WORK A Journal of Prevention,
Assessment & Rehabilitation
ELSEVIER
Work 9 (1997) 267-273
Proactive ergonomics
Hand care begins with prevention in elementary schools Gina M. Lucas* 13765 Fordham Court, Apple Valley, MN 55124, USA
Received 30 May 1996; revised; accepted 1 September 1996
Abstract Objectives: The purpose of this paper is to provide background information on the epidemic proportions of hand injuries related to computer use. It offers a solution of early health education in prevention of cumulative trauma disorders (CTDs) through specially designed instruction in elementary schools. Study design: The current literature is reviewed. Some physical impairments caused by poor biomechanics and computer overuse are identified. Disability factors are highlighted in relation to how the physical impairment affects an individual's performance in the domain of work. Handicapping factors that are the result of the individual's decline in performance roles of worker are noted. These factors impact our society in dollars spent on medical insurance and worker's compensation claims. A review of a pilot project aimed at early education in hand health basics is introduced, as a proactive ergonomic solution to the present epidemic of cumulative trauma disorders. Results: A positive response was displayed by the 950 elementary students and their staff to a 20-min program that introduced concepts of posture at the keyboard and basic upper body stretches. Children were instructed in their individual classes during their computer lab time. Daily follow-up, particularly for the forearm and hand stretches, was fostered by the computer lab coordinator, teachers, and wall posters. Parents were informed through a summary article printed in the monthly school newsletter. Conclusions: Wellness thinking and living can be learned at an early age to assure that basic principles of work practice such as posture and upper body stretches become a life skill. Review of the literature supports programs to educate individuals at an early age to develop life skills that would minimize the occurrence of cumulative trauma disorders, especially in relation to the use of computers. © 1997 Elsevier Science Ireland Ltd. Keyword~:
Promotion; Managed care; Computer; Injuries; Cumulative trauma disorders; Proactive Ergonomics life
skills
----_.
__..
* Corresponding author. Tel. + 1 612 432-3051. 1051-9815/97/$17.00, © 1997 Elsevier Science Ireland Ltd. All rights reserved. PH S1051-9815(97)00026-0
268
G.M. Lucas / Work 9 (J997) 267-273
1. Introduction
According to Sellers (1994, pp. 101-102) 'Computers in the classroom and at home have led to young, sophisticated computer literates. Computers are installed in 52% of elementary and secondary classrooms. While the positive impact on learning and skill development is accented, computers have a number of risks. When used without a sense of balance, they prompt social isolation and reduce physical exercise. Computer active children are vulnerable to the same computer-related ailments as adults'. Hazards or signal risk factors for children's health include: awkward neck, shoulder, wrist and finger postures due to wide keyboards, and high desk height for the visual display terminal (VDT); repetitive sustained exertions of the neck, shoulder, forearm, wrist, fingers and thumb resulting in muscle soreness; sensorimotor factors related to postural security when seated on chairs where their feet do not touch the floor; eye strain due to inadequate lighting or screen glare; thwarted psychosocial skill development when computer interaction replaces play and personal interaction; and reduced aerobic, endurance and strengthening opportunities from extended periods in a sedentary position (Sellers, 1994). 2. Literature review
Putz-Anderson (1987) stated that VDT injuries have reached an all time high and are on the rise in the workplace setting. Impairments that have now occurred in our nation's workplaces related to computer use are staggering. The Wall Street Journal ran an article in the spring of 1996 that indicated 20% of claims paid at the nation's largest workers compensation insurer, Liberty Mutual, were due to wrist injuries. Typing was the causative factor in 8000 of the claims, which amounted to about $50 million a year paid out (Sharpe, 1996). Sitting at a computer uses eye, neck, back, trunk, arm, hand and leg muscles (Sellers, 1994). Injuries involve a range of musculoskeletal disorders from neck and shoulder strain, to nerve impingements such as carpal tunnel syndrome or
cubital tunnel syndrome, and tendon inflammation problems such as De Quervain's tenosynovitis or lateral epicondylitis. Carpal tunnel syndrome is the most often recognized cumulative trauma disorder that is currently affecting data entry operators. According to Banham (1994), research has suggested that certain job tasks such as keyboard typing which require hand motions that are repetitious, continuous, without rest, forceful, and in particular, performed while the wrist is bent, may lead to carpal tunnel syndrome. The Bureau of Labor statistics found that in 1993, more than 41000 workers suffered from carpal tunnel syndrome to such a degree that time was lost from the job (Sharpe, 1996). Pascarelli and Quilter (1994) believe repetitive strain injuries can wreck careers, relationships and s~lf-esteem. At the disability level, the physical impairment has affected individual performance on the job. Stevens, the Director of the Occupational Safety and Health Administration, Office of Ergonomic Support in Washington, DC in 1993 job specialization as one of the primary causes that contribute to the rise of cumulative trauma injuries. Components of static and sustained posture of the neck, torso, arms, and hands are signal risk factors according to Keyserling (1986).
