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Occupational Therapy for the Computer User: A Balancing ActOccupational Therapy for the Computer User: A Balancing Act

Sandy Wagoner, OTD, MOTR/L, CHTSandy Wagoner, OTD, MOTR/L, CHT

ObjectivesObjectives

Participant will: Understand American Occupational Therapy Association (AOTA)

centennial vision and how OT can impact work, health and wellness

Understand the relationship between work, worker and work place during a work station assessment

Gain information for development of a high quality, evidence-based, OT intervention program, focused on preventing and reducing musculoskeletal disorders (MSDs) in computer users

Participant will: Understand American Occupational Therapy Association (AOTA)

centennial vision and how OT can impact work, health and wellness

Understand the relationship between work, worker and work place during a work station assessment

Gain information for development of a high quality, evidence-based, OT intervention program, focused on preventing and reducing musculoskeletal disorders (MSDs) in computer users

AOTA Centennial VisionAOTA Centennial Vision

“We envision that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society’s occupational needs” (AOTA, 2007, p 613).

“We envision that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society’s occupational needs” (AOTA, 2007, p 613).

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WorkWork

• Increases self esteem/self confidence• Economic advances• Skill competency• Mental health fulfillment

• Increases self esteem/self confidence• Economic advances• Skill competency• Mental health fulfillment

• Work injury creates: physical problem and pain as well as psychological, social and economic concerns (Lax & Klein, 2006)

• Potential impact:• Activities of daily living• Work• Rest• Leisure• Families’ domains

•

Benefits of Work and Potential ImpactBenefits of Work and Potential Impact

• Work is a critical occupation and dates back to the founding days of our profession

• Educated in anatomy, physiology and activity analysis, thus highly equipped to serve as evaluators and educators

• Empowering individuals to increase control over, and improve their own health (WHO, 2012)

Calling all OTsCalling all OTs

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Improving US Health Care: Patient Protection Affordable Care ActImproving US Health Care: Patient Protection Affordable Care Act

• Improving the experience of care• Improving the health of populations• Reducing health care expenditure

• Improving the experience of care• Improving the health of populations• Reducing health care expenditure

Two Practice Areas TargetedTwo Practice Areas Targeted

Work

Health and WellnessHealth & Wellness

Work, Worker & WorkplaceWork, Worker & Workplace

Free Clip Art, 2015

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Nonfatal Work Related InjuriesNonfatal Work Related Injuries

• The Bureau of Labor Statistics reported 4 million nonfatal work-related injuries and illnesses in 2013 (2014)

• Two most common injuries• Sprains, strains and tears• Soreness/pain

• The Bureau of Labor Statistics reported 4 million nonfatal work-related injuries and illnesses in 2013 (2014)

• Two most common injuries• Sprains, strains and tears• Soreness/pain

The ChallengeThe Challenge

• Absenteeism • Returning to work too soon• Aging workforce• Stress• Fatigue• Depression

All impact employer’s medical costs and employees’ productivity

• Absenteeism • Returning to work too soon• Aging workforce• Stress• Fatigue• Depression

All impact employer’s medical costs and employees’ productivity

Productivity LossesProductivity Losses

• Productivity losses linked to absenteeism cost employers $225.8 billion or average of $1,685 per employee per year (CDC, 2013).

• Productivity losses linked to absenteeism cost employers $225.8 billion or average of $1,685 per employee per year (CDC, 2013).

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PresenteeismPresenteeism

• People going to work when they are sick account for 2/3 of the total costs of worker illness

• Can cut productivity to 1/3 or more (Hemp, 2004)

• People going to work when they are sick account for 2/3 of the total costs of worker illness

• Can cut productivity to 1/3 or more (Hemp, 2004)

Aging WorkerAging Worker

• According to the U.S. Bureau of Labor Statistics, by 2020, one in four American workers will be over 55 (2014)• Muscle Strength/Range of Motion: In general lose 15-20% of strength between ages of 20-

60. • Cardiovascular & Respiratory: By age 30-65 the heart, lungs and circulatory systems

decrease ability to carry oxygen.

