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J Occup Rehabil (2007) 17:743765 DOI 10.

1007/s10926-007-9108-x

The Impact of a Computerized Work Environment on Professional Occupational Groups and Behavioural and Physiological Risk Factors for Musculoskeletal Symptoms: A Literature Review
Karin Lindgren Grifths Martin G. Mackey Barbara J. Adamson

Published online: 7 November 2007 Springer Science+Business Media, LLC 2007

Abstract Introduction Computers have become an essential tool for many ofce based professional occupations, but their use is also accompanied by change to work demands and psychosocial work environment. Whilst considerable research exists relating to the potential health risks associated with computer work amongst semi-skilled occupations, there is a paucity of knowledge regarding the impact of an increasingly computerized workplace on the physical and psychological wellbeing of professional occupations. Methods A literature search was conducted using OVID Medline, PsycINFO and Cinahl databases. Papers published between 1980 and 2007 were selected for review. These included epidemiological and experimental studies that explored the relationships among occupational demands and stressors, work behaviours and musculoskeletal health in workers operating in a computerized work environment. Results In response to workload, deadline and performance monitoring pressures, many professional workers are often encouraged to perform long hours of computer work with high mental demands; work at a hectic workpace resulting in heightened muscle tension and forces, and with inadequate work breaks. These factors were identied in this review as risk factors for work related musculoskeletal symptoms. Conclusion As new technology continues to computerise the way professionals do their work, it is important for organizations to identify and measure the risks to health and wellbeing associated with these changes. Further research with professional groups is needed to support effective risk management decisions. Keywords Computer work Work related musculoskeletal symptoms Psychosocial stressors Professional occupations
K. L. Grifths (&) CRS Australia, Australian Government, Canberra, Australia e-mail: karin.grifths@crsaustralia.gov.au M. G. Mackey Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, NSW, Australia B. J. Adamson Discipline of Behavioural and Community Health Sciences, Faculty of Health Sciences, University of Sydney, NSW, Australia

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Introduction The work environment for many skilled professional workers such as engineers, accountants, lawyers and architects has substantially changed in modern times with the computerization of their ofce workplace. An individuals work environment is formed by the work conditions at the organizational level and the job tasks at the individual level [1], determining how and where work is organised and performed. Computerization of work tasks, information storage and communication has provided many benets to organizations and their staff, increasing productivity and efciency of work performance, improving quality of professional service delivery to clients and enabling exibility in when and where work is completed. It is estimated that at least 76 million people in the United States used a computer in their workplace in 2003, accounting for at least 56% of all employed adults aged 18 years and older [2]. Of these, a growing proportion are in managerial and/or professional positions (52.1% for men and 48.2% for women) and it has been estimated that more than 25% of the workforce now work on a computer for more than half their working day [3]. However, computerization tends to change the way work is organised and therefore impacts on both biomechanical and psychological work demands and conditions [4]. Work organization is a characteristic of the work environment and deals with the way work is structured and processed including hours of work, task complexity, skill and effort, job control, work/break schedules etc. [5]. It is argued the technology made available by computerization of ofce based work, may indirectly inuence health status through how it is able to structure a job and affect the psychosocial work environment [6]. Computerization can also have negative consequences on workloads, deadlines and performance expectations [7]. It has been suggested it can contribute to the dehumanizing of some ofce work activity when it results in reduced opportunity for social interaction within a work environment [89]. The computer has become a work tool for most ofce based professions. It has introduced new, or added to existing work demands and psychosocial stressors within their work environment. Some of these are illustrated in Fig. 1, adapted from the Workstyle model developed by Feuerstein [10, p. 191]. This diagram also identies various individual behavioural or physiological responses that can be triggered or exacerbated by the work demands and psychosocial stressors within a computerized work environment, and suggests an impact on the risk of work related musculoskeletal symptoms. As tasks within a job become computerized, the biomechanical demands may subsequently change. For professional workers this may include the introduction of more repetitive upper limb work, with longer periods of sedentary postures, resulting in reduced task diversity and variability of muscle activity [11]. Professionals working with computer aided design software (CAD) such as engineers, design technicians and architects, may now spend many hours sitting and viewing a monitor whilst operating a computer mouse. This will signicantly reduce their exposure to different kinds of tasks that provide biomechanical variation, thought to be particularly important for computer based work characterized by static loading [12]. Similarly, professionals working with large numbers of clients may have adopted electronic ling systems in place of paper les within their workplace. This enables all client information to be accessed from the computer workstation, with all paper based documents being converted to electronic information. The benets include increased speed of access, quality and effectiveness of document handing [4], reduced demands on ofce space for le storage systems, more exibility in regards to where work is done, and it removes the risk of misplaced les. Yet from a biomechanical perspective, it also removes the opportunity to stand and walk away

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Fig. 1 Risk factors for musculoskeletal symptoms within a computerized ofce work environment in relation to professional occupational groups. Adapted from Workstyle Model [10, p. 191)], for purpose of identifying only those variables and relationships addressed in this review and this does not diminish the signicance of other variables within the model. Used and modied with permission from Taylor & Francis Ltd (UK) (1996) and author M. Feuerstein

from the ofce desk to locate a le or document, further lessening exposure to variability with the physical demands within a job. It is argued the psychological demands associated with the performance of some tasks with professional work may be increased by their computerization [13]. Whilst many basic tasks such as numerical calculations are simplied, others can become more complex. Additional demands may include increased information processing requirements and greater demands on attention and memory [5, 9, 14], high precision and concentration [15], and multi-tasking demands. A recent study by Dux et al. [16], demonstrated a bottleneck effect when attempting to execute two tasks simultaneously using a computer, with demonstrated neural limitations in the information processing required for multiple task demands. It is now relatively common for professional workers such as lawyers to draft documents on their desktop computer using sophisticated computer software, work that was previously dictated to and completed by their secretarial staff. This task can require simultaneous manual operation of a computer, navigation of professional software and at the same time perform work with high cognitive demands including memory recall, problem solving and professional decision making. It is argued by Hockey et al. [9] that greater demands are placed on working memory with computerized work, particularly with interactive computer tasks. This work often has the requirement to retrieve and keep track of a lengthy sequence of commands whilst working towards the task goal. They also claim that the increased job-related information and communication facilities delivered by computerization may result in greater demands on planning and decision making processes, potentially requiring work to be organized into larger task chunks.

