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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
156 G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users
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
G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users 157
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-
158 G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users
Tabl
e4
Inte
rven
tion
and
stud
yde
tails
orga
nize
dby
type
ofin
terv
entio
ns
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
Edu
catio
nB
erna
ards
,200
8Ph
ysic
ians
Hig
hU
tiliz
edth
ePr
ecau
tion
Ado
ptio
nPr
oces
sM
odel
(PA
PM)
and
Tra
ns-T
heor
etic
alM
odel
(sta
geof
chan
ge,
awar
e-ne
ss,se
lf-e
ffica
cy,an
dde
cisi
onba
lanc
e)to
crea
tean
in-
terv
entio
nth
atfo
cuse
don
beha
vior
chan
gere
sulti
ngin
the
RSI
@w
ork
styl
ein
terv
entio
ns.
I1:A
ttend
edm
eetin
gson
lyI2
:M
eetin
gs+
Phys
ical
activ
ityco
mpo
nent
.
RC
TS
Offi
cew
orke
rsC
=14
9I1
=14
1I2
=13
5*
I:6
mO
:12
mN
ethe
rlan
ds/
Offi
ce
Edu
catio
nB
ohr,
2000
OT
Hig
hI1
:Tra
ditio
nale
duca
tion
grou
pco
nsis
ting
ofale
ctur
ew
ithha
ndou
tsab
outof
fice
ergo
nom
ics;
I2:
Partic
ipat
ory
edu-
catio
nin
terv
entio
nle
ctur
ew
ithac
tive
lear
ning
and
disc
us-
sion
s,pr
oble
m-s
olvi
ngex
erci
ses,
supe
rvis
edw
orks
tatio
nev
alua
tion
and
mod
ifica
tion;
C:N
oin
terv
entio
n.
RC
TS
Offi
cew
orke
rsC
=47
*I1
=38
*I2
=39
*
I1:1
hI2
:2
hO
:3,6
&12
m
Uni
ted
Stat
es/
Offi
ce
Edu
catio
nG
ravi
na,2
007
OT
Hig
hTra
ined
rese
arch
assi
stan
tsob
serv
edsi
x“s
afe”
differ
ent
post
ures
that
wer
epe
rfor
med
during
norm
alw
ork
task
son
aco
mpu
ter.
Obs
erva
tion
sess
ions
last
ed10
min
/pa
rtic
-ip
antea
chda
y4–
6x/w
.U
seof
aR
olle
rmou
se(C
onto
urD
esig
n)w
hich
prev
ents
user
sfr
omre
achi
ngaw
ayfr
omth
eke
yboa
rdw
asal
sous
edan
dm
onito
red
during
the
obse
r-va
tion.
Eac
hpa
rtic
ipan
t’sw
orks
tatio
nw
asas
sess
edev
ery
wee
kby
anO
Tfo
rer
gono
mic
wor
ksta
tion
chan
ges.