Prevention education can be aimed at the following areas: engineering controls, administrative controls, and work practice controls (Jacobs and Bettencourt, 1995). Engineering controls would support computer station redesign to include: (1) properly fitted chairs that encourage 90° of hip flexion, depth of seat to allow at least 2 inches of space behind the knee and the edge of the chair, ability to place feet flat on the floor with ankles also bent at 90°, and back support, especially at the lower, lumbar area; (2) adjustable or small, medium and large countertop options for student stations to keep forearms parallel to the floor; (3) keyboard design that allows a neutral wrist - :s; 15° of extension, ::; 20° of flexion, :s; 20° of radial or ulnar deviation (Hedge et aI., 1996); and (4) VDT adjustment so that the top of the screen is at student eye level. Recent research is suggesting placing a conventional keyboard on a downward-sloping
C.M. Lucas / Work 9 (J997) 267-273
Fig. 1. 'The Quarter': Forearm turning - pronation/supination. When you are in a seated position, bend your elbows and rest your forearm on the table. Turn your forearm back until your palm faces up and your knuckles are resting on the table. This is the 'smiley face' or stretch position. Hold for 3 s. Release by turning your forearm down until your palms face the table.
Fig. 2. 'The Wave': Wrist lifting _. wrist extension/wrist flexion. While seated, rest your forearm on the table, letting your hand hang over the edge of the table. Pull your hand back from your wrist so that your fingers are pointed to the ceiling. This is the 'smiley face' or stretch position. Hold for 3 s. Release by pulling your hand forward so the fingers are pointing to the floor.
surface that tilts the base of the keyboard away from the user 5°-10° (Hedge and Power, 1995). Environmental design would account for a comfortable room temperature between 69° and 72°,
269
Fig. 3. 'The Slide': Wrist sliding - radial deviation/ulnar deviation. Stay seated with your arm resting on the table and your palm facing down. Slide you hand over so it angles towards your thumb. This is the 'smiley face' or stretch position. Hold for 3 s. Release by sliding it back toward your little finger.
taking into consideration that a lab of 30 computers, in close proximity generates a significant amount of heat. Proper lighting to reduce craning forward toward the screen and anti-glare shields on VDTs, if window or florescent light interferes, would minimize eye and neck strain (Jacobs and Bettencourt, 1995). Administrative controls could facilitate micropauses every 20-30 min, or home limits such as no more than 2 hours of cumulated computer time per night. Work practice controls consist of instruction in proper posture at the chair-keyboard-VDT triangle and use of stretches every 30 min. Stretching is critical because it brings oxygen-rich blood to the muscles, releases tension, reduces pain, promotes healing and makes you feel good. Stretches need to be taught so that individuals understand proper techniques and reasons behind the appropriate stretch (Pascarelli and Quilter, 1994). Compensating or breathing stretches last just a few seconds. They are different than flexibility stretches that require 20 seconds for the muscles to lengthen (Key, 1994). Compensating stretches focus on relaxing the overused muscles groups by stretching into the opposite motion. Young keyboard users might focus on forearm supination, wrist extension, finger extension and adduction, and thumb flexion because these mo-
270
G.M Lucas / Work 9 (1997) 267-273
Fig. 5. 'The Fan': Fingers pulling together, spreading apart adduction/abduction. Place your hand palm down on the table. Pull fingers together so there are no spaces between them. This is the 'smiley face' or stretch position you want to hold for at least 3 s. Release by spreading fingers apart like a fan.