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Psychosocial work stressors are those psychological demands that are capable of evoking a common stress response within employees. It has been suggested that the computerization of ofce work has introduced new psychosocial stressors within ofce environments [17, 18], that are additional to those already present in a job. They may include increased workload demands [8], reduced discretionary control over task scheduling, increased workpace, deadline and electronic performance monitoring pressures [6], the need for sustained concentration with diminished social interaction [14], a sense of being rushed [19], and a tendency for increased supervisory control with reduced autonomy [20]. Epidemiological evidence has demonstrated that computer based work is an important biomechanical risk factor for the development of upper body work related musculoskeletal symptoms and disorders [17, 2126], with the neck area being particularly vulnerable to the adverse effects of this type of work [27]. Studies within this area have tended to dene computer based work in terms of hours per day or per week, and inclusion criteria have included working on a computer more than 4 h per day or more than 15 h per week. The biomechanical risk factors associated with computer work have been well established and generally include prolonged periods of sitting and viewing the monitor, with sustained static muscle activity in the neck, shoulder and spinal areas. Additional to this static loading are repetitive movements of the ngers and wrists in order to operate a keyboard or mouse, a signicant risk factor for cumulative trauma disorders to the upper limbs, in particular tendons within the hand and wrist [28]. There is growing evidence that psychosocial factors associated with computer work may increase the risk of upper body musculoskeletal symptoms and disorders [2933], particularly neck/shoulder pain [34]. These factors include the psychological work demands and psychosocial stressors present within a work environment. Some researchers assert that psychosocial risk factors are at least as important as the biomechanical risk factors in the aetiology of work related musculoskeletal symptoms and disorders [35, 36] and may increase the effect of the biomechanical loading [37, 38]. Professional occupations generally perform work characterised by high psychological demands when compared to semi-skilled occupations [39] and they include problem solving, decision making, professional knowledge application, responsibility, customer/client interaction, memory demands, creativity, ongoing skill and knowledge development. Whilst psychosocial stressors may be present in all computerized work environments, it is suggested different stressors may be experienced between professional and non professional workers. In one study with semi-skilled ofce workers, higher rating stressors included low levels of: job control, skill utilization, social support and task clarity [40]. A study of professional nancial traders found the highest rating stressors within this occupational group were: a prot goal (1), long working hours (2), time pressure (3), fear of mistakes (4) and concentration (5) [41]. Wallace [42] cites several surveys with lawyers which found work demands within this profession are a major source of stress. These include long work hours, time pressure and deadlines, information overload and working with a prot-driven focus. In many professions a signicant psychosocial stressor is the emotion work required during interactions with clients or customers, particularly within helping professions where the sensitivity requirements are often greater and long duration non-scripted verbal interaction is more common [43]. Psychological demands and psychosocial stressors found to be associated with an increased risk of work-related musculoskeletal symptoms include working to time pressures and/or deadlines [41, 4448], mentally demanding work and high levels of concentration [18, 19, 49], perceived hectic workpace [50, 51] and electronic performance monitoring [6].

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The majority of studies involving the measure of risk factors for musculoskeletal symptoms or disorders with computerized work, have examined the separate effects of biomechanical or psychological demands and stressors and few have investigated their combined or interactive effect [52]. Linton [53] found that exposure to both psychosocial and biomechanical stressors resulted in higher estimates of risk for musculoskeletal symptoms than each one alone. An interactive effect for workers exposed to both biomechanical and psychological workplace risk factors was also reported by Devereux [54]. In this study using a cross-section of occupations, workers exposed to both types of factor were at highest risk of developing musculoskeletal symptoms. The potential for a synergist effect when exposed to combined biomechanical and psychological risk factors has been suggested by some authors [48, 52, 55]. It is argued that organizational factors can encourage certain workstyle behaviours and physiological responses that may add to the existing risk of developing, exacerbating or maintaining musculoskeletal symptoms [10, 29, 34, 45]. Workstyle is dened as a modiable response style that enables an individual to meet certain self and/or organizationally imposed work demands [56, p. 88]. Adverse workstyles associated with computer based work, also referred to as maladaptive coping behaviours [57], may include working long hours and/or at a high pace in order to keep output high, working with heightened levels of muscle activity, taking inadequate work breaks [56, 57], and applying excessive forces to the keyboard or mouse [58, 59]. Some of these factors have been identied in the literature as both biomechanical and psychological risk factors for the development of musculoskeletal symptoms [60, 61] and may be a voluntary behavioural or involuntary physiological response to organizational and/or self imposed work demands or stressors. It has been suggested that a workers capacity to manage biomechanical and psychosocial work demands may partly explain why some people exposed to similar work conditions develop musculoskeletal disorders while others do not [62]. The expansion of computerized tasks into the work environment of many professional jobs has created a new level of risk that does not appear to have been adequately addressed in the literature. Most related research has been conducted with semi-skilled occupations such as data entry and call-centre work and the transferability of the results of these studies into professional occupations is unclear. However, there is good evidence available which shows that psychological demands and stressors characteristic of professional work, such as mentally demanding tasks, high workloads and deadline pressures, are also strong predictors of risk for musculoskeletal symptoms. These are additional to the existing biomechanical risks clearly identied with computerized work with a potential interactive effect. The present paper discusses several work behaviours and physiological responses that may be an added risk factor for musculoskeletal symptoms within a computerized ofce work environment amongst professional workers. These behaviours and responses were selected for review based on a number of criteria including: proposed within the original Workstyle Model [10]; at least a moderate association with the risk of musculoskeletal symptoms [63], as reported by authors in the studies selected for this review; the number of studies with signicant ndings for each variable; and clinical observations of work practices amongst a range of ofce based professional workers. The literature search strategy involved a search of relevant electronic databases including Medline, Cinahl and PsycINFO, journals and websites using a number of keywords including: computer work, musculoskeletal symptoms or disorders, psychosocial stressors, workload; work or rest breaks. Relevant studies from reference lists were also manually searched. Literature ndings have shown that musculoskeletal and psychological wellbeing can be adversely affected with behaviours and work demand responses that result in working long hours and/or at a hectic workpace, working with a

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heightened psychophysiological reactivity including increased muscle tension or forces, and taking inadequate work breaks. The aim of this paper is to draw attention to the potential risks to musculoskeletal health with the computerization of work amongst professional occupational groups, particularly where organizational factors enable or encourage individual work behaviours and physiological responses that can signicantly add to this risk.

