AN EDUCATION BASED ERGONOMIC INTERVENTION PROGRAMME FOR GAUTENG CALL CENTRE WORKERS WITH UPPER EXTREMITY REPETITIVE STRAIN INJURIES. Sancha Eliot Johannesburg 2010 DECLARATION I SANCHA ELIOT declare that this research is my own work. It is being submitted for the Degree of Master of Science in Occupational Therapy in the University of the Witwatersrand, Johannesburg. It has not been submitted before for any degree or examination at this or any other university. ??????????????????? [Signature of candidate] ???????day of??????.. [month], 20 ACKNOWLEDGMENTS I would like to acknowledge the assistance of my supervisor: Denise Franzsen. Your help, guidance and continuous support has been invaluable. To my family, a big thank you for your patience and support. ABSTRACT Ergonomic interventions, addressing work and lifestyle factors, seem more effective in reducing computer related upper limb repetitive strain injury (RSI).This study considered the efficacy of such a programme on the resolution of RSI symptoms. A cross sectional survey, of 325 computer workers in a medical aid company call centres, in Gauteng, South Africa was used to establish a point prevalence of 30.23% for RSI symptoms, which correlates with those found elsewhere. An occupational therapy ergonomic intervention was then designed and piloted for efficacy. A randomised control trial conducted on 37 participants with RSI used the programme and computer generated ?Break Software?. The six week intervention included the assessment of: three physical outcome measures and lifestyle factors for, the experimental and control groups. Results indicated positive effects on pain, grip strength, and lifestyle factors including feelings of inefficiency, pressure at the end of the day, depression and work capacity, but little extrapolation of ergonomic knowledge to the workplace. Table of Contents DECLARATION .................................................................................................. 2 ACKNOWLEDGMENTS ..................................................................................... 3 ABSTRACT ......................................................................................................... 4 TABLE OF CONTENTS ...................................................................................... 5 LIST OF TABLES ................................................................................................ 9 LIST OF FIGURES ........................................................................................... 10 OPERATIONAL DEFINITIONS ......................................................................... 11 ABBREVIATIONS ............................................................................................. 13 CHAPTER 1 ............................................................ Error! Bookmark not defined. INTRODUCTION ..................................................... Error! Bookmark not defined. 1.1 STATEMENT OF THE PROBLEM ................. Error! Bookmark not defined. 1.2 PURPOSE OF THE STUDY .......................... Error! Bookmark not defined. 1.3 RESEARCH QUESTION ............................... Error! Bookmark not defined. 1.4 RESEARCH OBJECTIVES ............................ Error! Bookmark not defined. 1.5 NULL HYPOTHESIS ...................................... Error! Bookmark not defined. 1.7 JUSTIFICATION FOR THE STUDY .............. Error! Bookmark not defined. CHAPTER 2 ............................................................ Error! Bookmark not defined. LITERATURE REVIEW ........................................... Error! Bookmark not defined. 2.1 REPETITIVE STRAIN INJURY (RSI) ............. Error! Bookmark not defined. 2.1.1 Characteristics of Repetitive Strain Injury Error! Bookmark not defined. 2.1.1.1 Classification of Repetitive strain injuries according to Specific Body tissues ........................................................... Error! Bookmark not defined. 2.2 CAUSE AND DIAGNOSIS OF REPETITIVE STRAIN INJURIES ......... Error! Bookmark not defined. 2.2.1 Difficulty in reporting Repetitive Strain Injury ......... Error! Bookmark not defined. 2.2.2 The reporting of Repetitive Strain Injury in South AfricaError! Bookmark not defined. 2.2.3 Cost to individual and company ............... Error! Bookmark not defined. 2.3 INTERVENTION FOR REPETITIVE STRAIN INJURY Error! Bookmark not defined. 2.3.1 Ergonomic programmes .......................... Error! Bookmark not defined. 2.3.2 Education of Workers about ergonomics . Error! Bookmark not defined. 2.3.3 Warning/Break software programmes ..... Error! Bookmark not defined. 2.3.4 Workstyle/ Lifestyle programmes ............ Error! Bookmark not defined. 2.3.5 Non compliance with the Intervention ProgrammesError! Bookmark not defined. 2.3.6 Evaluation and limitations of the Intervention Programmes ............ Error! Bookmark not defined. 2.4 SUMMARY ..................................................... Error! Bookmark not defined. CHAPTER 3 ............................................................ Error! Bookmark not defined. METHODOLOGY .................................................... Error! Bookmark not defined. Screening Phase .............................................. Error! Bookmark not defined. 3.1 PHASE 1 ........................................................ Error! Bookmark not defined. 3.1.1.Screening Phase ..................................... Error! Bookmark not defined. 3.1.2 Research Design ..................................... Error! Bookmark not defined. 3.1.3 Participant selection ................................ Error! Bookmark not defined. 3.1.3.1 Call centres ....................................... Error! Bookmark not defined. 3.1.4 Measurement tool .................................... Error! Bookmark not defined. 3.1.5 Ethical Considerations ............................. Error! Bookmark not defined. 3.1.6 Research Procedure................................ Error! Bookmark not defined. 3.1.6.1 Screening procedure ......................... Error! Bookmark not defined. 