of keywords duringour search, our word choice may also have limited ourresults. We also made the decision to select the mostrecent articles, by limiting the dates to the year 1998and beyond.

In regards to limitations of our model, it was createdwith general CTD symptoms as opposed to specificCTD diagnoses, and did not address all symptoms atthat. For example, high quality articles that discussthe psychosocial aspects of CTD and how these affectthe development of or treatment for CTDs were notfound. This is an area where more research needs tobe conducted and occupational therapists should be anintegral part of this process. The model however, canbe utilized as a foundation for a more specific modeland can be adjusted in the future as new interventionsare researched.

We suggest further research be conducted onCTD in-terventions, especially with the increasing use of com-puters within child, adolescent and the older adult pop-ulations. The continued use of computers in the homefor all populations has yet to be addressed and inter-ventions to access those at risk for CTD in the com-munity are needed. A guide for proper positioning andcomputer workstation organization should become anintegral element included in manuals when individualspurchase computers for home use.

Laptop use is also more common, with individu-als often working from home or while traveling. Re-search examining the effects of incorrect positioningand repetitive use of a laptop is another area within thisfield of study that requires attention in order to cre-ate effective and all encompassingCTD prevention andintervention.

7. Conclusion/summary

Occupational therapists look at individuals holisti-callywithin theworkplace in order to preventCTDs andpromote overall health andwellness. The research teamfound that education, ergonomic keyboards, forearmssupports, ergonomic mice, exercise and rest breaks areall interventions that are often used within the work-place. Individuals with symptoms or needs outside ofthe occupational therapy scope of practice are encour-aged to consult, or can be referred to, alternative dis-ciplines such as physical therapy, rehabilitation engi-neering, specialists in ergonomics, or painmanagement


programs. Collaboration of disciplines, such as occu-pational and physical therapy, can be crucial in devis-ing an effective treatment plan for an individual withCTD. In addition, considering the severity of the indi-vidual’s condition and selecting the most suitable of thevarious intervention methods will ensure the client isable to meet their goals. The results from this system-atic review have been utilized to develop two modelsof practice for occupational therapists and other health-care professionals to help prevent and improve symp-toms of upper extremity cumulative trauma disorders inall computer users. With today’s continuous increasein computer use both within the home and office, fur-ther research is essential in order to more successfullyprevent and decrease CTD symptoms.

Appendix A

Description of Interventions Used for Both Modelsof Practice.

LEVEL 1

Education and Work Station Adjustment: Includeseducation on safe working posture, risk factors such asforce, static muscle loading, and repetition and infor-mation about rest breaks, exercise, and healthy workbehaviors. Workstation Adjustments includes assess-ing and making modifications to the tools, machines,parts, and materials for the job, analyzing the physicalenvironment, and addressing the individual job tasks.For example, adjusting the height of a chair, changingthe angle of the monitor, and or rearranging storagespace are a few workstation adjustments. In the caseof computer use, tools would include the computer ter-minals, monitors, keyboards, and phones. The work-station would include tables, desks chairs, and storagespace.

LEVEL 2

Exercise and Rest breaks: Performing stretching,range of motion, strengthening and posture exercisesinvolving the shoulders, forearms, wrists and digits ofthe hand. Rest breaks include getting up from the work-station for a period of time, performing relaxation ex-ercises/techniques, or doing another task besides work-ing at the computer in order to decrease and preventsymptoms of CTD.

LEVEL 3

Specific Ergonomic Equipment: Includes adding aspecific adaptive device to the workstation to preventCTD or decrease symptoms of CTD. It is more thanmaking an adjustment to the workstation because itinvolves using an alternative tool such as a forearmsupport, an alternative keyboard, and /or mouse.

Appendix B

Specific Examples of Interventions for the Symp-tomatic Model with References to Research to SupportThese Interventions.

LEVEL 1∗

Aaras, 2001 Installation of new adjustable tables andchairs, shelf withwrist support, and otherworksta-tion adjustments were used to promote ergonom-ically safe postures. This resulted in decreasedshoulder pain.

Bernaards, 2008 Interactive group meeting focusedon behavioral change (body posture, work stationadjustments and sufficient breaks) as well as cop-ing with work stress were used with the result ofdecreased shoulder pain.

Bohr, 2000 A two-hour session of active learning in-corporated problem solving and discussion. Partone contained hands-on workstation evaluationand modification, while the second part consistedof evaluating one’s own workstation and makingergonomic changes. Results included a decreasein upper extremity pain.

Desai, 2004 Ergonomicguidelines about safe worksta-tion postures were provided and necessary work-station modificationswere made to implement andsupport these safe postures.