Working Long Work Hours and Workload Pressures Working long hours appears to be a growing occupational health issue throughout the developed world. Recent labour statistics from the Australian Bureau of Statistics indicate the average working hours for full-time workers has increased over the last two decades and fathers of children under 15 years now spend an average of 43 h per week at work, with 33% working more than 50 h per week [64]. A study by the Australian Institute for Family Studies found the average hours worked by full-time employees in Australia have continued to increase since the late 1970s [65]. Upper white collar workers were more highly represented, with 59.6% of males from this group reporting they worked more than 60 h per week and 57.9% worked 4959 h per week. A more recent study of legal practitioners in NSW found the average weekly working hours in 2004 for male lawyers was 50.9 h and 48.1 for female lawyers [66]. There is a growing body of evidence that suggests working long hours has an adverse effect on health and wellbeing in general, with an increased risk of occupational stress, cardiovascular disease and musculoskeletal disorders [67]. When longer hours are worked with a computer, the duration of exposure to the biomechanical and psychological loading associated with computer work is increased. More hours at the ofce will also increase the exposure time to the psychosocial stressors associated with the job and reduces time available to wind down and recover after work. Oberlechner and Nimgade [41] found long working hours was rated as the second highest source of work stress amongst the group of nancial traders studied. Inadequate unwinding after work was identied by Melin and Lundberg as a signicant risk factor for work related musculoskeletal symptoms [37]. They identied a slow reversal of the stress response developed as a consequence of mental and physical work demands, as an important mechanism in sustained heightened muscle tension after nishing work and the development of work related musculoskeletal problems. Work conditions which require more hours of work under workload pressures will reduce the number of hours in a day to recover and opportunity to reverse the physiological stress response developed whilst at work. Epidemiological studies involving a range of occupations have shown there is a signicant relationship between daily duration of computer use and the risk of musculoskeletal symptoms [35, 47, 6873]. The main ndings from these studies are summarised in Table 1. Palmer et al. [74] found that operating a keyboard for more than 4 h per day was associated with a 4-fold increase in risk of neck and shoulder pain compared with those who used a keyboard minimally. Nakazawa et al. [75] gathered data from over 25,000 clerical workers and found a signicant relationship between biomechanical symptoms and duration of daily computer use, after adjustment for confounding factors. A signicant association between reported neck/ shoulder pain and duration of computer work per day was also reported by Kamwendo et al. [22]. The results of their cross-sectional study of 420 medical secretaries suggested the risk of neck/shoulder pain signicantly increased with 5 or more hours spent working on a computer per day. Similar results were obtained by Jensen et al. [71], who found the risk of neck or shoulder pain amongst women increased linearly as the proportion of work time at a computer per day increased. One study with non-clerical workers from seven different workplaces

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Table 1 Studies of the relationship between work hours, workload pressure and risk of musculoskeletal symptoms with computer work Reference Study population Study design Cross-sectional Risk factor Hrs working with computer/day Working under deadline Findings Greater than twofold risk of hand/wrist pain with typing [6 h/day. Increased risk for neck pain with hrs worked under deadline (OR = 1.7, 95% CI: 1.43.0) Working with computer [6 h/day associated with WMSDs in any of body regions identied (OR = 1.95, CI: 1.61 2.36), neck/sh. (OR = 1.88, CI: 1.48 2.38); elbow/wrist/ hand (OR = 2.01, CI: 1.283.15). Moderate assoc. with 46 h (ORs around 1.5). Adjustment for psychosocial factors with no inuence on effect estimates No predictive effect on reported neck/shoulder pain Overtime a risk factor for neck/shoulder pain with women Hectic work pace most common risk factor amongst women for neck/shoulder pain Increased risk of neck disorder with work pressure (OR = 2.4, CI: 1.55.8) Hrs worked predictive of pain intensity during work week, when combined with job stress & tendency to work with pain Increased risk of LB and UE symptoms with high time pressure exposure. For LB symptoms, OR = 2.96, 95% CI: 1.356.47. For UE symptoms, OR = 3.09, 95% CI: 1.396.88

Bernard et al. [44] Newspaper employees, professional & clerical (US) (n = 973)

Blatter and Bongers [69]

Range of ofce occupations (Netherlands) (n = 5,402)

Cross-sectional

Hrs working with computer/day Psychosocial factors (job demands, job control, skill discretion) Psychosocial factors (job demands, job control, skill discretion)

Evans and Patterson [76] Fredriksson et al. [51]

Non-clerical ofce workers (Hong Kong) (n = 170) Range of ofce occupations (Sweden) (n = 484)

Cross-sectional

Hrs working with computer/week Overtime hours

Retrospective

Hectic work pace

Hales et al. [46]

Telecommunication workers (US) (n = 512)

Cross-sectional

Work pressure

Hauer et al. [68] Symptomatic female Cross-sectional ofce workers (US) (n = 124)

Duration of working with computer/year

Huang et al. [48]

Ofce based jobs in US Marines (US) (n = 289)

