NECK PAIN
Ergonomic Intervention in the Treatment of a Patient With Upper Extremity and Neck Pain
+Author Affiliations
- Address all correspondence to Dr Fabrizio at: pfabrizio@gsu.edu
Abstract
Background and Purpose: Work-related musculoskeletal disorders are widespread among computer users and costly to the health care system. Workstation setup and worker postures contribute to upper-extremity and neck symptoms among computer users. Ergonomic interventions such as work risk analysis and workstation modifications can improve workers' symptoms. However, ergonomic interventions do not appear to be a common component of traditional physicaltherapy treatment.
Case Description: The patient was a 26-year-old woman with right upper-extremity and neck pain referred for physical therapy. A course of traditionalphysical therapy treatment was performed followed by an ergonomic intervention.
Outcomes: Following 4 weeks of traditional physical therapy, the patient showed a 1.0-cm improvement in her resting pain level but no change in her pain level during exacerbations on the visual analog scale. An ergonomic intervention was performed following traditional physical therapy. At the conclusion of the fullcourse of treatment (traditional physical therapy plus ergonomic intervention), resting pain level decreased by 4.6 cm and exacerbation pain level decreased by 3.2 cm. Improvements in Rapid Upper Limb Assessment and Workstyle scores also were realized.
Discussion: This case report demonstrates the importance of examining the work habits and work-related postures of a patient who complains of upper-extremity and neck pain that is exacerbated by work. Providing an ergonomic intervention in concert with traditional physical therapy may be the most beneficial course of treatment.
Jobs requiring the use of a computer input device and video display terminal (VDT) often expose workers to awkward and sustained postures and repetitive motions of the upper extremities, which have been demonstrated as causes of work-related shoulder and neck pain.1 The US Department of Health and Human Services estimated that in 1996 7% of US men and 9% of US women experienced some form of work-related neck pain.1 The incidence of upper-extremity work-related musculoskeletal disorder (MSD) claims for computer-related injuries increased from 1.6% of all upper-extremity injury claims in 1986 to 14.6% of all upper-extremity injury claims in 1993.2 The costs associated with upper-extremity work-related disorders, although difficult to assess, have been estimated to be in excess of $563 million in the United States in 1993 for upper-extremity work-related MSDs from all job types.3 A report examining the costs specific to work-related MSDs among VDT users showed an average cost per claim of $15,141 among VDT users in a petrochemical plant from 1990 to 1994.4 A recent estimate of the total costs associated with upper-extremity work-related MSDs put them in excess of $2 billion annually for the United States.5
The relationship between work-related MSDs and VDT use was explored by Marcus and Gerr,6 who reported a 63% incidence of neck and shoulder symptoms among 416 female office workers using VDTs daily in their jobs. More recently, Korhonen et al7 found that the annual incidence of neck pain among Finnish VDT workers was 34%. Sillanpää et al8 found that the incidence of neck pain and shoulder pain among 979 VDT users was 63% and 23%, respectively. These authors8 indicated a strong association between mouse use, including mouse position, and workers' pain symptoms. Hernandez et al9 reported an increased incidence of neck, shoulder, and hand work-related MSDs in 179 newspaper workers using VDTs compared with non-VDT users in the same company. Furthermore, they demonstrated that the type and amount of computer use and the posture of the worker were related to the incidence of work-related MSDs.
The incidence of neck pain combined with the increased numbers of workers using VDTs prompted the US Occupational Safety and Health Administration (OSHA) to institute guidelines and ergonomic evaluation procedures for working safely with VDTs.10 The OSHA VDT guidelines allow companies to determine the presence of work-related MSD risk factors and provide specific recommendations for safe seating and VDT setup in order to protect office workers.10 Altering the position of office equipment such as the VDT or mouse input device has been shown to modify muscle activity and reduce symptom complaints.11–14 Cook and Kothiyal11demonstrated that positioning the computer mouse closer to the keyboard and eliminating the numeric key pad resulted in a significantly lower deltoid muscle electromyographic activity in VDT users than when the mouse was placed in a position where the user was required to abduct the upper extremity and reach for the mouse. Static, low-level loading of the deltoid and upper trapezius muscles has been correlated with increased incidence of shoulder and neck pain.12 Marcus et al13 showed that there was a decrease in upper-extremity and neck symptoms in office workers who used more “ergonomically sound postures.” Specifically, a lower risk of work-related MSDs of the shoulder was associated with keyboard placement that put the elbows at a more neutral angle, described as “keyboard lower than elbow without arm abduction,” and a lower risk of neck symptoms was shown with a monitor position that allowed a head tilt angle of less than 3 degrees.13 Pillastrini et al14 and Hignett and McAtamney15 have shown that personalized ergonomic intervention, including a postural assessment and proper adjustments of the seat, desk, VDT, keyboard, and mouse, resulted in significant decreases in pain and Rapid Entire Body Assessment (REBA) scores for office workers using VDTs for 20 hours per week.