• Posture and Balance: Falls generally increase in the aging population• Sleep Regulation • Vision• Hearing• CognitionCanadian Center for Occupational Health and Safety, 2012

• According to the U.S. Bureau of Labor Statistics, by 2020, one in four American workers will be over 55 (2014)• Muscle Strength/Range of Motion: In general lose 15-20% of strength between ages of 20-

60. • Cardiovascular & Respiratory: By age 30-65 the heart, lungs and circulatory systems

decrease ability to carry oxygen.

• Posture and Balance: Falls generally increase in the aging population• Sleep Regulation • Vision• Hearing• CognitionCanadian Center for Occupational Health and Safety, 2012

StressStress

• Work related stress is the #1 workforce health issue ranking above physical inactivity and obesity (Towers Watson Survey, 2013)

• Work related stress is the #1 workforce health issue ranking above physical inactivity and obesity (Towers Watson Survey, 2013)

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FatigueFatigue

• Lacking sleep leads to• Worker error• Deceased productivity• Safety incident

• Lacking sleep leads to• Worker error• Deceased productivity• Safety incident

DepressionDepression

• 1 in 10 adults suffer from depression in the U.S. (CDC,2013)• Can result in

• Absenteeism• Short-term disability• Decreased productivity

• 1 in 10 adults suffer from depression in the U.S. (CDC,2013)• Can result in

• Absenteeism• Short-term disability• Decreased productivity

National Health ConcernNational Health Concern

CDC

http://www.bing.com/images/search?q=free+diabetic+cartoons&qpvt=free+diabetic+cartoons&qpvt=free+diabetic+cartoons&FORM=IGRE

Free Clip Art, 2015

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The Silent Killer: SittingThe Silent Killer: Sitting

o > One hour of sitting prompts biochemical changes in • Lipoprotein lipase activity (an enzyme involved in fat

metabolism)• Glucose metabolism

o Leads to deposits of fats in adipose tissue rather than being metabolized by muscle

o > One hour of sitting prompts biochemical changes in • Lipoprotein lipase activity (an enzyme involved in fat

metabolism)• Glucose metabolism

o Leads to deposits of fats in adipose tissue rather than being metabolized by muscle

Sitting Can Lead to…Sitting Can Lead to…

Obesity

Increased risk for chronic diseases• Cardiovascular disease• Type 2 diabetes• Cancer

• Kidney disease• Death

Today’s worker faces serious health challenges

Obesity

Increased risk for chronic diseases• Cardiovascular disease• Type 2 diabetes• Cancer

• Kidney disease• Death

Today’s worker faces serious health challenges

ObesityObesity

• U.S. workers who are overweight or obese with other chronic health conditions miss approximately 450 million more days of work compared to healthy workers costing more than $153 billion a year in lost productivity (Gallup-Healthways Well-Being Index, 2011).

• U.S. workers who are overweight or obese with other chronic health conditions miss approximately 450 million more days of work compared to healthy workers costing more than $153 billion a year in lost productivity (Gallup-Healthways Well-Being Index, 2011).

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Heart DiseaseHeart Disease

• Siting can increase the risk of heart disease by as much as 15% and early death by 13%

• Siting can increase the risk of heart disease by as much as 15% and early death by 13%

Heart Disease and StrokeHeart Disease and Stroke

• Treatment of these diseases accounts for approximately $1 of every $6 spent on U.S. health care (CDC, 2014).

• More than 795,000 people in the U.S. have a stroke each year (CDC, 2014).

• Treatment of these diseases accounts for approximately $1 of every $6 spent on U.S. health care (CDC, 2014).

• More than 795,000 people in the U.S. have a stroke each year (CDC, 2014).

DiabetesDiabetes

• U.S. health care costs totaled $245 billion

• 7th leading cause of death

• Every two hours middle aged women sat and watched television, there was an increased risk of obesity by 23% and 14% higher risk for developing diabetes

(American Diabetes Foundation, 2015)

• U.S. health care costs totaled $245 billion

• 7th leading cause of death

• Every two hours middle aged women sat and watched television, there was an increased risk of obesity by 23% and 14% higher risk for developing diabetes

(American Diabetes Foundation, 2015)

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Musculoskeletal SystemMusculoskeletal System

• Musculoskeletal system is also at risk as it is dependent on proper blood flow which decreased motion can impact

• Sitting places 50% increased force on the spine while in the sitting positioning compared to standing (Maltchev, 2012)

• Musculoskeletal system is also at risk as it is dependent on proper blood flow which decreased motion can impact