Cross-sectional

Time pressure/ work to be completed urgently

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750 Table 1 continued Reference Jensen et al. [81] Study population Range of computer based jobs (Denmark) (n = 3,475) Study design Cross-sectional

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Risk factor Hrs working with computer/day

Findings Duration a predictor of neck and shoulder symptoms amongst women (OR = 1.92, 95% CI: 1.213.02 & OR = 1.83, CI: 1.13 2.95 respectively) & predictor of hand/wrist symptoms amongst men (OR = 2.76, 95% CI: 1.515.06)

Kamwendo et al. [22]

Female medical secretaries (Sweden) (n = 420)

Cross-sectional

Hrs working with Signicant association between [5 h/day computer [5 h/ computer work & neck/ day shoulder pain Duration of computer use with and/ without breaks Duration of computer work a strong predictor of symptoms Time pressure associated with higher prevalence of symptoms in female workers Signicant increased risk of elbow & wrist/hand pain with time spent using mouse or keyboard, with no threshold effect for mouse use

Karlqvist et al. [55]

Computer operators, Cross-sectional 46 worksites, various occupations (Sweden) (n = 1,529)

Lassen et al. [72]

Technical & machine Prospective technicians (Denmark) (n = 6,943)

Duration of keyboard and mouse use

Leroyer et al. [73] Ofce administrative workers (France) (n = 762)

Cross-sectional

Increased prevalence of Working neck pain for additional hours employees who worked to normal week longer hours (OR = 1.43, 95% CI: 0.992.07) Duration of daily computer use Duration lineally related to MS symptoms score with no threshold effect. Consistent ndings over 3 year period Four-fold increase risk of neck/shoulder pain with [4 h keyboard use per day Duration of keyboard use was predictive of musculoskeletal symptoms Frequent deadlines and fast work pace increased risk of musculoskeletal symptoms

Nakazawa et al. [75]

Clerical workers (Japan) 25,964 29,711

Cross-sectional three studies over 3 year period

Palmer et al. [74]

Range of occupations Cross-sectional (UK) (n = 12,262)

Keyboard use [4 h/day

Polanyi et al. [47] Newspaper workers (Canada) (n = 1,007)

Cross-sectional

Daily time keyboarding

Fast work pace deadlines

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J Occup Rehabil (2007) 17:743765 Table 1 continued Reference Smith et al. [79] Study population Telecommunication workers (US) (n = 762) Study design Cross-sectional Risk factor Exposure to electronic performance monitoring Findings

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Greater prevalence of reported symptoms with workers exposed to EPM compared to workers not exposed: 81% monitored workers reported neck pressure compared to 60%; 76% monitored workers reported shoulder soreness compared to 57%, and 43% of monitored workers reported loss of feeling in ngers/ wrists compared to 27% with non monitored Increased prevalence of reported symptoms all areas with [4 h computer work/day

Yun et al. [70]

Bank VDU operators (South Korea) (n = 1,025)

Cross-sectional

Hrs working with computer/day

Abbreviations: BP = Blood Pressure; CAD = Computer Aided Design; CI = Condence Interval; CWT = Colour Word Test; HR = Heart Rate; hrs = hours; LB = Low Back; Sh = shoulder; min. = minute; MS = musculoskeletal; OR = Odds Ratio; UE = Upper Extremity; VDU = Visual Display Unit; WMSDs = Work related musculoskeletal disorders

including a government department, accounting and legal rm, found the hours of computer use per week was not a predictor of neck and shoulder pain [76]. The only predictive effects were found with perceived tension at work and gender (female). In the case of wrist/hand pain, Bernard et al. [44] suggested a possible dose-response with the number of hours spent typing, with a greater than twofold risk for those typing more than 6 h per day. Quantitative workload is dened as the amount of work the person is given to do (Yang and Carayon [18, p. 33]), and is claimed to be a critical stressor with computer work. It has been found that a computerized work environment may have the effect of increasing the workload within an ofce [4, 18], with a tendency to increase the pace of work performed [19]. Waersted and Westgaard [11] demonstrated that when the same pen and paper task was transferred to a computer aided task, the workpace tended to increase amongst the participants in their study. A high workpace was found to be a predictor of neck and hand/wrist symptoms by Jensen et al. [77] amongst over 5,000 computer users from 11 different companies. Fredriksson et al. [51] performed a longitudinal study over a 24 year period and found a feeling of hectic work pace and mental exhaustion at the end of a work day was the most common risk factor for neck and shoulder disorders amongst women. A study with enlisted US marines completed by Huang et al. [48] found the reported pressure (on marines) to work continuously and for such work to be completed urgently was associated with up to a twofold increase in risk of low back and upper extremity symptoms. They also found that these psychosocial risk factors were found to be independent of biomechanical factors. Working with high workloads and/or deadline pressures is a relatively common work demand and potential stressor within many professional jobs. Research ndings show an

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increased risk of work related musculoskeletal symptoms when computer work is performed under conditions where there are workload and/or deadline compliance pressures [4548] and these results are summarised in Table 1. Bernard et al. [44] suggest the requirement to consistently work to deadlines may increase both the biomechanical and psychological job demands of computer work through responses such as increased typing speed with more repetitive nger movements, longer periods in static postures, fewer rest breaks, increased musculoskeletal tension and greater psychological stress. There is evidence to support a psychophysiological link between workload pressure and increased risk of musculoskeletal symptoms. Wahlstrom et al. [78] found adding time pressure to a computer task resulted in increased muscle activity in the trapezius muscle and forces applied to the mouse button. It is argued prolonged and or excessive muscle tension or forces of application contribute to biomechanical overload resulting in musculoskeletal skeletal symptoms or disorders [35]. Literature ndings suggest the neck/shoulder area is especially vulnerable to the effects of workload pressure. Hales et al. [46] reported a modest association between work pressure and neck pain whilst Bernard et al. [44] found the number of hours worked under a deadline amongst the newspaper employees, was an important predictor for neck pain. Computerization of professional work tasks enables the implementation of an electronic performance monitoring (EPM) system. Many professionals such as accountants and lawyers are required to work with time costing systems which enable the organization to utilize ongoing electronic performance monitoring. Some argue this can increase workload pressures and work stressors [79]. Lawyers claim the daily billable targets established by their organization may require longer work hours in order to meet or exceed these targets with resultant increased work stress [80]. The lawyers described the system as the corporate equivalent of Chinese water torture with every minute of their work day being electronically monitored and this scrutiny adds to the stressors already present within their job. EPM is also used with semiskilled occupations and Smith et al. [79] found its use increased the levels of reported stress and musculoskeletal symptoms amongst telecommunication workers. Of the workers monitored by EPM, 49% reported wrist symptoms, 82% reported neck symptoms and 79% reported shoulder soreness, compared to 26, 58 and 54% respectively in non-monitored workers. There is evidence that computerization of work may have the effect of increasing workload, time, deadline and performance pressures. As a result, workers may be required or encouraged to work longer hours and at an increased pace, and/or react with an increased stress response. It is suggested that when these factors are combined with the existing biomechanical demands associated with computer based work, there can be an interactive effect and compound the risk of work related musculoskeletal symptoms and disorders.