Ergonomic interventions, although primarily designed to benefit the worker, also may benefit the company. The implementation of an ergonomic intervention has been shown to decrease work-related MSD claim costs.4 During the period of 1995–1998, Lewis et al4 implemented an ergonomic intervention program among VDT users in a petrochemical plant. Individual claim costs were reduced from an average of $15,141 before intervention to and an average of $1,553 after intervention.
Ergonomic interventions are based on reducing awkward postures that occur while the client is at the workstation while performing work tasks. Physical therapists have unique knowledge and training in identifying awkward postures and performing the appropriate tests and measures to determine the causes and consequences of awkward postures. However, in my experience, an assessment of a patient's awkward working postures is rarely made by the physical therapist while the patient demonstrates those postures at the workstation. Postural assessments usually are made while the patient is in the clinic and generally in the standing and seated positions. Furthermore, interventions for awkward postures assessed only in the clinic usually do not involve workstation modifications or work habit modifications. An ergonomic assessment and workstation modifications have been shown to reduce the incidence of work-related MSDs in a variety of work settings.4,11,13,14 From the aforementioned research, it may be concluded that the inclusion of an ergonomic assessment and intervention in the treatment of an office worker with complaints of neck and shoulder pain can result in improved patient outcomes when combined with traditional physical therapytreatment. The current literature demonstrates ergonomic interventions on a company-wide scale but does not examine the inclusion of an ergonomic intervention added after a course of traditional physical therapy treatment as a plan of care. The purpose of this case report is to describe the effects of traditional physical therapy treatment of a patient with right-sided neck and shoulder pain and the subsequent outcomes associated with ergonomic evaluation and intervention that were initiated after the traditional treatment.
Patient History and Review of Systems
The patient was a 26-year-old woman with a chief complaint of right upper-extremity pain and right-sided neck pain who was referred for physical therapywith orders from her primary care physician for “physical therapy for neck strain, evaluate and treat.” The patient initially described her pain as a dull ache of insidious onset approximately 3 months prior and worsening since that time. The pain appeared, to her, to radiate from her neck into her shoulder and arm, with pain intensity at the time of her initial appointment equal to 5.5/10 cm on a visual analog scale (VAS). The VAS was assessed by having the patient mark her pain rating on a 10-cm line between “no pain” (0 cm) or “the worst imaginable pain” (10 cm).16 The VAS has been shown to have good reliability for assessing acute pain (intraclass correlation coefficient=.99), good validity for measurement of chronic pain and temperature, and a minimum clinical significant difference of 1.6 cm.16,17 The patient described her 24-hour pain pattern as decreased pain in the morning (VAS score of 3.2 cm) and increasing pain as the day progressed (VAS score of 6.4 cm), which she noticed daily during her 40-minute drive home from work. She also described her pain as limiting her time spent at her computer station and “making her work uncomfortable.” The physician's report and the patient's past medical history were unremarkable, with no indication of any systemic disorders, neurological or cardiovascular concerns, or previous injuries to the upper extremities, neck, or back.
The patient was employed as an administrative secretary with a job requirement of typing and VDT use for 65% to 75% of her day. The remaining daily tasks were equally divided among using the telephone, scheduling appointments, and filing paperwork. She had been at her current position for 6 months and noted that a new partner had joined the law firm in the past 4 months and that her typing and VDT workload had increased to 85% as a result.