• Sitting places 50% increased force on the spine while in the sitting positioning compared to standing (Maltchev, 2012)

• Musculoskeletal disorders (MSDs) accounted for 33 percent of all work injury and illness cases in 2013

• Workers who sustained MSDs were out of work a median of 11 days

• The estimated cost of chronic pain is estimated to be as high as $635 billion per year (National Research Council & Institute of Medicine, 2011)

U.S. Bureau of Labor Statistics, 2014U.S. Bureau of Labor Statistics, 2014

Common MSDs in Computer UsersCommon MSDs in Computer Users

Neck and back pain Headaches Shoulder discomfort TendonitisCarpal tunnelCubital tunnel

Neck and back pain Headaches Shoulder discomfort TendonitisCarpal tunnelCubital tunnel

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Causes Causes

Repetitive motion Poor posturing Static work positions

• Sitting Poor work practices Physical fitness level and body shape Training Issues Stress Inadequate workstations Increased productivity Combination

Repetitive motion Poor posturing Static work positions

• Sitting Poor work practices Physical fitness level and body shape Training Issues Stress Inadequate workstations Increased productivity Combination

OT and WorkOT and Work

Evaluation Ergonomic Intervention Exercise Exposure Reduction Education

Evaluation Ergonomic Intervention Exercise Exposure Reduction Education

Worker

Work PlaceWork

Evaluation Evaluation

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Outcomes of an Injury Prevention ProgramOutcomes of an Injury Prevention Program

• Safety • Productivity

• Not widely included in ergonomic studies• Comfort

• Most commonly assessed

• Safety • Productivity

• Not widely included in ergonomic studies• Comfort

• Most commonly assessed

EvaluationEvaluation

• Observation• Videotaping• No gold standard for assessing biomechanical exposures

• Technically posture/joint ROM can be measured• Functional outcome assessments

• Less expensive• Low risk• Can have varying reliability and validity

• Observation• Videotaping• No gold standard for assessing biomechanical exposures

• Technically posture/joint ROM can be measured• Functional outcome assessments

• Less expensive• Low risk• Can have varying reliability and validity

Evidenced-based Outcome Measuresfor Computer UsersEvidenced-based Outcome Measuresfor Computer Users

RSI Quick Scan Short form Workstyle measure Rapid Upper Limb Assessment Rapid Office Strain Assessment (ROSA)Cornell University Discomfort Questionnaire (CUDQ)

RSI Quick Scan Short form Workstyle measure Rapid Upper Limb Assessment Rapid Office Strain Assessment (ROSA)Cornell University Discomfort Questionnaire (CUDQ)

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ROSAROSA

Picture centered posture checklist

Quantifies exposure to risk factors in an office work environment

Inter and intra-reliability is good

Research shows correlation between increasing discomfort levels and increasing ROSA (Sonne, Villalta, & Andrews, 2012)

Picture centered posture checklist

Quantifies exposure to risk factors in an office work environment

Inter and intra-reliability is good

Research shows correlation between increasing discomfort levels and increasing ROSA (Sonne, Villalta, & Andrews, 2012)

CUDQCUDQ

• Assessment tool that examines the frequency and intensity of worker discomfort and the effects that this discomfort has on productivity

• High validity and reliability (Erdine et al., 2008)

• Assessment tool that examines the frequency and intensity of worker discomfort and the effects that this discomfort has on productivity

• High validity and reliability (Erdine et al., 2008)

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Ergonomic Interventionand

Education

ErgonomicsErgonomics

• Greek origin; ergos meaning “work” nomos meaning “law”• Fitting the work to the user• Goal of ergonomics is to obtain a safe, comfortable, and efficient

work environment• Systems and holistic approach

• Greek origin; ergos meaning “work” nomos meaning “law”• Fitting the work to the user• Goal of ergonomics is to obtain a safe, comfortable, and efficient

work environment• Systems and holistic approach

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Ergonomic ConsiderationsErgonomic Considerations

• Body mechanics and posture• For the body to maximize strength, mobility, and stability,

alignment to the center of gravity is important• Without the alignment over the center of gravity and along the

base of support, the muscles become fatigued, increasing risk of injury to the muscle and supported joints