Working with Heightened Muscle Tension and Forces The normal physiological response to stress is an activation of the autonomic and central nervous systems. This will result in secretion of catecholamines (adrenalin and noradrenalin), corticosteroids (cortisol), and increased activity in the muscle tone regulatory system (reticular formation). Depending on the individual level of physiological reactivity to the stressor, there will be an increased activation of muscles, an increase in heart rate and blood pressure, with arteriolar vasoconstriction reducing nutrient delivery to soft tissues. Working with a sustained and heightened level of muscle activity exceeding what is required to perform a motor task, will increase the biomechanical loading associated with this activity. It is argued that there is a sufcient body of scientic evidence to demonstrate a biological relationship between the

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physiological stress responses affecting the musculoskeletal system, and the development of work related musculoskeletal symptoms or disorders [31]. The literature has identied a number of keyboard or mousing techniques and postural reactivity to work demands or psychosocial stressors, which may contribute to an increased risk of musculoskeletal symptoms with computer work. They include working with heightened muscle tension [37, 57, 82], applying increased forces to the keyboard or mouse [58, 83, 84], or working with an increased speed of mouse click [85]. Findings from relevant studies are summarised in Table 2. It is suggested that a person may develop a relatively stable method or style of working over a period of time and as a consequence of individual characteristics and/or social learning, may be predisposed to additional risk of musculoskeletal symptoms within their job [86]. Professional work is generally characterised by greater cognitive demands when compared to semi-skilled ofce occupations. A number of studies have demonstrated increased muscle activity occurs in the trapezious muscle in the neck/shoulder area when experimentally induced mentally demanding work is added to a computer entry task [15, 52, 87, 88]. Some studies have demonstrated an interactive effect between biomechanical and psychological loading and suggest psychophysiological mechanisms for musculoskeletal symptoms, particularly in the neck area [88]. Pre-existing static and low-level muscle activation associated with computer work may tend to interact with and be compounded by a heightened psychophysiological response when a mentally demanding task is added, resulting in additional muscle activation. Waersted and Bjorklund [89] refer to a psychogenic muscle tension response to increased psychological demands, where predominantly increased static loading occurs in shoulder muscles independent of postural demands with work such as computer based task. Larsson et al. [49] found that the addition of a mentally demanding task to static loading conditions increased trapezius (neck) muscle activation by approximately 20%. It has been demonstrated with industrial workers that the risk of developing musculoskeletal symptoms is substantially increased when excessive force is combined with a repetitive activity [90, 91]. Feuerstein et al. [92] argue the application of more force than is necessary for keyboard or mouse activation contributes to the exacerbation and maintenance of musculoskeletal symptoms. In a case-controlled study with symptomatic ofce workers, researchers found that the force exerted on the keys was a more important factor than degree of repetition, and that the mean key activation force was between 4 and 5 times greater than the force necessary to activate a key. Signicantly higher forces were measured for those that performed more than 4 h computer work per day compared to a control group. In an earlier study, Martin et al. [59] compared electromyography (EMG) readings in the forearm muscles with keyboard reaction forces. They found there was a tendency for keyboard users to depress the keys with over 5 times the necessary activation force and the highest absolute force was exerted by the thumb on the space bar. Wahlstrom et al. [78] measured the physiological effect of time pressure in the rst dorsal interosseus, extensor digitorum and trapezius muscles in the right arm with computer mouse activity using electromyography. This controlled trial compared the physiological response between performing the same computer task with no time constraint and then with instructions to work as fast as possible with time constraints. They found increased physiological activity when participants were required to work under time pressure. This included increased muscle activity, peak forces applied to the mouse button, heart rate and blood pressure. In a study with assembly plant workers it was found that a requirement to perform repetitive work at a faster pace, was accompanied by increased forces and higher muscle tension was in the hands and arms. It was concluded that this individual reaction to time pressure was a risk factor for work related musculoskeletal symptoms [93].

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Table 2 Studies of the relationship between mental work demands, heightened muscle tension, forces and risk of musculoskeletal symptoms with computer work Reference Study population Study design Intervention or risk factor Findings

Birch et al. [15]

Female CAD Operators (Denmark) (n = 14)

Repeated measures

Time pressure, mental Higher EMG activity for all muscles tested demand and (trapezious, precision infraspinatus, deltoid & intervention added ext. digitorum) with to standardised high time pressure (+ computer task in low precision + low eight random mental demands). No exposure effect with high mental combinations demand, yet productivity reduced Increased EMG activity Mentally stressful with signicantly large tasks added to data inter-individual entry; mental variations arithmetic and modied CW (colour word) test Keyboard force and keying rate measured during 15 min keyboarding task Higher keyboard forces (45 times greater than activation force) for workers with more severe symptoms. No correlation observed with keying rate Approx. 20% increase EMG activity in trapezius muscle when mental stress added to static loading Signicant increase in trapezius muscle activity with mental stressors with evidence of synergist effect when CWT added to physical load (ie incr. in EMG activity signicantly greater with combination than when each one alone is added) Increased speed of mouse click with experimental group. No association with anxiety measures Large variability in peak reaction forces with some exerting [5 times force needed to depress key. Higher forces with space bar.

