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Amick III, PhD1,2, Mark Jenkins, MD2, Michelle Robertson, PhD, CPE3, Ira Janowitz, CPE,4 David M. Rempel, MD4, Jack T. Dennerlein, PhD5, Che-Hsu Chang5, Jeffrey N. Katz, MD, MS6, and Ron Harrist, PhD1 UTHHSC School of Public Health, Houston, TX, USA, 2Rice University, Houston, TX, USA, Liberty Mutual Research Institute for Safety, Hopkinton, MA, USA, 4University of California at Berkeley, Berkeley, CA, USA, 5Harvard School of Public Health, Cambridge, MA, USA, 6Robert B. Brigham Multipurpose Arthritis and Musculoskeletal Diseases Center, Division of Rheumatology, Immunology and Allergy, Brigham and Womens Hospital, Harvard Medical School, Boston, MA, USA.
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Upper extremity musculoskeletal disorders continue to be a substantial public health problem. They account for a tremendous proportion of all lost workday cases as well as billions of dollars in workers compensation costs. Because the labor market has changed where the proportion of young workers is increasing, musculoskeletal disorders are affecting young workers aged 24 years and younger as well. Furthermore, recent studies conducted on college students have revealed upper extremity musculoskeletal symptoms, while using the computer, as well as unhealthy computing habits. Currently there is little data available linking computer use habits with upper extremity musculoskeletal symptoms in this vulnerable population. The purpose of this study was to evaluate computer use duration, frequency, and intensity, computer use postures, and upper extremity musculoskeletal symptoms using a variety of methods. Better methods of exposure and outcome characterization are called for as one of the needs of the National Institute of Occupational Safety and Health National Occupational Research Agenda. The findings of this study will provide meaningful information as to the advantages and disadvantages of each method used with respect to validity and practicality in characterizing computing habits.

INTRODUCTION Musculoskeletal disorders (MSDs) continue to be a substantial public health problem. In 2001 they accounted for more than one-third of all lost workday cases (BLS, 2001a). Their cost is staggering each year more than $2 billion in workers compensation costs are spent on upper extremity MSDs (NIOSH, 2003). These occupational injuries are not limited to older workers. Almost 12% of occupational injuries involving MSDs affected workers aged 24 years and younger (BLS, 2001b). Upper extremity MSDs associated with computing do not necessarily begin after joining the workforce (Katz et al., 2000). A recent study found 54% of college students surveyed experienced upper extremity symptoms while using the computer (Katz et al, 2000). Computer use plays a tremendous role in both the academic and social aspects of college life (Jones,

2002). With current college enrollment for this age group expected to reach almost 10 million nationwide, college students stand to contribute tremendously to this costly public health problem (Gerald & Hussar, 2002). There is little data available linking computer use with upper extremity musculoskeletal symptoms or disorders among college students (Katz et al, 2000, Cortes et al, 2002). The few studies focusing on this population are cross-sectional in nature and incomplete in their exposure characterization. Known exposures involved with computing such as posture and force have not been included in these studies. Other exposures, such as computing duration, have been characterized using ascertainment methods with questionable validity. One recently conceptualized exposure has binge computing showing promise as a potential risk factor but the binge computing has only been assessed using traditional self-reported methods (Amick et al). It is


well known that more reliable and valid methods are needed to evaluate exposure (National Research Council and the Institute of Medicine, 2001). College students represent a future workforce already vulnerable to upper extremity MSDs. Appropriate exposure ascertainment and modeling of exposure-symptoms relationships would serve to identify appropriate interventions. The objective of this study is to compare measurement methods for several exposures and outcomes of interest related to college computing habits: computer use duration, frequency, and intensity, posture, and upper-extremity musculoskeletal symptoms. MATERIALS AND METHODS Undergraduate students of a particular college at a private university were invited to participate in the study. These undergraduate students had access to their own computer and were 18 years or older. A convenience sample of fifteen females and fifteen males were chosen. Students were enrolled as they completed the baseline survey, consent form, and contact information. Students agreed to participate in three oneweek data collection periods. Each included one week of answering a questionnaire on a randomly beeping palm pilot, one week of software installed on the computer to monitor keyboard usage, and one 45-minute session of videotaped computer use and observation where posture measurements would be taken and computer use checklists completed. Figure 1 depicts a typical dormitory room at this college where the observation sessions were held. These sessions occurred over the course of the semester and were scheduled mainly in late February, mid-to-late March, and through April in an attempt to capture different workloads throughout the semester. Spring Break and large social functions were not included so as to minimize non-participation. Three completed one-week data collection periods were obtained for each of the fifteen females and fifteen males. Each participant was given $20 cash incentive at the end of a completed data collection period. At the end of the last data collection period a 10-minute ergonomic training in optimal computer use intensity, posture and workstation layout was given. This included a color flowchart of helpful hints that was reviewed with each participant at the completion of the study. The University of Texas at Houston Health Sciences Center Committee for the Protection of Human Subjects and Rice University Internal Review Board approved the study protocol. Figure 1. Standard unadjustable desk and chair found in a typical dorm room at this university. Survey Instruments Baseline Survey: The baseline survey was given at baseline, took approximately 30 minutes to complete and consisted of 10 sections. These sections included a range of questions on the following topics: computing time by location, computing duration per week and by activity, break times, workstation adjustability, upper extremity musculoskeletal symptoms, student functional limitations, health services utilization, medications use, demographics and extracurricular activities. Palm Pilot Questionnaire: The palm pilot questionnaire was administered for one week (typically a Sunday through a Saturday) and was programmed to beep randomly for a certain time period each day over the course of the week. The software was developed at the University of Washington, modified by the first author, and was installed on each of 18 Palm Zire 21 Handhelds (Consolvo & Walker, 2003). A battery charger was distributed to each student as well when the handhelds were passed out each Sunday. When the handheld began beeping, the student would tap the screen with the stylus to begin answering the questionnaire. The questionnaire consists of 28 questions designed to capture computer use duration, frequency, and intensity as well as symptoms. Odometer Software: Concurrently with the palm pilot distribution software was installed on each participants computer for the same week of data collection. This software was designed by Harvard University for the purposes of tracking keyboard usage (alphabetical keyboard vs. numeric keypad), mouse usage (direction),