• Body mechanics and posture• For the body to maximize strength, mobility, and stability,

alignment to the center of gravity is important• Without the alignment over the center of gravity and along the

base of support, the muscles become fatigued, increasing risk of injury to the muscle and supported joints

• Uneven forces places stress on the spine

• Uneven forces places stress on the spine

Neutral PositionNeutral Position

Elbows close to sides Reduce reachingWrists straight (slight 20 degrees extension) Ears over shoulders Shoulders over hips Hips in line with feet No rotation of spine

Elbows close to sides Reduce reachingWrists straight (slight 20 degrees extension) Ears over shoulders Shoulders over hips Hips in line with feet No rotation of spine

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Neutral takes time to learn Neutral takes time to learn

ChairChair

• Suggested 90 degrees of flexion at the hips, knees and ankles. • Chair too high

• Blood vessels may become impinged in posterior thigh (Tichauer & Gage, 1978)

• Encourages worker to sit to front of chair which can lead to low back muscle contraction (Harisinghani et al., 2004)

• Chair too low• Increased pressure under buttock potentially causing spinal lean

and pelvic rotation, which can compromise the lumbar spine curve (Harrison et al., 1999)

• Suggested 90 degrees of flexion at the hips, knees and ankles. • Chair too high

• Blood vessels may become impinged in posterior thigh (Tichauer & Gage, 1978)

• Encourages worker to sit to front of chair which can lead to low back muscle contraction (Harisinghani et al., 2004)

• Chair too low• Increased pressure under buttock potentially causing spinal lean

and pelvic rotation, which can compromise the lumbar spine curve (Harrison et al., 1999)

ChairChair

• Depth• Too long, low back support will be decreased or lost• Too short, pressure is increased on the back of the thigh causing

compressed blood vessels and nerves (Tichauer & Gage, 1978)

• Depth• Too long, low back support will be decreased or lost• Too short, pressure is increased on the back of the thigh causing

compressed blood vessels and nerves (Tichauer & Gage, 1978)

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ArmrestsArmrests

• Shoulders relaxed• No sharp edges • Soft in nature (Szabo & Gelberman, 1987)• Avoid compression at the cubital tunnel

• Shoulders relaxed• No sharp edges • Soft in nature (Szabo & Gelberman, 1987)• Avoid compression at the cubital tunnel

Lumbar SupportLumbar Support

• Should be adjustable• Placed at worker’s lumbar region supporting natural curve

• Without this support, the ligaments tendons and muscles of the back can be compromised (Harrison et al., 1999)

• Directly in front of worker• Placed to side can cause neck strain

• Should be adjustable• Placed at worker’s lumbar region supporting natural curve

• Without this support, the ligaments tendons and muscles of the back can be compromised (Harrison et al., 1999)

• Directly in front of worker• Placed to side can cause neck strain

MonitorMonitor

• 40-75 centimeters• Generally can gauge with worker placing at arm’s length• Top of monitor screen at eye level of seated worker (Canadian

Standards Association, 2000)• Deviations can cause increased muscle strain to neck and upper

shoulders

• 40-75 centimeters• Generally can gauge with worker placing at arm’s length• Top of monitor screen at eye level of seated worker (Canadian

Standards Association, 2000)• Deviations can cause increased muscle strain to neck and upper

shoulders

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KeyboardKeyboard

• Elbows placed at approximately 90 degrees with shoulders relaxed• Wrists neutral• Avoid wrist placement on hard surfaces (Canadian Centre for

Occupational Health and Safety, 2005)• Deviation can increase upper back and shoulder muscle activity

(Korhonen et al., 2003)

• Elbows placed at approximately 90 degrees with shoulders relaxed• Wrists neutral• Avoid wrist placement on hard surfaces (Canadian Centre for

Occupational Health and Safety, 2005)• Deviation can increase upper back and shoulder muscle activity

(Korhonen et al., 2003)

MouseMouse

• Fit the size of the worker’s hand• Positioned in line with the worker’s shoulder with wrist neutral• Same surface as keyboard• Deviation can cause increased UE muscle activity (Cook & Kothiyal,

1998)

• Fit the size of the worker’s hand• Positioned in line with the worker’s shoulder with wrist neutral• Same surface as keyboard• Deviation can cause increased UE muscle activity (Cook & Kothiyal,

1998)