Ekberg et al. [87]

Female VDU Workers (Sweden) (n = 20)

Repeated measures

Feuerstein et al. [58]

Symptomatic ofce workers (US) (n = 48)

Case-controlled

Larsson et al. [49]

Female hospital workers (Sweden) (n = 20)

Repeated measures

Static loading of trapezius and then combined with mentally demanding tasks (CW task) Combination of mental stressors (Stroop CWT and mental arithmetic) and physical load with standardised computer task

Lundberg et al. [52]

Female cash register operators (62) and university students (20) (Sweden)

Repeated measures

Macaulay [85] University students (UK) (n = 60)

Randomised controlled trial

Cognitive activity including test following tutorial with computer Keyboard reaction forces measured during keyboard task

Martin et al. [59]

University students and staff (US) (n = 10)

Case-controlled

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755

Waersted and Westgaard [88]

Students (Norway) (n = 37)

Repeated measures

Increased EMG activity, more prevalent in the frontalis and upper trapezius muscles Increased EMG activity, force applied to mouse button, BP and HR

Wahlstrom et al. [78]

Various occupations (Sweden) (n = 15)

Repeated measures

For notes, see Table 1

Working with higher muscular activity than is needed for the performance of a task will increase biomechanical loading, additional to the loading already associated with a job. In the case of computer based work, this behaviour or workstyle may persist over a number of hours, days or weeks resulting in potential cumulative overload and subsequent increased risk of musculoskeletal symptoms or disorders. Various pathomechanisms have been suggested to provide an explanation for this increased risk of symptoms when work is performed in the presence of heightened muscle tension and/or forces. These include biomechanical overload and potential cumulative harm to tendons and muscles; accumulation of metabolites as a consequence of reduced circulation [62]; interference with repair mechanisms [24, 94]; pain related to hypoxia, ischaemia or the metabolic effects of energy decit of muscle cells, accumulation of calcium in muscle which damages cells, or alteration of the biomechanical composition of the muscle interstitium to a level where nociceptors are activated [94]. Experimental studies have demonstrated that when psychological demands such as mentally demanding work and high concentration is combined with computer work, there is a tendency to work with heightened muscle tension and/or application forces to the keyboard or mouse. This has been identied as a risk factor for work related musculoskeletal symptoms and has signicant relevance for ofce based professional occupations. These occupations are typically characterised by higher psychological demands and when combined with the added biomechanical demands associated with more computer aided work within their job, the potential interactive effect of these risk factors may need greater consideration by organizations.

Working with Inadequate Breaks Professional workers generally have greater job control than semi-skilled ofce workers [39] and therefore it is reasonable to assume they are more able to take discretionary work breaks from prolonged periods of computer based work. Adequate work breaks have been identied as benecial for health and wellbeing within a computerized work environment and in some places are governed by occupational health and safety regulations. In South Korea, a 10 min break per 50 min of computer work is required within all workplaces, although observations of work practices suggest this often does not occur in practice [70]. Bergqvist et al. [23], found reported limited rest break opportunity with computer work resulted in increased odds ratios for musculoskeletal symptoms in most upper body areas surveyed, particularly tension neck syndrome where the results suggested there was a strong increased risk of reported problems.

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Work breaks enabling movement away from sitting at a computer workstation can address the biomechanical risk factors with computer work through variation in muscle activity, reduced periods of static loading to postural muscles, and shorter duration of repetitive work cycles [12, 95]. In contrast to rest breaks, it is thought work breaks that address the postural xity and biomechanical inactivity which occurs with computer work is of greater importance than factors such as working posture [35]. An often overlooked benet of work breaks is that they may also reduce the risks associated with the psychological demands and stressors with computer work. This may be particularly relevant to professional occupations characterized by more mentally demanding work with sustained periods of concentration and attention to a task. The National Institute for Working Life in Sweden recommends work breaks during computer work should be used to talk to a co-worker or clear out your head in a quiet place and .the more stressful, your work is, the more often and for longer periods you should do this [96]. Oberlechner and Nimgade [41] found in their study with nancial traders, encouragement of traders to take downtime in order to relax and be noisy was important for the management of stress within their job. Adequate rest and recovery breaks are considered as important for reversing the state of psychophysiological arousal and muscle tension that may develop under stressful work conditions [36]. It has also been argued that computerization of an ofce work environment may adversely affect social interaction by isolating work to the computer workstation and separating it from the usual social environment [9, 14]. This may reduce access to social support mechanisms, an important buffer between job stressors and worker stress [18]. Toomingas et al. [97] found the strongest and most consistent association between psychosocial factors and reported neck and low back musculoskeletal symptoms, occurred in conditions of low social support and high mental demands. It is suggested that social interaction with work colleagues may be limited by the availability of work breaks and social support is more difcult to access when there are inadequate breaks away from the computer workstation due to high workload demands. As demonstrated by literature ndings summarised in Table 3, there is considerable variation in the work break interventions used in the experimental studies identied. The majority of studies have also focused on the management of the biomechanical risk factors with computer work and involved semi-skilled occupations. Little research appears to have been directed towards evaluating the effect of altering work break behaviour for management of the interrelationship between biomechanical and psychosocial risk factors associated with computer work. Work break interventions studied have included rest or passive breaks, activity and/or exercise or stretching breaks, and scheduled or discretionary breaks. They also vary in duration and frequency, ranging from frequent micro-pauses of a few seconds to less frequent longer breaks of up to 10 min in duration. However, few studies have attempted to match work break protocol to the varying biomechanical and psychological demands of a job, especially in relation to computer based occupations. Winkel and Oxenburgh [98] argue that work break activity with computer work needs to involve meaningful tasks that can be integrated into normal work practices and involve biomechanical variation. Studies comparing active work breaks with passive breaks have found increased preference by workers for active breaks with mixed results on their effectiveness for reducing the risk of musculoskeletal symptoms [99, 100]. Sundelin and Hagberg [101] compared the use of passive and active work pauses on neck and shoulder EMG activity and reported discomfort with computer work. They found active pauses were preferred to passive pauses by the participants and they argued that the change in muscle activity resulting from active pauses was important for management of the static loading biomechanical risk factors.