Fig. 4. 'The Flower': Open and closed fist _.- finger extension/flexion. Open hand spreading out and straightening fingers. Hold for 3 s in this 'smiley face' or stretch position. Release by closing hand, curling fingers into a fist.
tions allow the overused muscles groups to relax and rest, preventing fatigue and muscle soreness. A suggested sequence during prolonged computer access begins with closing your eyes for a moment, then gazing at a distant object; turning your head from side-to-side; rolling shoulders backwards; placing hands behind the head with elbows out to the side, turning forearms so palms
are facing up; pulling wrists back; straightening and moving fingers together; and bending thumbs into your palm. Intervals of every 10-20 min are valuable in minimizing muscle fatigue. It is important to stretch the muscles in the opposite way from their usual work position. Strengthening is also important because it gives balance to the muscle groups of the upper quadrant. As shoulders round forward, the anterior trunk muscles shorten and the posterior trunk muscles are lengthened. The shorter muscle groups tends to restrict range of motion and the longer group becomes weak. Wall push-ups are one example of an exercise to strengthen the upper back and shoulders. Pascarelli and Quilter (1994, p. 189) stated that, 'all the ergonomic equipment in the world won't prevent repetitive strain injuries, unless people who use computer keyboards learn how to safely
G.M. Lucas / Work 9 (1997) 267-273
pace themselves and care for their bodies.' Education, ergonomics and adapted technology are becoming increasingly popular preventive measures that may be used along with the conventional methods of treatment (Dahl, 1989, p. 2). Travis (1988), identifies two major components of a high level wellness program: (1) awareness education; and (2) growth orientation of the individual. Pascarelli (1994) advocates teaching safe keyboard techniques early in schools and job training programs. 3. Methods
Children begin VDT use now as toddlers. By the time they reach adulthood, their accumulated time spent at the keyboard is going to be significantly higher than their parents. A pilot project was launched during the fall of 1995 and early winter of 1996. The purpose of the pilot project was to : (1) introduce the concept of small muscle care through warm-up and cool down hand stretches for computer and band students; and (2) provide community information on prevention of hand injuries through small muscle care. The anticipated outcomes of this project were: (1) the development of a life skill for young students in hand care; (2) the facilitation of in-
Fig. 6. 'Cheerios': Thumb to fingertips - opposition. Make O's with your thumb and the tip of each fingertip, index, middle, ring and small finger. Open your hand wide after touching each fingertip and stretch for 3 s. This is the 'smiley face' position.
271
creased community awareness; (3) the advocacy of managed care through prevention and self-care education; and (4) the reduction of CTDs. Nine-hundred and fifty elementary school students, ages 5 through 11, were instructed in upper body posture tips and hand exercises during their computer lab time. The basic hand exercises covered both the extrinsic and intrinsic muscles that are used when operating a computer. Figs. 1-8 indicate the specific movements instructed (Lee and Marcus, 1990) The compensating stretch positions were emphasized and highlighted by a smiley face on the posters. The students were instructed to 'Hold the smiley face position for 3 seconds. Posters were made and displayed on three of four walls in the computer lab reviewing the six basic hand stretches. Children were asked to pick at least one stretch to do each time after their computer lab before going back to their regular classroom. Parents were informed and requested to reinforce the effort of hand care through the publication of a summary article in the school's monthly newsletter.
Fig. 7. 'The Table'; Large knuckle bending, finger joint straightening - MCP tendon gliding. Make a tabletop with your fingers, keeping the wrist and small finger joints straight and bending only at your large knuckles. This is the 'smiley face' stretch position. Hold for 3 s before releasing by straightening all the finger joints so that the whole hand is tall.
272
C.M. Lucas / Work 9 (1997) 267-273
Fig. 8. 'Knuckle folding': Large knuckle straightening, small finger joint bending - DIP/PIP tendon gliding. Keep your wrist and large knuckles straight, then curl your fingers by bending at the middle and end finger joints. This is the 3-s stretch or 'smiley face' position. Release by uncurling the middle and end joints making the hand tall.