TelephoneTelephone

• Placement should be within easy reach in order to eliminate excessive reaching

• Avoid ear and shoulder as source of stabilization

• Placement should be within easy reach in order to eliminate excessive reaching

• Avoid ear and shoulder as source of stabilization

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Ergonomics & CounselingErgonomics & Counseling

• Two studies documented positive effects on UE MSDs• Bohr, 2000• Peper, Gibney & Wilson, 2004

• One high level study identified significant improvements• Bernaards, Ariens, Knol, & Hildebrandt, 2007

• Several medium quality studies with significant improvements in comfort• (Bayeh & Smith, 1999; Gatty, 2004; Henning et al.,

1996, Mirmohammadi, Mehrparvar, Olia & Mirmohammadi, 2012; Rasoulzadeh & Gholamnia, 2012; Voerman et al. 2007a. 2007b; Voerman, Vollenbroek-Hutten, Sandsjo, Kadefors, & Hermens, 2007)

• Two studies documented positive effects on UE MSDs• Bohr, 2000• Peper, Gibney & Wilson, 2004

• One high level study identified significant improvements• Bernaards, Ariens, Knol, & Hildebrandt, 2007

• Several medium quality studies with significant improvements in comfort• (Bayeh & Smith, 1999; Gatty, 2004; Henning et al.,

1996, Mirmohammadi, Mehrparvar, Olia & Mirmohammadi, 2012; Rasoulzadeh & Gholamnia, 2012; Voerman et al. 2007a. 2007b; Voerman, Vollenbroek-Hutten, Sandsjo, Kadefors, & Hermens, 2007)

Mixed Evidence

• Means of educating were varied• Booklets, one-on-one

training, group training

• Length of sessions varied• Number of session varied

Mixed Evidence

• Means of educating were varied• Booklets, one-on-one

training, group training

• Length of sessions varied• Number of session varied

Ergonomic Training & Workstation AdjustmentErgonomic Training & Workstation Adjustment

• One high quality study found positive effect on the elbow and forearm (Martin, Irvine, Fluharty, & Gatty, 2003)

• One high quality study found positive effect on the elbow and forearm (Martin, Irvine, Fluharty, & Gatty, 2003)

• One high quality study found participant’s ability to rearrange their workstation properly (Levanon, Gefen, Lerma, Givon, & Ratzon, 2012)

• One level I study showed decreased UE pain via three hour training session incorporating:

• Discussion groups and didactic interaction• Workstation problem solving and dialogue centered

• Exercise• Work organization• Micro-breaks (Green, 2005)

Ergonomic Training, Workstation Adjustment and Micro-Break DiscussionErgonomic Training, Workstation Adjustment and Micro-Break Discussion

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Alternative Keyboards (Mixed Evidence)Alternative Keyboards (Mixed Evidence)

Level I showed a Microsoft Natural Multimedia keyboard effective in reducing MSDs (Ripat et al., 2006)

Level I found an alternative halved keyboard, located at right angles to be more effective than traditional (Swanson & Sauter, 2006)

Level I found increased comfort with the use of an Apple adjustable keyboard with a split design (Tittiranonda, Rempel, Armstrong, & Burastero, 1999)

MouseMouse• Concept is to decrease pronation• Level I found positive effects for a

trackball compared to a conventional mouse (Rempel et al., 2006)

• Level I showed participants who used an Anir mouse for six months decreased pain in the shoulder, forearm, wrist and hand (Aaras, Daindof, Ro, & Rhorensen, 2002)

• Concept is to decrease pronation• Level I found positive effects for a

trackball compared to a conventional mouse (Rempel et al., 2006)

• Level I showed participants who used an Anir mouse for six months decreased pain in the shoulder, forearm, wrist and hand (Aaras, Daindof, Ro, & Rhorensen, 2002)

Mixed evidenceMixed evidence

Arm SupportsArm Supports

• Moderate evidence supporting the use of arm supports especially for the dominant arm (Conlon, Krause, & Rempel, 2008; Rempel et al., 2006)

• Moderate evidence supporting the use of arm supports especially for the dominant arm (Conlon, Krause, & Rempel, 2008; Rempel et al., 2006)

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Exercise Exercise

Exercise/MovementExercise/Movement

• Mixed evidence

• Two high quality studies found positive effects for the neck (Lundblad, Elert & Gerdle, 1999; Sjogren et al., 2005)