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Table 3 Studies of the relationship between work break behaviour and risk of musculoskeletal symptoms with computer work Reference Study population Study design Intervention or risk factor Limited rest break opportunity Findings

Bergqvist et al. [23]

VDU work incl. numerical input, data accessing, word processing (Sweden) (n = 260)

Cross-sectional

For limited rest break opportunity: incr. risk of tension neck syndrome (OR = 7.4: 95% CI: 3.117.4); neck/ shoulder discomfort (OR = 2.7; 95% CI: 1.25.9) and any arm/ hand diagnosis (OR = 2.7; 95% CI: 0.89.1) Increase in discomfort during test period, although curbed by exercise intervention. Two operators reported wrist discomfort with stretching exercise. Reduction in reported musculoskeletal symptoms

Fenety and Walker [105]

Directory assistance operators (US) (n = 11)

Prospective cohort Passive stretching exercises

Ferreira et al. [103]

Call-centre workers (Brazil) (n = 106)

Retrospective over 30 month period Repeated measures

10 min break every hour

Galinsky et al. Data entry operators [100] from IRS (US) (n = 42)

Supplementary 5 min Reduced symptoms with break every hr intervention group for all body areas Encouraged active breaks Signicant reduction in small day-to-day increases in right forearm, wrist and hand discomfort

Henning et al. Insurance claim [99] processors (US) (n = 92)

Randomised controlled trial

No effect with additional Four additional short duration work breaks/hr (3 9 30 s breaks on upper body and 1 9 3 min) for discomfort two experimental groups. Stretching Active work breaks exercises added to preferred to passive one of these groups Working [2 h without break Increased prevalence of symptoms in all upper body areas

Karlqvist et al. VDU workers from 46 Cross-sectional [55] different worksites and range of occupations (Sweden) (n = 1,529) McLean et al. [102] Data entry and word Randomised controlled trial processing operators (Canada) (n = 15)

Reduced discomfort scores Three microbreak with additional protocols: microbreaks, especially discretionary; 30 s when taken every every 20 min; 30 s 20 min every 40 min

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Intervention or risk factor Compared active (with stretching), passive (rest only) and diverting (left desk to walk into corridor)

Findings

Sundelin and Hagberg [101]

Repeated Word processor measures operators (Sweden) (n = 12)

Breaks with activity preferred EMG readings of trapezius muscle demonstrated change in habitual muscle activity pattern with active pauses

Winkel and Oxenburgh [98]

Data entry operators Repeated measures (accounts dept) (Sweden) (n = 45) Cross-sectional

Able to vary between Active work breaks more effective than inactive sitting and standing to perform work More than 10 min or more break within every hour of computer work Increased prevalence of reported MS symptoms in all areas for those that did not take mandatory break. With breaks: 17.6% reported neck symptoms compared to 39.2% without breaks; 27.5% reported shoulder symptoms compared to 52.8% without breaks, 13.7% reported wrist symptoms compared to 22.2% without breaks, 21.6% reported upper back symptoms compared to 31.9% without breaks and 19.6% reported lower back symptoms compared to 39.6% without breaks

Yun et al. [70] Bank VDU operators (South Korea) (n = 1,025)

For notes, see Table 1

Other studies have examined the effectiveness of pause or micro breaks, arguing short frequent breaks are needed to enable changes in motor unit activity in postural muscles and allow musculoskeletal recovery [99]. McLean et al. [102] found no statistically signicant association between muscle cyclic behaviour and reported discomfort in 15 data entry and work processing operators, when prompted to take a scheduled 30 s break every 20 min and then every 40 min. Yet in this small study, participants did report reduced discomfort when schedules microbreaks were taken. There is some evidence that frequent short breaks may be disruptive and a potential psychological stressor for some workers. Sundelin and Hagberg [101] found frequent work pauses were regarded by participants as disturbing to work routines, a nding which may be relevant to professional occupations where sustained periods of concentration are often required. Longer duration work breaks have been found to reduce the risk of musculoskeletal symptoms and disorders. In a retrospective study completed with Brazilian call centre workers, it was found that the introduction of a 10 min rest break for every hour of work reduced the risk of musculoskeletal disorders [103]. They also concluded that this intervention was more

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effective than other risk reduction inventions including workstation design, work posture and stretching. The effectiveness of incorporating stretching exercises during work breaks has been examined in a number of studies [104, 105], with no strong evidence that stretching reduces the risk of musculoskeletal symptoms. However, a signicant limitation of these studies is related to often poor compliance of study participants with the experimental intervention. Monsey et al. [106] stated that factors affecting compliance with stretching exercises included lack of immediate benets, lack of time and lack of recall of exercises. Henning et al. [99] found on average only 45.08% of participants complied with the stretching protocol in their study and proposed the reported task disruption that occurs with frequent, short duration scheduled work breaks may have been a contributing factor to this lack of compliance. Winkel and Oxenburgh [98] excluded what are termed as pause gymnastics from their study with data entry operators, claiming employees usually give up on these exercises as they are not meaningful to their daily work. They felt changes in work organization enabling increased work breaks was more important for reducing neck/shoulder discomfort with computer based work than other factors, including workstation redesign. The literature supports the use of active work breaks for the reduction in the risk of musculoskeletal symptoms. Mathiassen [12] argues the signicance of breaks is more related to the opportunity for variation in job demand exposure, including both biomechanical and mental variation [9, 107], rather than the contents of rest itself. There appears scarcity of research on the use of work breaks for the management of the psychological demands and stressors within a job and associated risk factors. Professional occupations may have a greater need for systems of work that enable and encourage healthy work break behaviours than is generally recognised and more research in this area would be benecial to identify what work break practices should be facilitated by organizations within their ofce workplaces. Although it can be argued professional workers are generally more able to utilise discretionary breaks as they tend to have greater job control, organizational factors such as workload demands and productivity requirements may discourage effective work break behaviours.