3.1.7 Data Analysis .......................................... Error! Bookmark not defined. 3.2 PHASE 2 ........................................................ Error! Bookmark not defined. Intervention Programme development ............. Error! Bookmark not defined. 3.2.1 Booklet Development .............................. Error! Bookmark not defined. 3.2.1.1 Pilot study 1 Content validity of interactive education based ergonomic programme booklet with experts ................... Error! Bookmark not defined. 3.2.1.2 Pilot study 2. Content validity of interactive education based ergonomic programme with similar participantsError! Bookmark not defined. 2.3.2 Computer based ?Break Software? .......... Error! Bookmark not defined. PHASE 3 .............................................................. Error! Bookmark not defined. 3.3 Intervention Phase ..................................... Error! Bookmark not defined. 3.3.1 Research design ..................................... Error! Bookmark not defined. 3.3.1.1. Selection of research participants .... Error! Bookmark not defined. 3.3.1.2 Sample size ...................................... Error! Bookmark not defined. 3.3.2 Ethical considerations: ............................. Error! Bookmark not defined. 3.3.3 Measurement techniques ........................ Error! Bookmark not defined. 3.3.3.1 Pain ................................................... Error! Bookmark not defined. 3.3.3.2 Wrist active range of motion (AROM)Error! Bookmark not defined. 3.3.3.3 2 Pinch strength ................................ Error! Bookmark not defined. 3.3.3.4 Grip strength ..................................... Error! Bookmark not defined. 3.3.3.5 Working conditions and health at call centres questionnaire ... Error! Bookmark not defined. 3.3.3.6 Checklist ........................................... Error! Bookmark not defined. 3.3.4. Research procedure ............................... Error! Bookmark not defined. 3.3.4.1 Assessment procedure ..................... Error! Bookmark not defined. 3.3.4.2 Implementation of the Intervention .... Error! Bookmark not defined. 3.3.6 Data Analysis .......................................... Error! Bookmark not defined. CHAPTER 4 ............................................................ Error! Bookmark not defined. RESULTS ................................................................ Error! Bookmark not defined. 4.1 RESULTS PHASE 1 ...................................... Error! Bookmark not defined. 4.2 RESULTS OF PHASE 3 ................................ Error! Bookmark not defined. 4.2.1 Demographics ...................................... Error! Bookmark not defined. 4.2.2 Physical Outcomes Measurements ......... Error! Bookmark not defined. 4.2.2.1 Range of Motion of the Wrist ............ Error! Bookmark not defined. Wrist Flexion ................................................. Error! Bookmark not defined. Wrist Extension ............................................. Error! Bookmark not defined. Radial Deviation ............................................ Error! Bookmark not defined. Ulnar Deviation ............................................. Error! Bookmark not defined. 4.4.2.2 Pinch and Grip Strength .................... Error! Bookmark not defined. Pinch Strength .............................................. Error! Bookmark not defined. Grip Strength ................................................ Error! Bookmark not defined. 4.2.2.3 Pain ................................................... Error! Bookmark not defined. Visual Analogue Scale ? Pain on ResistanceError! Bookmark not defined. Visual Analogue Scale-Pain on Movement ... Error! Bookmark not defined. Visual Analogue Scale- Pain at Rest ............ Error! Bookmark not defined. Visual Analogue Scale - Worst Pain ............. Error! Bookmark not defined. 4.2.3 Results for ?Working conditions and health at call centres? Questionnaire ......................................................................... Error! Bookmark not defined. 4.2.3.1 Ergonomics Training ......................... Error! Bookmark not defined. Question 37 .................................................. Error! Bookmark not defined. 4.2.3.2 Work Space Design .......................... Error! Bookmark not defined. Question 38 .................................................. Error! Bookmark not defined. 4.2.3.3 Effect of Work on Stress and Energy Levels ... Error! Bookmark not defined. Question 48 .................................................. Error! Bookmark not defined. Question 59 .................................................. Error! Bookmark not defined. Question 60 .................................................. Error! Bookmark not defined. This question deals with the measures during the past month to reduce RSI symptoms/problems. Answers are either ?No?=1 or ?Yes?=2. This question was only answered if RSI symptoms were present thus participants who had no problems did not answer these questions on both occasions. ........ Error! Bookmark not defined. Question 61 .................................................. Error! Bookmark not defined. Question 64 .................................................. Error! Bookmark not defined. 4.3 Summary .................................................... Error! Bookmark not defined. CHAPTER 5 ............................................................ Error! Bookmark not defined. DISCUSSION .......................................................... Error! Bookmark not defined. 5.1 Effect of the Intervention Programme on Symptoms of Repetitive Strain Injury ............................................................................. Error! Bookmark not defined. 5.1.1 Physical outcome measures .................... Error! Bookmark not defined. 5.1.1.a ROM ................................................. Error! Bookmark not defined. 5.1.1.b Pinch and Grip strength .................... Error! Bookmark not defined. 5.1.1.c Pain ................................................... Error! Bookmark not defined. 5.1.1.d Ergonomic Training ........................... Error! Bookmark not defined. 