and computer use duration, frequency, and intensity. This software was running each time the computer was in use. Interview Sheet: Each time the observer came to watch and videotape each student on the computer the participant was asked to complete an interview sheet asking about computer usage with respect to activities for the past week. Computer Workstation Checklist: This checklist was designed to evaluate computer usage and postures during keyboarding and mousing activities by the University of California, San Francisco, Ergonomics Program. It was completed once during each observational session. The checklist is designed so that an overall score representing risk for upper extremity musculoskeletal symptoms and disorders can be calculated. Rapid Upper Limb Assessment: RULA was designed to assess in a 15-minute time period the postures of each of the upper limbs when typing on the computer. Pictures were used to help the observer choose the most representative posture. This questionnaire was complete once during each observational session. RULA is designed so that an overall score representing risk for upper extremity musculoskeletal symptoms and disorders can be calculated. Goniometric measurements: A 6-inch and 12-inch plastic goniometer was used to measure upper extremity body angles during computer use three separate times during each observational session. Videotaping: In order to catch any activities or movements that may have been missed by the observer, each participant was videotaped during each session of computer use. Consent forms for videotaping were signed at each session. This study used multiple methods to collect data on computer use habits. Computing postures were collected using the Rapid Upper Limb Assessment, Computer Workstation Checklist, and goniometric measurements. It is hypothesized that computing postures will not change over each of the three observation periods. It is also hypothesized that there is no difference in posture characterization between the two posture survey instruments, RULA and the Computer Workstation Checklist. Computer use duration, frequency, and intensity were captured using the Odometer software, baseline survey, and palm pilot. Baseline information will be used to characterize computer use duration, frequency, and intensity as that occurring during the beginning of a semester, whereas the software and palm pilot will reveal changes in computer duration,

frequency, and intensity that occur as the semester progresses. It is hypothesized that computer use duration, frequency, and intensity will change as the semester progresses. Upper extremity musculoskeletal symptoms were measured by the baseline survey and on the palm pilots throughout the semester. The baseline survey is expected to reveal symptoms prevalence at the beginning of the semester whereas the palm pilot will measure changes in symptoms as the semester progresses. It is hypothesized that upper extremity musculoskeletal symptoms will become more prevalent as the semester progresses. In determining which methods of exposure characterization best describe the experience of upper extremity musculoskeletal symptoms changes throughout the semester, symptoms changes will be modeled on each of the exposure variables according to method used. REFERENCES Amick BC, Robertson MM, Tullar J, Fossel AH, Coley C, et al. (2003) Health risks associated with college student computing. Working Paper #228. Institute for Work and Health, Toronto, Canada. Bureau of Labor Statistics. Lost-worktime injuries and illnesses: characteristics and resulting days away from work, 2001a. Table C. Available at: Accessed July 2003. Bureau of Labor Statistics. 2001b. Table 11. Available at: Accessed July 2003. Chemor-Ruiz A, Barrero L, Becker T, Johnson P, Dennerlein J. Distribution of keyboard and mouse use across different computer tasks. Proceedings of the 15th Triennial Congress of the International Ergonomics Association (IEA 2003), Seoul, South Korea 2003. Consolvo, S., Walker, M., "Using the Experience Sampling Method to Evaluate Ubicomp Applications," IEEE Pervasive Computing Mobile and Ubiquitous Systems: The Human Experience, Vol. 2, No. 2 (Apr-Jun 2003), pp. 24-31. Cortes MC, Hollis C, Amick BC, Katz JN. An invisible disability: qualitative research on upper extremity


disorders in a university community. Work 2002; 18:315-321. Dennerlein JT, Chemor-Ruiz A, Johnson P, Sommerich C. A proposed taxonomy for describing computer input device usage. Proceedings of the 15th Triennial Congress of the International Ergonomics Association (IEA 2003), Seoul, South Korea 2003

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Gerald DE and Hussar WJ. 2002, Projections of Education Statistics to 2012, US Department of Education, National Center for Education Statistics, Washington, DC.

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Jones S. The Internet Goes to College: How college students are living in the future with todays technology. Pew Internet & American Life Project. September 15, 2002. Katz JN, Amick BC, Carroll BB, Hollis C, Fossel AH, Coley CM. Prevalence of Upper Extremity Musculoskeletal Disorders in College Students. American Journal of Medicine 2000;109(7):586-8. Lueder R. A proposed RULA for computer users. Proceedings of the Ergonomics Summer Workshop, UC Berkely Center for Occupational & Environmental Health Continuing Education Program. 1996. San Francisco. National Institute of Occupational Safety and Health National Occupational Research Agenda. Musculoskeletal Disorders of the Upper Extremities. Available at: Accessed July 2003. National Research Council and the Institute of Medicine (2001) Musculoskeletal Disorders and the Workplace: Low Back and Upper Extremities. Panel on Musculoskeletal Disorders and the Workplace. Commission on Behavioral and Social