4. Future considerations A long range study of this group of 950 elementary students could determine if we can impact the occurrence of CTDs by the implementation of proactive education in hand health basics at an elementary age. 5. Conclusion How does the occurrence of these symptoms on workers affect our society? American employers spend more than $7.4 billion per year in worker's compensation costs related to CTDs. According to the CTD News (1994) 'cumulative trauma disorders continued to ravage US workplaces by growing 10% in 1994, renewing the debate over the need for governmental regulation or guidance to help stem the steep 10-year climb in CTDs'. In 1993, each worker who required surgery for carpal
tunnel syndrome, cost the company $60,000 in medical costs (American Health Consultants, 1993) The managed care model fits in with the wellness concept by supporting prevention, education and self-care, for the purpose of promoting greater health while decreasing costs of medical intervention. Budnick states, 'ideally, ergonomics is applied proactively, beginning with the earliest design phases for product and process designs and carried on throughout the life of those products and processes. This is the most effective and efficient opportunity in terms of both cost and long-term success. In the absence of proactive ergonomics, a reactive approach may be required to control existing or unforeseen hazards. This is generally less effective and more expensive than proactive approaches'. (Key, 1994, p. 83). If we do not train our young computer enthusiasts today in good engineering and work practice controls such as computer station design, upper body posture and compensating stretches, what will the numbers look like in 5 years? Will society be absorbing costs of worker's compensation claims at an earlier age for individuals? How will occupational performance in additional roles be affected? . 6. Comments Proactive ergonomics needs to begin with more hand health basics in our home and elementary schools. Key (1994, p. 83) stated that 'giving each individual the knowledge to recognize, understand the effects of, and ultimately the power to initiate control of ergonomic hazards, will have long lasting positive effects'. The impact would minimize physical impairments such as CTDs, functional disability in the accomplishment of necessary tasks in the areas of work, play, and daily living activities; and the drain on our nation's financial resources from workmen's compensation and medical insurance claims because of resulting handicapping conditions of the upper quadrant that affect role performance.
G.M. Lucas / Work 9 (1997) 267--273
Witter Bynner (1881-1968) stated, 'the biggest problem in the world could have been solved when it was small.' References American Health Consultants. Carpal tunnel claims may become the back injuries of the 90's. Occup Health Manage January 1993;3(1):4. Banham R. The new risk in ergonomic solutions. Risk Manage 1994;41(5):22-30. CTD News. Special issue, 1994;3(8):3. Dahl R. Occupational therapy: the underutilized resource for human factors research and design. Work programs 3(2). American Occupational Therapy Association. June 1989:3-8. Hedge A, McCrobie D, Morimoto S, Rodriguez S, Land B. Toward pain-free computing. Ergonomics in design, 1996:5. Hedge A, Power JR. Wrist posture while keyboarding: effects of a negative slope keyboard system and full-motion forearm supports. Ergonomics 1995;38:508-517.
273
Jacobs K, Bettencourt C. Ergonomics for therapists. Boston: Butterworth-Heinemann, 1995. Key G. Industrial therapy. St. Louis: Mosby, 1994:166. Keyserling W, Chaffin D. Occupational ergonomics - methods to evaluate physical stress on the job. Ann Rev Pub Health 1986;(7):80. Lee K, Marcus S. Home rehabilitation exercises. American Occupational Therapy Association. Rockville, 1990. Pascarelli E, Quilter D. Repetitive strain injury. New York: John Wiley, 1994. Putz-Anderson V. CTD manual for the upper extremity. US Department of Health and Human Services. Cincinnati, 1987:4. Sellers D. ZAP! How your computer can hurt you and what you can do about it. Berkeley: Peachpit Press, 1994. Sharpe R. Work week - a special news report about life on the job .- and trends taking shape there. Palo Alto: Wall Street Journal, April 9, 1996. Travis J, Ryan R. Wellness workbook. Berkeley: Ten Speed Press, 1988.