Examination
The patient initially was seen in an outpatient physical therapy clinic and underwent traditional evaluation and treatment, which are outlined below. The patient was right-hand dominant. Observation of her posture in a standing position revealed a forward head posture with bilateral forward shoulders. The thoracic spine curve was unremarkable, and the lumbar curve was slightly lordotic. Upper-extremity posture demonstrated an elevated right shoulder and increased bulk of the right periscapular muscles.
Significant physical examination findings are summarized below. Active range of motion (AROM) of the cervical spine and upper extremities was within normal limits for all motions. Muscle length examination revealed tightness of the bilateral pectoralis minor muscles, and manual muscle tests revealed weakness in the bilateral middle and lower trapezius muscles. Neer and Hawkins-Kennedy tests were positive for shoulder impingement on the right, and upper-limb tension tests were positive for median nerve entrapment in the arm. The Neer and Hawkins-Kennedy tests have shown sensitivity of 75% to 88.7% and 92.1%, respectively, for subacromial impingement and a high specificity value of 96%.18,19 Palpation revealed increased bulk with an active myofascial trigger point (MTrP) in the right upper trapezius muscle and right levator scapulae muscle distal attachment.
At the initial visit, the patient completed the QuickDASH outcome tool, scoring 50 on the disability symptom score and 75 on the work and sport/performing arts modules (Table).20 The QuickDASH is a shorter version of the original Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire that has demonstrated good agreement with the DASH (intraclass correlation coefficient=.96) and good test-retest reliability (intraclass correlation coefficient=.93) related to function, where higher values indicate a greater level of disability.20 The QuickDASH does not appear to have established values for minimum clinical significant difference.
The diagnosis by the treating physical therapist was Guide to Physical Therapist Practice musculoskeletal preferred practice pattern 4E (“Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation”) and musculoskeletal preferred practice pattern 4F (“Impaired Joint Mobility, Motor Function, Muscle Performance, Range of Motion, and Reflex Integrity Associated With Spinal Disorders”).21 The patient indicated that her goals for physical therapy were to be pain-free, to work at her desk without symptoms for 1 hour, and to participate in yoga and aerobics sessions without being interrupted by her symptoms.
Traditional Physical Therapy Intervention
Physical therapy treatment commenced at a frequency of 3 times per week for 4 weeks. Initially, manual soft tissue techniques and spray and stretch were used to relieve the MTrPs in the right upper quarter.22 The patient received an education program on treatment day 1 consisting of posture correction, a home exercise program of strengthening exercises for the middle and lower trapezius, and self-neurodynamic gliding exercises.
The in-clinic treatments, started on treatment day 2, consisted of manual neurodynamic gliding for the median nerve, soft tissue mobilization and MTrP release, and a therapeutic exercise program consisting of exercising on an upper-body ergometer followed by progressive resistive exercises for the periscapular muscles. The patient was consistent with her physical therapy appointments, attending 12 of 12 sessions over 4 weeks, and reported consistency with her daily home program. Following 4 weeks of traditional physical therapy, the patient's MTrPs were resolved, neurodynamic testing and impingement tests were negative, and posture, as examined visually by the treating physical therapist, was improved. The patient reported her pain level at that time as 4.5 cm (VAS), with exacerbations of 6.4 cm (VAS) and abatement of symptoms to 2.2 cm (VAS) (Table). The changes in the patient's symptoms were 1.0 cm for present pain and 1.0 cm for best level of pain, and the minimum clinically significant difference has been established as 1.6 cm.17 The QuickDASH disability symptom score was reduced from 50 to 36, and scores on the sports/performing arts modules were reduced from 75 to 50 for each module (Table). During the traditional physicaltherapy treatment and the subsequent ergonomic assessment and treatment, the patient continued to perform her normal work duties.