• Mixed evidence

• Two high quality studies found positive effects for the neck (Lundblad, Elert & Gerdle, 1999; Sjogren et al., 2005)

Exposure Reduction Exposure Reduction

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Repetitive MotionRepetitive Motion

• Can cause:• Muscle fatigue• Joint pain and injury

• Neurological problems

• Can cause:• Muscle fatigue• Joint pain and injury

• Neurological problems

Static PositioningStatic Positioning

• Muscles contract for long periods of time• Causes reduced oxygenation• Muscles tighten

• Can occur with in large or small body motions

• Vascular compromise (varicose veins)• Standing or crouching too long• Veins need the movement of muscles around them to keep blood

from pooling and causing pain

• Muscles contract for long periods of time• Causes reduced oxygenation• Muscles tighten

• Can occur with in large or small body motions

• Vascular compromise (varicose veins)• Standing or crouching too long• Veins need the movement of muscles around them to keep blood

from pooling and causing pain

StandingStanding

Standing is being advocated because this uses more muscle activity burning 20% more calories.

Standing is being advocated because this uses more muscle activity burning 20% more calories.

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Standing Too Long…Standing Too Long…

Increased load to circulatory system

• Men with ischemic heart disease: increases the progression of carotid atherosclerosis because of increased load

• Increases risk of varicose veins and accounts for 20% of all cases in working ages

• Fine motor tasks more difficult

Increased load to circulatory system

• Men with ischemic heart disease: increases the progression of carotid atherosclerosis because of increased load

• Increases risk of varicose veins and accounts for 20% of all cases in working ages

• Fine motor tasks more difficult

Rest BreaksRest Breaks

Level I and III (Galinsky, Swanson, Sauter, Hurrell, & Schleifer, 2000; Galinsky et al., 2007) found positive effects of a five minute break every hourOr30 second break every 20 minutes (McLean, Tingley, Scott, & Rickards, 2001) has positive effect on UE MSDs

Level I and III (Galinsky, Swanson, Sauter, Hurrell, & Schleifer, 2000; Galinsky et al., 2007) found positive effects of a five minute break every hourOr30 second break every 20 minutes (McLean, Tingley, Scott, & Rickards, 2001) has positive effect on UE MSDs

Rest Breaks with ExerciseRest Breaks with Exercise

Insufficient evidence to determine whether combination has an effect on UE MSDs (Kennedy, et al., 2010)

Insufficient evidence to determine whether combination has an effect on UE MSDs (Kennedy, et al., 2010)

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OtherOther

• Biofeedback/Myofeedback:

• No evidence by itself (Larsman et al., 2009)

• Yoga

• Level II study by Joshi and Bellad report potentially useful intervention for computer related MSDs (2011)

• Biofeedback/Myofeedback:

• No evidence by itself (Larsman et al., 2009)

• Yoga

• Level II study by Joshi and Bellad report potentially useful intervention for computer related MSDs (2011)

Augusta Health’s ProgramAugusta Health’s Program

Referral

Evaluation

Intervention

Follow-up

Workplace Wellness

Employee Wellness

Referral

Evaluation

Intervention

Follow-up

Workplace Wellness

Employee Wellness

WorkWork

• One of eight areas of occupations• Members of Work & Industry Special Interest Section (WSIS):

• 269 occupational therapists• 21 assistants• Smallest membership of the eleven Special Interest Sections

• Compared to 3,856 occupational therapists and 455 occupational therapy assistants in the largest group, Physical Disabilities (AOTA, 2013a).

• Membership not growing

• One of eight areas of occupations• Members of Work & Industry Special Interest Section (WSIS):

• 269 occupational therapists• 21 assistants• Smallest membership of the eleven Special Interest Sections

• Compared to 3,856 occupational therapists and 455 occupational therapy assistants in the largest group, Physical Disabilities (AOTA, 2013a).

• Membership not growing

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ReferencesAaras, A., Daindoff, M., Ro, O., & Thoresen, M. (2002). Can a neutral position of the forearm when operating a computer mouse reduce the pain level for visual display unit operators? International Journal of Industrial Ergonomics, 30, 307-324.

