KARNATAKA, BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1 / Name of the Candidate
And Address
(in block letters): / RIJI JOSEPH
LAXMI MEMORIAL COLLEGE OF PHYSIOTHERPY,
A.J TOWERS, BALMATTA,
MANGALORE - 2
2. / Name of the Institute: / LAXMI MEMORIAL COLLEGE OF PHYSIOTHERPY
3. / Course of study and subject : / MPT, MUSCULOSKELETAL AND SPORTS PHYSIOTHERAPY
4. / Date of Admission to Course : / 10.07.2012
5. / Title of the topic: / “EFFECTIVENESS OF WORK STATION MODIFICATION IN ADDITION TO NECK EXERCISES IN THE MANAGEMENT OF NECK PAIN IN COMPUTER OPERATORS.”
6 / Brief resume of intended study
6.1 Need for the study
Computer based customer service work or call centre work is one of the most rapidly growing occupations in the world.1 The work involves the simultaneous use of a telephone and computer for activities such as airline reservations, banking, sales, insurance, scheduling, billing, and health related services. Musculoskeletal disorders of the upper extremities and neck are the most common occupational health problem associated with this type of work and account for the majority of work related lost time.1,2
Sustained pain in the upper extremity and neck regions and specific musculoskeletal disorders, such as wrist tendonitis, epicondylitis, and trapezius muscle strain are higher among computer users. The most consistently observed risk factors are increasing hours of mouse or keyboard use and sustained awkward postures, such as increasing wrist extension and keyboard above elbow height.3,4 Other important risk factors include being female and work organisational factors (for example, high work load, low job control).5,6
The relationship between work-related MSDs and VDT use was explored by Marcus and Gerr,7 who reported a 63% incidence of neck and shoulder symptoms among 416 female office workers using VDTs daily in their jobs. More recently, Korhonen et al8 found that the annual incidence of neck pain among Finnish VDT workers was 34%. Sillanpää et al9 found that the incidence of neck pain and shoulder pain among 979 VDT users was 63% and 23%, respectively. Hernandez et al10 reported an increased incidence of neck, shoulder, and hand work-related MSDs in 179 newspaper workers using VDTs compared with non-VDT users in the same company. Furthermore, they demonstrated that the type and amount of computer use and the posture of the worker were related to the incidence of work-related MSDs.
The incidence of neck pain combined with the increased numbers of workers using VDTs prompted the US Occupational Safety and Health Administration (OSHA) to institute guidelines and ergonomic evaluation procedures for working safely with VDTs.11 Altering the position of office equipment such as the VDT or mouse input device has been shown to modify muscle activity and reduce symptom complaints.12-15 Cook and Kothiyal12 demonstrated that positioning the computer mouse closer to the keyboard and eliminating the numeric key pad resulted in a significantly lower deltoid muscle electromyographic activity in VDT users than when the mouse was placed in a position where the user was required to abduct the upper extremity and reach for the mouse. Static, low-level loading of the deltoid and upper trapezius muscles has been correlated with increased incidence of shoulder and neck pain.13 Marcus et al14 showed that there was a decrease in upper-extremity and neck symptoms in office workers who used more “ergonomically sound postures.”
Specifically, a lower risk of work-related MSDs of the shoulder was associated with keyboard placement that put the elbows at a more neutral angle, described as “keyboard lower than elbow without arm abduction,” and a lower risk of neck symptoms was shown with a monitor position that allowed a head tilt angle of less than 3 degrees.14Pillastrini et al15 and Hignett and McAtamney16 have shown that personalized ergonomic intervention, including a postural assessment and proper adjustments of the seat, desk, VDT, keyboard, and mouse, resulted in significant decreases in pain and Rapid Entire Body Assessment (REBA) scores for office workers using VDTs for 20 hours per week. Ergonomic interventions, although primarily designed to benefit the worker, also may benefit the company. The implementation of an ergonomic intervention has been shown to decrease work-related MSD claim costs.5
Pragmatic reviews have in the past extolled the virtues of a variety of treatments for neck pain.17-19These include education, rest, collars, posture control, exercises, physical modalities, traction, mobilization, massage, analgesics, tricyclic antidepressants, psychological interventions, trigger point injections, occipital nerve blocks, epidural steroid injections, neurectomy, discectomy, fusion, soft tissue technique, muscle energy technique, thrust technique, myofascial release, manipulation under anaesthesia and craniosacral manipulation. None of the reviews, however, provided any scientific evidence of efficacy of any of these traditional interventions.20
Ergonomic interventions are based on reducing awkward postures that occur while the client is at the workstation while performing work tasks. Physical therapists have unique knowledge and training in identifying awkward postures and performing the appropriate tests and measures to determine the causes and consequences of awkward postures. Postural assessments usually are made while the patient is in the clinic and generally in the standing and seated positions. Furthermore, interventions for awkward postures assessed only in the clinic usually do not involve workstation modifications or work habit modifications. An ergonomic assessment and workstation modifications have been shown to reduce the incidence of work-related MSDs in a variety of work settings.12,14,15
From the aforementioned research, it may be concluded that the inclusion of an ergonomic assessment and intervention in the treatment of an office worker with complaints of neck and shoulder pain can result in improved patient outcomes when combined with traditional physical therapy treatment. The current literature demonstrates ergonomic interventions on a company-wide scale but does not examine the inclusion of an ergonomic intervention added after a course of traditional physical therapy treatment as a plan of care. The purpose of this study is to determine the effects of physical therapy treatment along with ergonomic evaluation and intervention.