Ergonomic Assessment
Following completion of traditional physical therapy, the patient was referred to another physical therapist for an ergonomic work risk analysis (WRA). The physicaltherapist performing the WRA was a Certified Ergonomic Assessment Specialist (Back School of Atlanta) and had 8 years of experience in performing ergonomic assessments. The pain rating and the QuickDASH scores were repeated, and the Workstyle short-form measure of work demands was assessed.23 The WRA was completed using the Occupational Safety and Health Administration (OSHA) W-1 Basic Screening Tool,24 the OSHA VDT workstation checklist10 (Appendix), and the Rapid Upper Limb Assessment (RULA).25,26
The OSHA W-1 Basic Screening Tool identifies risk factors for work-related MSDs related to awkward postures, repetition, force, contact stress, and vibration and is a general assessment tool for use in all types of industry.24 The OSHA VDT workstation checklist is used specifically for identifying risk factors for work-related MSDs associated with workstation postures and devices.10 The OSHA assessment tools are a logical primary step in ergonomics assessment because they are readily available, simple, and easy to use and are supported by current research and NIOSH recommendations. The RULA tool is used to estimate the risks of work-related upper-limb disorders and scores the worker's awkward postures at the workstation into action levels ranging from 1 (“sound positioning/safe”) to 7 (“worst posture/immediate risk for injury”).25,26
The initial WRA identified risk factors for work-related MSDs using the OSHA W-1 Basic Screening Tool in the categories of awkward postures and repetition. The OSHA VDT workstation checklist revealed specific risks for work-related MSDs related to positioning of the head, neck, shoulders, and trunk, as well as seating issues. The VDT workstation checklist also identified risks associated with keyboard and mouse position, monitor position, and lack of document holder, wrist rests, and telephone hands-free headset. The RULA tool identified risks associated with shoulder abduction and elevation, forearm flexion, wrist flexion and ulnar deviation, neck flexion and rotation, trunk flexion and rotation, and leg position. The initial RULA score was 7, indicating the need for immediate ergonomic intervention.25,26 The RULA score presented for this case report represents only the affected side. The RULA was completed for the noninvolved side, but the data are not presented here to preserve the clarity of the case. The WRA involved the therapist observing the patient for a 2-hour period while she performed her normal work duties on what was deemed by the patient to be a typical day of work. The awkward postures were averages of what had been visualized by the therapist. The subsequent scores were an average of the postures and positions as seen over the examination period.
In addition to the WRA performed by the therapist, the patient completed a Workstyle short-form survey. The Workstyle short form survey measures the individual's perception of his or her job and workstation in relation to symptoms in the following categories: working through the pain, social reactivity, limited workplace support, deadlines and pressure, self-imposed workplace and workload, breaks, mood, and autonomic response.23 The Workstyle short-form survey has been shown to have good internal consistency (α=.89) and good test-retest reliability (r=.88) and is correlated with measures of pain (r=.41) and upper-extremity symptoms (r=.33).23 The Workstyle score for the current patient was 52, with an “at risk” score defined as greater than 28.23 The Workstyle short-form survey was completed following the observation period.
A specific description of the patient's workstation follows. The patient's monitor was low and offset; the top of the monitor was positioned below eye level; and the monitor was set to the left of the work surface, requiring flexed and rotated trunk and neck postures. The keyboard was positioned on the desk surface, higher than the elbow position, resulting in bilateral wrist extension and shoulder elevation. The mouse was positioned 25.4 cm (10 in) away from the keyboard, requiring right arm abduction and shoulder elevation. The chair height and seat pan angle could not be adjusted, contributing to increased trunk and neck flexion and unsupported bilateral foot position and contact stress in the popliteal fossa.
Ergonomic Intervention
The ergonomic intervention was undertaken immediately after completing the scoring of the outcome measures and followed guidelines in OSHA document 3092, “Working With Video Display Terminals,” which describe head, trunk, upper-extremity, and lower-extremity positioning that is in agreement with current research regarding safe VDT working postures.10 An adjustable seat from an unused workstation was substituted for the patient's seat. The new seat height was adjusted to accommodate the monitor viewing angle combined with a relaxed leg and foot position, as well as the shoulder and elbow positions that are described below. An adjustable chair provides a platform from which all other adjustments can be manipulated. The addition of an adjustable seat, combined with ergonomic education, has been shown to reduce pain complaints in workers whose jobs required sitting for four hours per day while working at a VDT.27 Rempel et al28demonstrated that adding a properly fitted, adjustable chair significantly reduced shoulder and neck pain in seated workers.