American Diabetes Association. (2015). Overall numbers, diabetes and prediabetes. Retrieved from http://www.diabetes.org/diabetes-basics/statistics/

American Occupational Therapy Association. (2007). AOTA’s Centennial Vision and executive summary. American Journal of Occupational Therapy, 62, 613-614.

American Occupational Therapy Association. (2013a). Membership statistics and data. Bethesda, Maryland.

Bayeh, A.D., & Smith, M.J. (1999). Effect of physical ergonomics on VDT workers’ health: A longitudinal intervention field study in a service organization. International Journal of Human Computer Interaction, 11(2), 109-135.

Bernaards, C., Ariens, G.A.M., Knol, D.L., & Hildebrandt, V.H. (2007). The effectiveness of a work style intervention and a lifestyle physical activity intervention on the recovery from neck and upper limb symptoms in computer workers. Pain, 132(1-2), 142-153.

Bohr, P.C. (2000). Efficacy of office ergonomics education. Journal of Occupational Rehabilitation, 10(4), 243-256.

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Canadian Standards Association (CSA) International. (2000). CSA-Z412: Guideline on office ergonomics. CSA, Toronto.

Centers for Disease Control and Prevention. (2013, October). Workplace Productivity. Retrieved from http://www.cdc.gov/workplacehealthpromotion/businesscase/reasons/productivity.html

Colon, C.F., Krause, N., & Rempel, D.M. (2008). A randomized controlled trial evaluating an alternative mouse and forearm support on upper body discomfort and musculoskeletal disorders among engineers. Occupational Environmental Medicine, 65(5), 311-318.

Cook, C.J., & Kothiyal, K. (1998). Influence of mouse position on muscular activity in the neck, shoulder and arm in computer users. Applied Ergonomics, 29(6), 439-443.

Erdinc, O., Hot, K., & Ozkaya, M. (2008). Cross-cultural adaptation, validity and reliability of Cornell Musculoskeletal Discomfort Questionnaire (CMDQ) in Turkish language (Research Report). Retrieved from http://content.iospress.com/articles/work/wor01173

Galinsky, T.L, Swanson, N.G., Sauter, S.L., Hurrell, J.J., & Schleifer, L.M. (2000). A field study of supplementary rest breaks for data-entry operators. Ergonomics, 43(5), 622-638.

Galinsky, T.L, Swanson, N.G., Sauter, S.L., Dunkin, R., Hurrell, J.J., & Schleifer, L.M. (2007). Supplementary breaks and stretching exercises for data entry operators: A follow up study. American Journal of Industrial Medicine, 50(7), 519-527.

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Greene, B.L., Dejoy, D.M., & Olejnik, S. (2005). Effects of an active ergonomics training program on risk exposure, worker beliefs, and symptoms in computer users. Work, 24, 41-52.

Grontved and Hu (2011). Television viewing and risk of type 2 diabetes, cardiovascular disease, and all-cause mortality: a meta-analysis. Journal of the American Medical Association. 305(23), 2448-2455.

Harrison, D.D., Harrison, S.O., Croft, A.C., Harrison, D.E., & Troyanovich, S.J. (1999). Sitting biomechanics part 1: Review of the literature. Journal of Manipulative and Physiological Therapeutics, 22(9), 594-609.

Hemp, P. (2004, October). Presenteeism: At work-but out of it. Harvard Business Review. Retrieved from https://hbr.org/2004/10/presenteeism-at-work-but-out-of-it/ar/1

Henning, R.A., Callaghan, E.A., Ortega, A.M., Kissel, G.V., Guttman, J.I., & Braun, H.A. (1996). Continuous feedback to promote self-management of rest breaks during computer use. International Journal of Industrial Ergonomics, 18(1), 71-82.

Joshi, V.S., & Bellad, A.S. (2011). Effect of yogic exercises on symptoms of musculoskeletal disorders of upper limbs among computer users: A randomized controlled trial. Indian Journal of Medical Science, 65(10), 424-428.

Kennedy, C.A., Amick, B.C., Dennerlein, J.T., Brewer, S., Catli, S., Williams, R.,…Rempel, D. (2010). Systematic review of the role of occupational health and safety interventions in the prevention of upper extremity musculoskeletal symptoms, signs, disorders, injuries, claims and lost time. Journal of Occupational Rehabilitation, 20, 127-162. doi: 10.1007/s10926-009-9211-2

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