Hypothesis
Null hypothesis
Work station modifications in addition to neck exercises are not effective in reducing pain and disability in computer operators with neck pain.
Alternative hypothesis
Work station modifications in addition to neck exercises are effective in reducing pain and disability in computer operators with neck pain.
6.2 Review of Literature
Gallagher in a literature review of physical limitations and musculoskeletal complaints associated with work in unusual or restricted postures states that work in unusual and restricted postures was associated with significantly higher rates of musculoskeletal complaints compared to workers not adopting these postures in epidemiology studies (Odds Ratios ranging from 1.13 to 13). Some studies suggested a dose-response relationship, with longer exposures leading to increased musculoskeletal complaints.21
Ketolaet al in a study evaluated the effect of an intensive ergonomic approach and education on workstation changes and musculoskeletal disorders among workers who used a video display unit (VDU). Results showed that intensive and training groups showed less musculoskeletal discomfort than the reference group after 2 months of follow-up. Positive effects on discomfort were seen primarily for the shoulder, neck, and upper back areas. No significant differences were found for the strain levels or prevalence of pain. They concluded that both the intensive ergonomics approach and education in ergonomics help reduce discomfort in VDU work. In attempts to improve the physical ergonomics of VDU workstations, the best result will be achieved with cooperative planning in which both workers and practitioners are actively involved.22
Amicket al conducted a study to determine the effect of office ergonomics intervention in reducing musculoskeletal symptom growth over the workday and, secondarily, pain levels throughout the day. Results showed that the chair-with-training intervention lowered symptom growth over the workday after 12 months of follow-up compared to control group. They concluded that workers who received a highly adjustable chair and office ergonomics training had reduced symptom growth over the workday.23
Rempelet al conducted a randomized controlled trial to evaluate the effect of chair design on neck/shoulder pain among sewing machine operators. Results showed that participants who received the flat seat chair experienced a decline in pain of 0.14 points per month compared with those in the control group, while those who received the curved seat experienced a decline of 0.34 points per month compared with those in the control group. They concluded that an adjustable height task chair with a curved seat pan can reduce neck and shoulder pain severity among sewing machine operators.24
Verhagenet al conducted a systematic review to determine whether conservative interventions have a significant impact on outcomes for work-related complaints of the arm, neck or shoulder (CANS) in adults. Results showed limited evidence for the effectiveness of keyboards with an alternative force-displacement of the keys or an alternative geometry, and limited evidence for the effectiveness of exercises compared to massage, breaks during computer work compared to no breaks; massage as an add-on treatment to manual therapy, and manual therapy as an add-on treatment to exercises.25
Hoe et al conducted a systemic review to assess the effects of workplace ergonomic design or training interventions, or both, for the prevention of work-related upper limb and neck MSDs in adults. Results showed that there is moderate-quality evidence to suggest that the use of arm support with alternative mouse may reduce the incidence of neck/shoulder MSDs and moderate-quality evidence to suggest that the incidence of neck/shoulder and right upper limb MSDs is not reduced when comparing alternative and conventional mouse with and without arm support. However, given there were multiple comparisons made involving a number of interventions and outcomes, high-quality evidence is needed to determine the effectiveness of these interventions clearly.26
Chiu et al conducted a RCTto evaluate the efficacy of a neck exercise program in patients with chronic neck pain in 145 patients. Patients in the control group were given infrared irradiation and neck care advice. In addition to infrared irradiation and advice, patients in the exercise group had undergone an exercise program with activation of the deep neck muscles and dynamic strengthening of the neck muscles for 6 weeks. Subjective pain and disability and isometric neck muscle strength were measured at baseline, 6 weeks, and 6 months. Analysis was by intention-to-treat. Results showed that at week 6, the exercise group had a significantly better improvement in disability score, subjective report of pain, and in isometric neck muscle strength in most of the directions than the control group. However, significant differences between the two groups were found only in the subjective report of pain and patient satisfaction at the 6-month follow-up.27
Ylinenet al conducted a study toevaluate the efficacy of intensive isometric neck strength training and lighter endurance training of neck muscles on pain and disability in women with chronic, nonspecific neck pain. Results showed that at the 12-month follow-up visit, both neck pain and disability had decreased in both training groups compared with the control group. Maximal isometric neck strength had improved flexion by 110%, rotation by 76% and extension by 69% in the strength training group. The respective improvements in the endurance training group were 28%, 29%, and 16% and in the control group were 10%, 10%, and 7%. Range of motion had also improved statistically significantly in both training groups compared with the control group in rotation, but only the strength training group had statistically significant improvements in lateral flexion and in flexion and extension. They concluded that both strength and endurance training were effective methods for decreasing pain and disability in women with chronic, nonspecific neck pain.28