Sing
leSu
bjec
tM
ultip
leB
asel
ine
AU
nive
rsity
wor
kers
I=
5
I/O
:5m
Uni
ted
Stat
es/
Offi
ce
Edu
catio
nG
reen
e,20
05PT
Hig
hI:
Act
ive
ergo
nom
icstrai
ning
(AET)i
nclu
ded
wor
ksta
tion
anal
ysis
,act
ive
partic
ipat
ion,
and
impl
emen
tatio
nof
mul
-tip
lepr
even
tion
stra
tegi
esal
ong
with
wor
ksta
tion
desi
gn,
exer
cise
,w
ork
orga
niza
tion,
and
mic
robr
eaks
.O
ccur
red
2x/1
wfo
r3
hs
Pros
pect
ive
RC
TA
&S
Uni
vers
ityw
orke
rsI=
43C
=44
I:3
h–2
x/1w
O:1
yU
nite
dSt
ates
/O
ffice
Edu
catio
nM
arco
ux,2
000
Nie
uwen
huijs
en,
2004
PT
Hig
hFu
nctio
nal
activ
ities
focu
sed
onus
ing
min
imal
inte
rven
-tio
ns:
e-m
ailm
essa
ges,
post
ers
(pla
cem
entro
tate
d3x
/y),
ake
yboa
rdte
mpl
ate
with
stre
tch
exer
cise
s/st
ress
relie
v-in
gac
tiviti
es,6
wor
ksho
ps,in
stru
ctio
nalbo
okw
ithpo
si-
tive
post
ures
,illu
stra
tions
ofpo
stur
es,w
elln
esser
gono
mic
team
,and
job
anal
ysis
Pret
est/P
ostte
stlo
ngitu
dina
lst
udy
A&
SO
ffice
wor
kers
I=
40*
I:6
wI/O
:1y
+3
mU
nite
dSt
ates
/Sc
hool
Edu
catio
n/W
orks
tatio
nM
odifi
catio
ns
Goo
dman
,20
05O
TM
ediu
mI:
Lec
ture
oner
gono
mic
san
dco
mpu
terw
orks
tatio
ns,r
est
brea
ks(r
ecom
men
datio
nof
5m
inbr
eak/
h),
educ
atio
non
adap
tive
equi
pmen
tan
dba
sic
exer
cise
prin
cipl
es,an
dco
unse
ling
onst
ress
redu
ctio
n.
Des
crip
tive
one
year
post
-hoc
eval
uatio
n
A&
SO
ffice
wor
kers
I=
13*
I/O
:1y
Uni
ted
Stat
es/
Offi
ce
Edu
catio
nSh
inn,
2002
OT
Med
ium
Con
duct
edin
-ser
vice
onpr
oper
body
mec
hani
csan
der
-go
nom
ics
forco
mpu
terw
orks
tatio
nsQ
uasi
-exp
erim
enta
lw
ithqu
estio
nnai
reA
Stud
ents
I=
117*
I=
11d
O=
18d
Uni
ted
Stat
es/
Scho
ol
G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users 159
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
Edu
catio
n/Erg
onom
icTra
inin
g
Rob
erts
on,
2008
Erg
onom
ics/
Occ
upat
iona
lSa
fety
Hig
hI1
:Erg
onom
ics
trai
ning
-onl
ysp
anni
ng2
hin
clud
ing
ale
c-tu
re,g
roup
exer
cise
s,br
eak
outs
essi
ons,
hand
outs
,w
orks
tatio
nan
alys
isw
ithth
efa
cilit
ator
,an
dem
ailre
min
ders
;I2
:Fl
exib
lew
orks
pace
-onl
yco
nsis
ting
ofso
ft“U
”sh
aped
with
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
160 G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users
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
.
G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users 161
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
162 G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users
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
.
G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users 163
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
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,6-
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.
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tion
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st-
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com
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nan
dth
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ntro
lgro
ups(p
<0.
001)
.H
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ith
164 G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users
Tabl
e5,
cont
inue
d
Firs
taut
hor
Res
earc
hqu
estio
nsan
d/or
hypo
thes
esO
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me
mea
sure
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inte
rpre
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n
mod
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tran
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info
rmat
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lted
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sed
posi
tion
adju
stm
ents
(p<
0.00
1).
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yat
tent
ion
was
in-
crea
sed
inth
eco
mpu
terw
arni
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<0.
01).
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know
ledg
e,at
titud
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belie
fs,a
ndm
otiv
atio
n).
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vina
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term
ine
the
effe
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enes
sof
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gono
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and
beha
vior
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rven
tion
for
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safe
typi
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effe
cts
offo
urin
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tva
riab
les:
wor
ksta
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.
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prov
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tsin
wrist
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shou
lder
for
am
ajor
ityof
the
partic
ipan
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<0.
05).