The height and seat pan of the patient's new chair were adjusted to allow proper positioning of the trunk and upper extremities with the elbows at 80 degrees of flexion, elbows higher than the keyboard, and neutral wrist position of 0 degrees of flexion or extension while resting on the keyboard or mouse. The neutral shoulder/elbow/wrist position is designed to decrease muscle activation during seated postures that may be caused by constant low-level loading of the upper-extremity muscles. Previous research12,29 has shown that constant low-level muscle loading at the shoulder, neck, and forearms produced by positioning the elbow and wrist in non-neutral postures leads to an increase in pain at the shoulder, neck, and wrist. The mouse was positioned at the right upper corner of the keyboard to eliminate excessive shoulder abduction and decrease muscle activation and fatigue.30,31 The monitor height was adjusted to the proper eye level by using a 10.16-cm (4-in) riser, and the monitor was positioned directly in front of the patient's view to approximate the appropriate viewing angle and distance from the patient's eyes.32 Previous work by Marcus et al13 showed that monitor height adjustment requiring less than a 3-degree tilt angle produced a significant decrease in neck and shoulder symptoms.
Subsequent intervention involved ordering a split keyboard to reduce ulnar deviation strain.33 Marklin and Simoneau33 demonstrated that using a split keyboard, compared with a conventional keyboard, reduced ulnar deviation by as much as 10 degrees, allowing the wrist to be at a more neutral position and reducing RULA wrist position score. A keyboard tray and mouse tray were ordered and later incorporated to better align input devices while reducing the shoulder/elbow/wrist awkward postures.11,30,31 A document holder was later implemented to reduce head and neck movement and to reduce the chance that the patient would encounter a head tilt angle that put her at risk for neck pain.13The patient also was educated on the postural adjustments made to her body and her workstation and was instructed to take 20-second “microbreaks” as a means to break any sustained posture and relieve her symptoms by reducing myoelectric activity in the shoulder girdle musculature.34 Each microbreak consisted of a 20-second period of standing stretches (AROM for shoulder flexion, wrist flexion and extension, and scapular adduction) performed every 30 minutes while at her desk.
The duration of the ergonomic intervention consisted of 2 hours of assessment combined with the immediate workstation changes discussed above. A single 1-hour follow-up visit occurred 1 week after the initial ergonomic intervention to implement the new devices that were ordered and to review patient education regarding the new working postures.
Outcome
The outcome measures were reassessed at 1 month following implementation of the ergonomic intervention. During the period following the ergonomic intervention and to the day of the reassessment, the patient was no longer being treated with formal physical therapy and reported continuing her home exercise program 4 days per week. The results of the reassessment are summarized in theTable and briefly presented here. The patient's “present level of pain” rating on the VAS decreased by 1.0 cm following 4 weeks of traditional physical therapy and decreased by an additional 3.6 cm following the ergonomic intervention period. The patient's “worst pain” rating did not decrease during traditional physicaltherapy, but showed a decrease of 4.4 cm following the ergonomic intervention. The patient's “best pain” rating improved by 1.0 cm following traditional physicaltherapy and by an additional 2.2 cm following the ergonomic intervention. The QuickDASH disability score improved by 28% following traditional physical therapyand by 100% following the ergonomic intervention. The RULA and Workstyle ratings improved by 86% and 81%, respectively, following the ergonomic intervention. Four weeks after the ergonomic intervention, the patient's outcome scores for disability, pain, and work risk showed greater improvement than during traditional physical therapy alone.
Discussion
The purpose of this case report was to describe the effects of traditional physicaltherapy and ergonomic intervention in the treatment of a patient with neck and shoulder pain. It appears that the combined interventions of ergonomic assessment and modifications following 4 weeks of traditional physical therapyprovided a greater decrease in symptoms than the patient experienced during traditional physical therapy alone. However, it is difficult to say whether either intervention was more beneficial. Additionally, it is important to note that assessments using the RULA and Workstyle tools were not performed prior to beginning traditional physical therapy. Therefore, a true comparison between treatments cannot be accurately assessed using the RULA and Workstyle tools.
The patient had been continuing her home exercise program from the traditionalphysical therapy stage through the ergonomic intervention and had been instructed on proper postural corrections during traditional physical therapy. She also had been continuing to work at full capacity in her current position. Therefore, it may not be appropriate to conclude that the ergonomic intervention was the sole mechanism for the patient's pain relief. Although it has previously been demonstrated that improvements in neck and upper-extremity pain can be seen following adjustments to the workstation combined with postural adjustments of the worker, the role of exercise provided through the initial traditional physical therapy protocol and the educational component provided to the patient also need to be considered.35 A possible confounding element in the current case is the home exercise program. Patients experiencing neck pain previously demonstrated a decrease in pain symptoms and a decreased disability score following 6 weeks of exercise therapy alone when compared with controls.36Perhaps, in the present case, a greater portion of the decrease in symptoms was realized through the patient's continuing her home exercise program rather than through the introduction of ergonomic interventions.