Greene, 2005 An intervention groupmet two times for3 hours in the same week and focused on didac-tic interactions, discussion, and problem-solvingactivities. The first session focused on body me-chanics and workstation adjustments. The secondsession began with questions and was followedby problem-solving case studies of poor worksta-tion designs. Also discussed were exercise, workorganization, and micro-breaks. Results includedecreased upper extremity pain.

Omer, 2004 One-hour education meetings for eachtopic: basic ergonomics, correct use of body me-chanics, effects of exercise and health problems.This combined with an exercise program resultedin decreased shoulder pain.


LEVEL 2∗

Desai, 2004 Three types of exercises were to be usedthroughout the day at each employees conve-nience: 1) 2 minute micro-break (not a break fromwork, but instead doing a task that uses differentmuscles), 2) rest break every 30–60 minutes re-quiring of getting up and moving, and 3) one ex-ercise break every 1–2 hours to stretch the neck,shoulder, elbow, wrist, and hand.

Omer, 2004 Participants performed stretching, rangeof motion, strengthening and posture exercises aswell as relaxation exercises involving shoulder andwrists. These were to be done 3 days per weekduring a one hour lunch.

LEVEL 3∗

Aaras, 2002 The participants who used an Anir mousefor 6 months showed decreased pain in shoulderforearm, wrist, and hand.

Conlon, 2008 A large butterfly-shaped forearm sup-port board 36 by 21 inches with 5 degree incline.It is padded and large enough to accommodate akeyboard and mouse and secured to a desk.

Ripat, 2006 Microsoft Natural multimedia keyboard(standard or LightTouch) were found to be themost effective.

Swanson, 2006 Non-adjustable alternative keyboardwith the keyboard halves at fixed angles showedto be more effective than a conventional keyboard.

*See Appendix A for description of level.

Appendix C

Specific Examples of Interventions for the Asymp-tomatic Model with References to Research to SupportThese Interventions.

LEVEL 1∗

Aaras, 2001 Installation of new adjustable tables andchairs, shelf withwrist support, and otherworksta-tion adjustments were used to promote ergonom-ically safe postures. This resulted in decreasedshoulder pain.

Desai, 2004 Ergonomicguidelines about safeworksta-tion postures were provided and necessary work-station modificationswere made to implement andsupport these safe postures.

Greene, 2005 An intervention groupmet two times for3 hours in the same week and focused on didac-tic interactions, discussion, and problem-solvingactivities. The first session focused on body me-chanics and workstation adjustments. The secondsession began with questions and was followedby problem-solving case studies of poor worksta-tion designs. Also discussed were exercise, workorganization, and micro-breaks. Results includedecreased upper extremity pain.

Marcoux, 2000 The main focus was on functionalactivities to prevent CTD and not the medicalmanagement of CTD. Seven workshops wereheld throughout the intervention and information-al booklets were distributed. 10 posters depict-ing correct body mechanics while working at thecomputer were displayed throughout the facilityand rotated three times a year. Then every 12 daysa tip on correct ergonomicswas displayed throughemail.

Robertson, 2008 Through a two hour workshop er-gonomic training was conducted on the psychoso-cial aspects of the work environment, muscu-loskeletal health, and work effectiveness. Adjust-ments were made to a U shaped workstation aswell as to work chairs and storage spaces.

LEVEL 2∗

Desai, 2004 Three types of exercises were to be usedthroughout the day at each employees conve-nience: 1) 2 minute micro-break (not a break fromwork, but instead doing a task that uses differentmuscles), 2) rest break every 30–60 minutes re-quiring of getting up and moving, and 3) one ex-ercise break every 1–2 hours to stretch the neck,shoulder, elbow, wrist, and hand.

LEVEL 3∗

Conlon, 2008 A large butterfly-shaped forearm sup-port board 36 by 21 inches with 5 degree incline.It is padded and large enough to accommodate akeyboard and mouse and secured to a desk.

Rempel, 2006 Wrap-around, padded arm support witha 30.5 cm depth, 76.2 cm width, 2.5 cm heightwasfound to be most effective to decrease shoulderpain.

Tittitranonda, 1999 An Apple adjustable keyboard(split design) with hands to be open to 28 degreesor to the degree where client feels most comfort-able.


Stevenson, 2005 Easy motion CPM platform unit in-stalled beneath the keyboardwhich moves throughan arc of 20 degree from 5 degrees of wrist ex-tension, past neutral to 15 degrees of wrist flexionand back. The cycle time for this range was set at90 seconds for the 6 weeks of use.

Swanson, 2006 Non-adjustable alternative keyboardwith the keyboard halves at fixed angles showedto be more effective than a conventional keyboard.

*See Appendix A for description of level.

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