Assessment & Rehabilitation
ELSEVIER
Work 9 (1997) 267-273
Proactive ergonomics
Hand care begins with prevention in elementary schools Gina M. Lucas* 13765 Fordham Court, Apple Valley, MN 55124, USA
Received 30 May 1996; revised; accepted 1 September 1996
Abstract Objectives: The purpose of this paper is to provide background information on the epidemic proportions of hand injuries related to computer use. It offers a solution of early health education in prevention of cumulative trauma disorders (CTDs) through specially designed instruction in elementary schools. Study design: The current literature is reviewed. Some physical impairments caused by poor biomechanics and computer overuse are identified. Disability factors are highlighted in relation to how the physical impairment affects an individual's performance in the domain of work. Handicapping factors that are the result of the individual's decline in performance roles of worker are noted. These factors impact our society in dollars spent on medical insurance and worker's compensation claims. A review of a pilot project aimed at early education in hand health basics is introduced, as a proactive ergonomic solution to the present epidemic of cumulative trauma disorders. Results: A positive response was displayed by the 950 elementary students and their staff to a 20-min program that introduced concepts of posture at the keyboard and basic upper body stretches. Children were instructed in their individual classes during their computer lab time. Daily follow-up, particularly for the forearm and hand stretches, was fostered by the computer lab coordinator, teachers, and wall posters. Parents were informed through a summary article printed in the monthly school newsletter. Conclusions: Wellness thinking and living can be learned at an early age to assure that basic principles of work practice such as posture and upper body stretches become a life skill. Review of the literature supports programs to educate individuals at an early age to develop life skills that would minimize the occurrence of cumulative trauma disorders, especially in relation to the use of computers. © 1997 Elsevier Science Ireland Ltd. Keyword~:
Promotion; Managed care; Computer; Injuries; Cumulative trauma disorders; Proactive Ergonomics life
skills
----_.
__..
* Corresponding author. Tel. + 1 612 432-3051. 1051-9815/97/$17.00, © 1997 Elsevier Science Ireland Ltd. All rights reserved. PH S1051-9815(97)00026-0
268
G.M. Lucas / Work 9 (J997) 267-273
1. Introduction
According to Sellers (1994, pp. 101-102) 'Computers in the classroom and at home have led to young, sophisticated computer literates. Computers are installed in 52% of elementary and secondary classrooms. While the positive impact on learning and skill development is accented, computers have a number of risks. When used without a sense of balance, they prompt social isolation and reduce physical exercise. Computer active children are vulnerable to the same computer-related ailments as adults'. Hazards or signal risk factors for children's health include: awkward neck, shoulder, wrist and finger postures due to wide keyboards, and high desk height for the visual display terminal (VDT); repetitive sustained exertions of the neck, shoulder, forearm, wrist, fingers and thumb resulting in muscle soreness; sensorimotor factors related to postural security when seated on chairs where their feet do not touch the floor; eye strain due to inadequate lighting or screen glare; thwarted psychosocial skill development when computer interaction replaces play and personal interaction; and reduced aerobic, endurance and strengthening opportunities from extended periods in a sedentary position (Sellers, 1994). 2. Literature review
Putz-Anderson (1987) stated that VDT injuries have reached an all time high and are on the rise in the workplace setting. Impairments that have now occurred in our nation's workplaces related to computer use are staggering. The Wall Street Journal ran an article in the spring of 1996 that indicated 20% of claims paid at the nation's largest workers compensation insurer, Liberty Mutual, were due to wrist injuries. Typing was the causative factor in 8000 of the claims, which amounted to about $50 million a year paid out (Sharpe, 1996). Sitting at a computer uses eye, neck, back, trunk, arm, hand and leg muscles (Sellers, 1994). Injuries involve a range of musculoskeletal disorders from neck and shoulder strain, to nerve impingements such as carpal tunnel syndrome or
cubital tunnel syndrome, and tendon inflammation problems such as De Quervain's tenosynovitis or lateral epicondylitis. Carpal tunnel syndrome is the most often recognized cumulative trauma disorder that is currently affecting data entry operators. According to Banham (1994), research has suggested that certain job tasks such as keyboard typing which require hand motions that are repetitious, continuous, without rest, forceful, and in particular, performed while the wrist is bent, may lead to carpal tunnel syndrome. The Bureau of Labor statistics found that in 1993, more than 41000 workers suffered from carpal tunnel syndrome to such a degree that time was lost from the job (Sharpe, 1996). Pascarelli and Quilter (1994) believe repetitive strain injuries can wreck careers, relationships and s~lf-esteem. At the disability level, the physical impairment has affected individual performance on the job. Stevens, the Director of the Occupational Safety and Health Administration, Office of Ergonomic Support in Washington, DC in 1993 job specialization as one of the primary causes that contribute to the rise of cumulative trauma injuries. Components of static and sustained posture of the neck, torso, arms, and hands are signal risk factors according to Keyserling (1986).