Previous research also has shown that initial education regarding ergonomic postures at VDT workstations can influence symptoms.37 The initial postural education during traditional physical therapy may have contributed to the end result. However, Ketola et al37 showed that a combination of ergonomic education and workstation modifications provided a greater positive effect on patients’ symptoms than ergonomic education alone. This finding may implicate one of the shortcomings of traditional physical therapy. In many cases, it seems physicaltherapists may discuss or show a patient the proper posture for sitting at a VDT, but without actual assessment and modification of the workstation, significant symptom relief may not be achieved. The evidence from Ketola et al37 would suggest that there is greater value in the therapist's actually observing the patient in his or her natural working environment while performing the tasks required of the job. Patients may try to demonstrate artificially constructed work-related tasks in the clinic in the manner that they think the physical therapist wants to see. In the workplace, the bias is removed and the patient is more likely to perform tasks and exhibit postures more closely representative of his or her daily habits.
It is equally important to note that the patient in this case underwent traditionalphysical therapy for an extended period with minimal improvement. The VAS scores reflect the minimal improvement in the patient's symptoms after traditional treatment, with values remaining below the minimum clinically significant difference for the VAS. Had the ergonomic assessment and intervention been undertaken earlier in the treatment plan, perhaps the patient would have achieved her results in less time. In the current case, the VAS scores exceeded the minimum clinically significant difference after the completion of the full course of treatment, which included the ergonomic intervention. At a time when the health care industry continually strives to provide efficient care, a treatment plan that is not yielding results should be reevaluated or, in the present case, where the combined treatment of traditional physical therapy and ergonomics was shown to be beneficial, the office assessment should have been performed earlier. In the current case, the patient completed 12 visits of traditional physical therapywithout significant improvement of her symptoms.
Had the ergonomic assessment and intervention taken place earlier and possibly during the traditional physical therapy, perhaps the patient would have achieved a decrease in symptoms in a timelier manner, thus removing any indication of possible overutilization of physical therapy. For example, the cost of the ergonomic assessment in this case was $300. The cost of the ergonomic interventions (workstation devices to modify posture) was approximately $150. Therefore, the total cost of the ergonomic assessment and intervention was $450. In contrast, the cost of traditional physical therapy in this case was approximately $1,200. An ergonomic assessment is a cost-effective choice for the initial stages of treatment in patients with upper-extremity dysfunction that may appear to be work-related. Furthermore, the range of costs in individual workstation modifications allows the ergonomic intervention phase to remain cost-effective.
To more adequately assess the benefits of ergonomic intervention alone, the work risk assessment (RULA, Workstyle) should be performed prior to beginning a program of physical therapy treatment as a part of the initial evaluation procedures. Additionally, a course of ergonomic intervention should be explored prior to beginning physical therapy to assess the interaction of ergonomic intervention with traditional physical therapy. The amount and type of education regarding workstation posture also needs to be controlled in order to assess the true impact of the ergonomic intervention. In the current report, it is difficult to assess the extent to which the initial introduction of physical therapy treatment may have been responsible for the patient's progress. Would reversing the treatments, with an ergonomic intervention as the initial treatment and physicaltherapy intervention implemented 4 weeks later, show the same results? There is a need for continued research into and study of ergonomic intervention and its relationship to patient symptoms and its role in augmenting traditional physicaltherapy. One must consider that if ergonomic measures were to be implemented for all patients with seemingly work-related upper-extremity and neck symptoms, there must be a screening mechanism to predict which patients would benefit from ergonomic intervention.
Appendix.
Appendix.
Occupational Safety and Health Administration (OSHA) VDT Workstation Checklist10
aMSD=musculoskeletal disorder, VDT=video display terminal.
- Received July 8, 2008.
- Accepted January 12, 2009.
- American Physical Therapy Association
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