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safe
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tsfo
rthe
wrist
,ar
ms,
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lder
sin
atle
ast3
ofth
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partic
i-pa
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(p<
0.05
).Pe
erob
serv
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assh
own
toim
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post
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for4/
4of
the
partic
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ifica
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disc
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ploy
ees
wer
ere
solv
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thei
rsa
tisfa
ctio
non
eye
arla
ter
Szet
oTo
eval
uate
the
wrist
join
tang
les
and
fore
arm
mus
cle
activ
ities
com
paring
the
use
ofth
eco
nven
tiona
lst
an-
dard
keyb
oard
and
the
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roso
ftN
atur
alke
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rd.Is
ther
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inw
rist
post
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cleac
tivat
ion
inth
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rear
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gane
wly
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oard
com
pare
dto
ast
anda
rdke
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noli
2:EM
GM
axVol
unta
ryC
ontrac
tion
and
angl
esof
wrist
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arde
viat
ion
One
-way
AN
OVA
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rew
asa
sign
ifica
ntdi
ffer
ence
inw
rist
exte
nsio
n(p
=0.
03)an
dul
narde
viat
ion
(p=
0.01
)w
ithal
tern
a-tiv
eke
yboa
rdus
e.The
rew
asal
soa
sign
ifica
ntdi
ffer
-en
cein
mus
cle
activ
ityof
exte
nsor
carp
iul
naris
(p=
0.04
4)w
ithth
eal
tern
ativ
eke
yboa
rd.
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evic
Toev
alua
teth
ein
fluen
ceof
thre
eke
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rds
onha
ndpo
sitio
n,ty
ping
prod
uctiv
ity,a
ndke
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ence
.
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deo
anal
ysis
usin
gA
PAS
(Ariel
Perf
orm
ance
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lysi
sSy
stem
),K
eybo
ard
pref
eren
cevi
a10
poin
tnum
eric
alsc
ale,
Prod
uctiv
ityvi
aW
ords
Per
Min
ute
(WPM
)
One
-way
AN
OVA
Fore
arm
and
hand
post
ures
wer
ecl
oser
tone
utra
l,w
hile
typi
ngon
the
alte
rnat
ive
keyb
oard
sw
hen
com
pare
dto
the
stan
dard
keyb
oard
(p<
0.05
).The
wrist
was
ina
mor
ene
utra
lpo
sitio
nfo
ra
long
erpe
riod
oftim
ew
hen
partic
ipan
tsus
edth
eFI
XED
keyb
oard
vs.th
eot
hert
wo
desi
gns.
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ngpr
oduc
tivity
was
redu
ced
by10
%on
the
FIX
ED
and
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onth
eO
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(p<
0.05
)an
dw
asm
oste
ffici
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partic
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est
anda
rdke
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ifica
ntdi
ffer
ence
betw
een
pref
eren
ceof
FIX
ED
orst
anda
rdke
yboa
rd(p
>0.
05).
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nTo
see
ifan
in-s
ervi
ceon
prop
erbo
dym
echa
nics
and
ergo
nom
ics
for
com
pute
rw
orks
tatio
nus
age
can
in-
crea
sea
stud
ent’s
know
ledg
ere
gard
ing
thes
ear
eas.
H1:
Are
the
curr
entco
mpu
terst
atio
nser
gono
mic
ally
corr
ect?
H2:
Isth
ereane
edfo
rpre
vent
ativ
eed
ucat
ion
asm
easu
red
byba
selin
epr
e-te
stsc
ores
?
Non
-sta
ndar
dize
dqu
estio
nnai
re;
Erg
onom
icch
eckl
ist
Two-
taile
dt-te
stH
1:W
asno
tte
stab
ledu
eto
the
test
ing
envi
ronm
ent
lack
ing
prop
ereq
uipm
ent.
H2:
The
reis
adi
ffer
ence
betw
een
thepr
ean
dpo
st-tes
tsco
ressu
gges
ting
lear
ning
took
plac
e(P
=0.
001)
.Pr
etes
tsc
ores
indi
cate
ane
edfo
rer
gono
mic
educ
atio
nin
the
clas
sroo
m.
H:H
ypot
hesi
s;I:
Inte
rven
tion;
C:C
ontrol
.
G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users 165
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
166 G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users
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
G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users 167
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-
168 G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users
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
G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users 169
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.
170 G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users
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.
G. Goodman et al. / Effective interventions for cumulative trauma disorders of the upper extremity in computer users 171
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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