Prevention education can be aimed at the following areas: engineering controls, administrative controls, and work practice controls (Jacobs and Bettencourt, 1995). Engineering controls would support computer station redesign to include: (1) properly fitted chairs that encourage 90° of hip flexion, depth of seat to allow at least 2 inches of space behind the knee and the edge of the chair, ability to place feet flat on the floor with ankles also bent at 90°, and back support, especially at the lower, lumbar area; (2) adjustable or small, medium and large countertop options for student stations to keep forearms parallel to the floor; (3) keyboard design that allows a neutral wrist - :s; 15° of extension, ::; 20° of flexion, :s; 20° of radial or ulnar deviation (Hedge et aI., 1996); and (4) VDT adjustment so that the top of the screen is at student eye level. Recent research is suggesting placing a conventional keyboard on a downward-sloping
C.M. Lucas / Work 9 (J997) 267-273
Fig. 1. 'The Quarter': Forearm turning - pronation/supination. When you are in a seated position, bend your elbows and rest your forearm on the table. Turn your forearm back until your palm faces up and your knuckles are resting on the table. This is the 'smiley face' or stretch position. Hold for 3 s. Release by turning your forearm down until your palms face the table.
Fig. 2. 'The Wave': Wrist lifting _. wrist extension/wrist flexion. While seated, rest your forearm on the table, letting your hand hang over the edge of the table. Pull your hand back from your wrist so that your fingers are pointed to the ceiling. This is the 'smiley face' or stretch position. Hold for 3 s. Release by pulling your hand forward so the fingers are pointing to the floor.
surface that tilts the base of the keyboard away from the user 5°-10° (Hedge and Power, 1995). Environmental design would account for a comfortable room temperature between 69° and 72°,
269
Fig. 3. 'The Slide': Wrist sliding - radial deviation/ulnar deviation. Stay seated with your arm resting on the table and your palm facing down. Slide you hand over so it angles towards your thumb. This is the 'smiley face' or stretch position. Hold for 3 s. Release by sliding it back toward your little finger.
taking into consideration that a lab of 30 computers, in close proximity generates a significant amount of heat. Proper lighting to reduce craning forward toward the screen and anti-glare shields on VDTs, if window or florescent light interferes, would minimize eye and neck strain (Jacobs and Bettencourt, 1995). Administrative controls could facilitate micropauses every 20-30 min, or home limits such as no more than 2 hours of cumulated computer time per night. Work practice controls consist of instruction in proper posture at the chair-keyboard-VDT triangle and use of stretches every 30 min. Stretching is critical because it brings oxygen-rich blood to the muscles, releases tension, reduces pain, promotes healing and makes you feel good. Stretches need to be taught so that individuals understand proper techniques and reasons behind the appropriate stretch (Pascarelli and Quilter, 1994). Compensating or breathing stretches last just a few seconds. They are different than flexibility stretches that require 20 seconds for the muscles to lengthen (Key, 1994). Compensating stretches focus on relaxing the overused muscles groups by stretching into the opposite motion. Young keyboard users might focus on forearm supination, wrist extension, finger extension and adduction, and thumb flexion because these mo-
270
G.M Lucas / Work 9 (1997) 267-273
Fig. 5. 'The Fan': Fingers pulling together, spreading apart adduction/abduction. Place your hand palm down on the table. Pull fingers together so there are no spaces between them. This is the 'smiley face' or stretch position you want to hold for at least 3 s. Release by spreading fingers apart like a fan.