Ylinenconducted a randomized study to evaluate the rate of change in neck strength following high- and low-intensity neck muscle training and their effects on pain and disability in 180 women with chronic neck pain. The neck training consisted of isometric exercises in the STG and dynamic exercises in the ETG. Strength tests, neck pain, and disability indices were evaluated at the baseline, at the follow-ups after 2 and 6 months in the training groups, and after 12 months in all groups. In both groups the greatest gains in neck strength, as well as decrease in neck pain and disability, were achieved during the first 2 months. The STG achieved the greatest strength gains at all follow-ups. The CG showed only minor changes, and significant differences were found in favor of the training groups in all measures. The change in neck pain and disability indices correlated with the isometric neck strength. They concluded that neck and shoulder muscle training was shown to be an effective therapy for chronic neck pain and it can be maintained and even improved with long-term training.29
Gallagher et al conducted a study to assess the validity and reliability of the visual analog scale (VAS) in the measurement of acute abdominal pain, and to identify the minimum clinically significant difference in VAS scores among patients with acute abdominal pain. Results showed that reliability and validity was high and the minimum clinically significant difference in acute abdominal pain was 16 mm. They concluded that the VAS is a methodologically sound instrument for quantitative assessment of pain and for detecting clinically important changes in pain.30
Vernon andMiordeveloped a modification of the Oswestry Low Back Pain Index producing a 10-item scaled questionnaire entitled the Neck Disability Index (NDI). Test-retest reliability was conducted on an initial sample of 17 consecutive "whiplash"-injured patients in an outpatient clinic, resulting in good statistical significance. The alpha coefficients were calculated from a pool of questionnaires completed by 52 such subjects resulting in a total index alpha of 0.80, with all items having individual alpha scores above 0.75. Concurrent validity was assessed in two ways. First, on a smaller subset of 10 patients who completed a course of conservative care, the percentage of change on NDI scores before and after treatment was compared to visual analogue scale scores of percent of perceived improvement in activity levels. These scores correlated at 0.60. Secondly, in a larger subset of 30 subjects, NDI scores were compared to scores on the McGill Pain Questionnaire, with similar moderately high correlations (0.69-0.70). This study demonstrated that the NDI achieved a high degree of reliability and internal consistency.31
6.3 Objectives
The objectives of the study is to find the effectiveness of
- Work station modifications in addition to neck exercises in reducing pain and disability in computer operators with neck pain.
- Neck exercises in reducing pain and disability in computer operators with neck pain.
- Compare the work station modifications in addition to neck exercises and Neck exercises alone in reducing pain and disability in computer operators with neck pain.
7 / Materials and Methods
Study design
Pre and post test experimental study
7.1 Source of Data
BPO and Call center, Mangalore
Sample Size
30 subjects with non specific neck pain
7.2 Method of collection of data
Sampling technique
Convenience sample
Inclusion Criteria
- Non specific neck pain
- Age between 20 and 40 years
- Both gender
- History of systemic disease
- History of spinal and upper limb surgery
- History of fracture or dislocations of spine and upper limbs
- Vestibulo basilar insufficiency
- History of hypertension and coronary artery disease
- Neuromuscular disease
- Spondylosis
- Spinal neoplasm and infections
- Metabolic and Endocrine disorders
- Visual Analogue scale
- Neck Disability Index measurement scale
- Workstyle short form
- OSHA VDT workstation checklist
Group I
Group I will consist of 15 patients of both gender with non specific neck pain and they will undergo neck exercises and work station modification.
Group II
Group II will consist of 15 patients of both gender with non specific neck pain and they will undergo only neck exercises.
Neck exercises
Both groups will undergo static and dynamicneck flexion and extension, right and left side flexion and right and left side rotation. Each contraction will be held for 10 seconds. Each movement will be repeated 10 times. The exercise will be done 4 times a week for 4 weeks.
Work station Modification
Following neck exercises work station modifications will be done for patients in group I. The procedure is as follows.
Ergonomic Assessment
Following completion of physical therapy, the patient will undergo an ergonomic work risk analysis (WRA). The pain rating and the NDI scores will be repeated, and the Workstyle short-form measure of work demands will be assessed.32 The WRA will be completed using the Occupational Safety and Health Administration (OSHA)VDT workstation checklist.11
The OSHA VDT workstation checklist is used specifically for identifying risk factors for work-related MSDs associated with workstation postures and devices.11 The OSHA assessment tools are a logical primary step in ergonomics assessment because they are readily available, simple, and easy to use and are supported by current research and NIOSH recommendations.
The OSHA VDT workstation checklist reveales specific risks for work-related MSDs related to positioning of the head, neck, shoulders, and trunk, as well as seating issues. The VDT workstation checklist also identifies risks associated with keyboard and mouse position, monitor position, and lack of document holder, wrist rests, and telephone hands-free headset. The WRA involves the therapist observing the patient for a 2-hour period while he/she performs normal work duties on what will be deemed by the patient to be a typical day of work. The scores are an average of the postures and positions as seen over the examination period.