Discussion Computerization of the ofce work environment amongst professional occupational groups appears to have signicantly changed the way their work is organised and performed. Whereas semi-skilled occupations have typically worked with an ofce tool such as a typewriter or accounting machine for decades, ofce based professional workers have tended to be limited to much more basic tools such as a pen, pencil and telephone. With the understanding that this change has increased efciencies and capabilities of their work, there is also evidence that the consequences may include factors such as increased workloads, added time and performance monitoring pressure, greater information processing, memory and multi-tasking demands. It is argued these factors have added to the existing biomechanical and psychological demands with ofce based work amongst professional occupational groups, and has also introduced new psychosocial stressors. Whilst the risk factors for work related musculoskeletal symptoms with computer work have been extensively researched and are generally well established, most studies have involved semi-skilled occupations. Although the biomechanical demands may be similar to professional occupations, the varied job characteristics between these occupational groups result in different types and levels of psychological demands and psychosocial stressors. Therefore the results from studies with semi-skilled occupations may only be

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partially transferable to professional workers. It is argued the rapid progression of computerized work tasks within ofce based professional occupations warrants more research specically with these groups. The decision to introduce or extend the computerization of professional work tasks into an ofce work environment are generally made by the organization and is usually done for valid or essential reasons including increased efciency of work processes, necessitated by a competitive commercial market. Whilst these changes are often welcomed by workers, the additional risk factors for musculoskeletal symptoms or disorders introduced through the interaction and/or combination between the biomechanical demands, psychological demands and psychosocial stressors associated with computer work should also be recognised, measured and controlled. It is proposed that there is an interactive relationship between these risk factors, with a potential synergist effect. That is the risk of work related musculoskeletal symptoms with a combination of these risk factors is greater than the sum of each one alone. For example, the introduction of a work system change, such as the requirement to learn how to use a new software system or work to a more precise electronic monitoring system, may result in increased cognitive demands and/or psychosocial stressors, which may interact and combine with existing biomechanical risk factors for musculoskeletal disorders. Depending on an individuals coping mechanisms for these work system changes, a worker may respond in a potentially harmful way, such as: working with heightened muscle tension, increasing work pace and/or forces, taking fewer work breaks or remaining in static work postures for longer periods. These behaviours may prolong or augment any existing muscle tension associated with the computerized work activity. The progression towards muscle fatigue and overwhelming of the normal ongoing reparative ability of the musculoskeletal system, resulting in cumulative microtrauma, has been suggested as a potential pathophysiological mechanism for the development of symptoms and/or disorder [108]. It is also suggested that work demands and/or psychosocial stressors characteristic within professional occupational groups such as workload, deadline and performance pressures, may exacerbate or encourage work behaviours and responses that further heighten the risk factors for work related musculoskeletal symptoms. Literature search results have demonstrated that working long hours with a computer, with inadequate breaks, at an increased work pace, and/or with heightened muscle tension or excessive application forces to the keyboard or mouse, are all factors that may further increase the risk of the development, exacerbation or maintenance of musculoskeletal symptoms with computer based work. This paper has attempted to highlight the need for organizations to consider and address the potential biomechanical and psychosocial hazards associated with the expansion or upgrading of computerized work tasks amongst their professional staff. By recognition of the potential adverse effect on existing biomechanical and psychological risk factors with computer work, strategies to moderate or buffer these effects can be considered and implemented. Based on the literature ndings within this paper, the establishment of a work environment that enables and promotes reasonable work hours, realistic workload, deadline and performance monitoring expectations, and adequate work break opportunity may be an effective means of controlling higher risk work behaviours and physiological responses when performing computer based work. Whilst individual factors such as age, gender, personality, and biomechanical characteristics are also recognised as valid contributors to the risk of musculoskeletal symptoms with computer work, the power to manage how work is organised is generally within the hands of an organization [1]. Effective risk management for the prevention of work related disease or injury requires an environmental approach, creating a work environment which can accommodate the risk factors introduced into the work system and provide pre-event intervention measures [109].

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Whilst workstation ergonomics has not been addressed in this paper, it continues to be considered as important for reduction in risk of musculoskeletal symptoms with computer work. Yet occupational disease statistics tend to show that although there have been improved ergonomic conditions in ofces, there has been no signicant decrease in reported work related musculoskeletal disorders [37]. Swedish statistics demonstrate the reported cases of musculoskeletal illness where computer work was given as the reason for the illness, increased by 20% between 1992 and 1998 [84]. There is now growing evidence that the psychosocial risk factors within a computerized work environment may be at least as important as other factors [33] and ergonomic risk factors are of less signicance than previously assumed [76]. In conclusion, computer technology will continue to improve productivity and performance within ofces with many benets to both employers and employees and it has not been the purpose of this paper to critically address these developments. As was recently observed by a young accountant, computer functions now do the grunt work, freeing these professionals from paper ledgers and endless documentation [110]. Effective management of occupational health risks is more effective when risk factors generated by a changing work environment and the organization of how work is done, are recognised, measured and controlled in order to minimize the incidence of WMSDs. It is argued more research is required to identify and measure the risk factors for musculoskeletal symptoms specically for professional occupations who work in a computerized work environment, this includes the interactive or synergist effect on the level of risk between all biomechanical and psychological demands and stressors. This should also include a measure of the how organizational factors common to professional workplaces may encourage, exacerbate and maintain individual work behaviours and reactivity to work demands and stressors, which may compound existing risk factors for musculoskeletal symptoms found to be present within a computerized work environment.

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