Fig. 4. 'The Flower': Open and closed fist _.- finger extension/flexion. Open hand spreading out and straightening fingers. Hold for 3 s in this 'smiley face' or stretch position. Release by closing hand, curling fingers into a fist.
tions allow the overused muscles groups to relax and rest, preventing fatigue and muscle soreness. A suggested sequence during prolonged computer access begins with closing your eyes for a moment, then gazing at a distant object; turning your head from side-to-side; rolling shoulders backwards; placing hands behind the head with elbows out to the side, turning forearms so palms
are facing up; pulling wrists back; straightening and moving fingers together; and bending thumbs into your palm. Intervals of every 10-20 min are valuable in minimizing muscle fatigue. It is important to stretch the muscles in the opposite way from their usual work position. Strengthening is also important because it gives balance to the muscle groups of the upper quadrant. As shoulders round forward, the anterior trunk muscles shorten and the posterior trunk muscles are lengthened. The shorter muscle groups tends to restrict range of motion and the longer group becomes weak. Wall push-ups are one example of an exercise to strengthen the upper back and shoulders. Pascarelli and Quilter (1994, p. 189) stated that, 'all the ergonomic equipment in the world won't prevent repetitive strain injuries, unless people who use computer keyboards learn how to safely
G.M. Lucas / Work 9 (1997) 267-273
pace themselves and care for their bodies.' Education, ergonomics and adapted technology are becoming increasingly popular preventive measures that may be used along with the conventional methods of treatment (Dahl, 1989, p. 2). Travis (1988), identifies two major components of a high level wellness program: (1) awareness education; and (2) growth orientation of the individual. Pascarelli (1994) advocates teaching safe keyboard techniques early in schools and job training programs. 3. Methods
Children begin VDT use now as toddlers. By the time they reach adulthood, their accumulated time spent at the keyboard is going to be significantly higher than their parents. A pilot project was launched during the fall of 1995 and early winter of 1996. The purpose of the pilot project was to : (1) introduce the concept of small muscle care through warm-up and cool down hand stretches for computer and band students; and (2) provide community information on prevention of hand injuries through small muscle care. The anticipated outcomes of this project were: (1) the development of a life skill for young students in hand care; (2) the facilitation of in-
Fig. 6. 'Cheerios': Thumb to fingertips - opposition. Make O's with your thumb and the tip of each fingertip, index, middle, ring and small finger. Open your hand wide after touching each fingertip and stretch for 3 s. This is the 'smiley face' position.
271
creased community awareness; (3) the advocacy of managed care through prevention and self-care education; and (4) the reduction of CTDs. Nine-hundred and fifty elementary school students, ages 5 through 11, were instructed in upper body posture tips and hand exercises during their computer lab time. The basic hand exercises covered both the extrinsic and intrinsic muscles that are used when operating a computer. Figs. 1-8 indicate the specific movements instructed (Lee and Marcus, 1990) The compensating stretch positions were emphasized and highlighted by a smiley face on the posters. The students were instructed to 'Hold the smiley face position for 3 seconds. Posters were made and displayed on three of four walls in the computer lab reviewing the six basic hand stretches. Children were asked to pick at least one stretch to do each time after their computer lab before going back to their regular classroom. Parents were informed and requested to reinforce the effort of hand care through the publication of a summary article in the school's monthly newsletter.
Fig. 7. 'The Table'; Large knuckle bending, finger joint straightening - MCP tendon gliding. Make a tabletop with your fingers, keeping the wrist and small finger joints straight and bending only at your large knuckles. This is the 'smiley face' stretch position. Hold for 3 s before releasing by straightening all the finger joints so that the whole hand is tall.
272
C.M. Lucas / Work 9 (1997) 267-273
Fig. 8. 'Knuckle folding': Large knuckle straightening, small finger joint bending - DIP/PIP tendon gliding. Keep your wrist and large knuckles straight, then curl your fingers by bending at the middle and end finger joints. This is the 3-s stretch or 'smiley face' position. Release by uncurling the middle and end joints making the hand tall.
4. Future considerations A long range study of this group of 950 elementary students could determine if we can impact the occurrence of CTDs by the implementation of proactive education in hand health basics at an elementary age. 5. Conclusion How does the occurrence of these symptoms on workers affect our society? American employers spend more than $7.4 billion per year in worker's compensation costs related to CTDs. According to the CTD News (1994) 'cumulative trauma disorders continued to ravage US workplaces by growing 10% in 1994, renewing the debate over the need for governmental regulation or guidance to help stem the steep 10-year climb in CTDs'. In 1993, each worker who required surgery for carpal
tunnel syndrome, cost the company $60,000 in medical costs (American Health Consultants, 1993) The managed care model fits in with the wellness concept by supporting prevention, education and self-care, for the purpose of promoting greater health while decreasing costs of medical intervention. Budnick states, 'ideally, ergonomics is applied proactively, beginning with the earliest design phases for product and process designs and carried on throughout the life of those products and processes. This is the most effective and efficient opportunity in terms of both cost and long-term success. In the absence of proactive ergonomics, a reactive approach may be required to control existing or unforeseen hazards. This is generally less effective and more expensive than proactive approaches'. (Key, 1994, p. 83). If we do not train our young computer enthusiasts today in good engineering and work practice controls such as computer station design, upper body posture and compensating stretches, what will the numbers look like in 5 years? Will society be absorbing costs of worker's compensation claims at an earlier age for individuals? How will occupational performance in additional roles be affected? . 6. Comments Proactive ergonomics needs to begin with more hand health basics in our home and elementary schools. Key (1994, p. 83) stated that 'giving each individual the knowledge to recognize, understand the effects of, and ultimately the power to initiate control of ergonomic hazards, will have long lasting positive effects'. The impact would minimize physical impairments such as CTDs, functional disability in the accomplishment of necessary tasks in the areas of work, play, and daily living activities; and the drain on our nation's financial resources from workmen's compensation and medical insurance claims because of resulting handicapping conditions of the upper quadrant that affect role performance.
G.M. Lucas / Work 9 (1997) 267--273
Witter Bynner (1881-1968) stated, 'the biggest problem in the world could have been solved when it was small.' References American Health Consultants. Carpal tunnel claims may become the back injuries of the 90's. Occup Health Manage January 1993;3(1):4. Banham R. The new risk in ergonomic solutions. Risk Manage 1994;41(5):22-30. CTD News. Special issue, 1994;3(8):3. Dahl R. Occupational therapy: the underutilized resource for human factors research and design. Work programs 3(2). American Occupational Therapy Association. June 1989:3-8. Hedge A, McCrobie D, Morimoto S, Rodriguez S, Land B. Toward pain-free computing. Ergonomics in design, 1996:5. Hedge A, Power JR. Wrist posture while keyboarding: effects of a negative slope keyboard system and full-motion forearm supports. Ergonomics 1995;38:508-517.
273
Jacobs K, Bettencourt C. Ergonomics for therapists. Boston: Butterworth-Heinemann, 1995. Key G. Industrial therapy. St. Louis: Mosby, 1994:166. Keyserling W, Chaffin D. Occupational ergonomics - methods to evaluate physical stress on the job. Ann Rev Pub Health 1986;(7):80. Lee K, Marcus S. Home rehabilitation exercises. American Occupational Therapy Association. Rockville, 1990. Pascarelli E, Quilter D. Repetitive strain injury. New York: John Wiley, 1994. Putz-Anderson V. CTD manual for the upper extremity. US Department of Health and Human Services. Cincinnati, 1987:4. Sellers D. ZAP! How your computer can hurt you and what you can do about it. Berkeley: Peachpit Press, 1994. Sharpe R. Work week - a special news report about life on the job .- and trends taking shape there. Palo Alto: Wall Street Journal, April 9, 1996. Travis J, Ryan R. Wellness workbook. Berkeley: Ten Speed Press, 1988.