5.1.1.e Computer Software ........................... Error! Bookmark not defined. 5.2 Effect of the Intervention Programme on Attitude of Participants .......... Error! Bookmark not defined. 5.3 Evaluation of the Effectiveness of the Intervention ...... Error! Bookmark not defined. 5.4 Summary ........................................................ Error! Bookmark not defined. CHAPTER 6 ............................................................ Error! Bookmark not defined. CONCLUSION ......................................................... Error! Bookmark not defined. 6.1 Recommendations ......................................... Error! Bookmark not defined. REFERENCES ........................................................ Error! Bookmark not defined. APPENDICES ......................................................... Error! Bookmark not defined. APPENDIX A - Questionnaire, With Permission From The National Institute For Working Life. ........................................................ Error! Bookmark not defined. APPENDIX B - Physical Outcomes Assessment: Range of Movement. ..... Error! Bookmark not defined. APPENDIX C - Physical Outcomes Measurement: Pinch Strength ............ Error! Bookmark not defined. APPENDIX D -Physical Outcomes Measurement: Grip StrengthError! Bookmark not defined. APPENDIX E -Physical Outcomes Measurement: Pain ..... Error! Bookmark not defined. APPENDIX F- Letter of Permission ...................... Error! Bookmark not defined. APPENDIX G- Information Sheet for Phase 1 ..... Error! Bookmark not defined. APPENDIX H - Information Sheet for Phase 2..... Error! Bookmark not defined. APPENDIX J -Intervention Booklet ...................... Error! Bookmark not defined. APPENDIX K- Screening Questionnaire (abbreviated version of final questionnaire ............................................................................. Error! Bookmark not defined. APPENDIX L: Data Collection Sheets ................. Error! Bookmark not defined. APPENDIX M: Comment form for Phase 2. ......... Error! Bookmark not defined. List of Tables Table 4.1 Loss to follow up of participants over timeError! Bookmark not defined. Table 4.2 Demographics of the experimental and control groupError! Bookmark not defined. Table 4.3 Work demographics of the experimental and control group at Baseline? ................................................................................ Error! Bookmark not defined. Table 4.4 Results for range of motion of wrist flexion over three measurements?.. ................................................................................ Error! Bookmark not defined. Table 4.5 Results for range of motion of wrist extension over three measurements. ................................................................................ Error! Bookmark not defined. Table 4.6 Results for range of motion of wrist radial deviation over three measurements ......................................................... Error! Bookmark not defined. Table 4.7 Results for range of motion of wrist ulnar deviation over three measurements ......................................................... Error! Bookmark not defined. Table 4.8 Results for pinch strength over three measurements:Error! Bookmark not defined. Table 4.9 Results for grip strength over three measurements:Error! Bookmark not defined. Table 4.10 Results for Visual Analogue Scale ? pain on resistance over three measurements: ........................................................ Error! Bookmark not defined. Table 4.11 Results for Visual Analogue Scale ? pain on movement over three measurements: ........................................................ Error! Bookmark not defined. Table 4.12 Results for Visual Analogue Scale ? pain at rest over three measurements ......................................................... Error! Bookmark not defined. Table 4.13 Results for Visual Analogue Scale ? worst pain over three measurements: ........................................................ Error! Bookmark not defined. List of Figures Figure 4.1 Wrist flexion range of motion over three measurements for the control and experimental groups ................................................ Error! Bookmark not defined. Figure 4.2 Wrist radial deviation over three measurements for control and experimental groups ................................................ Error! Bookmark not defined. Figure 4.3 Grip strength over three measurement for control and experimental groups ..................................................................... Error! Bookmark not defined. Figure 4.4 Pain score on the Visual Analogue Scale for pain on resistance over three measurements for control and experimental groups .... Error! Bookmark not defined. Figure 4.5 Pain score on a Visual Analogue Scale for pain on movement over three measurements for control and experimental groups Error! Bookmark not defined. Figure 4.6 Pain score on a Visual Analogue Scale for pain at rest over three Error! Bookmark not defined. measurements for control and experimental groups Error! Bookmark not defined. Figure 4.7 Pain score on a Visual Analogue Scale for worst pain over three measurements for control and experimental groups Error! Bookmark not defined. Figure 4.8 Change in scores from Baseline to Time 2 for the combined groups for Question 37. ............................................................ Error! Bookmark not defined. Figure 4.9 Change in scores from Baseline to Time 2 for the experimental and control groups for Question 38f. .............................. Error! Bookmark not defined. Figure 4.10 Percentage of participants whose answers differed on Question 48e? ................................................................................ Error! Bookmark not defined. Figure 4.11 Percentage of participants whose answers differed on Question 48g... ................................................................................ Error! Bookmark not defined. Figure 4.12 Percentage of participants whose answers differed on Question 48s?. ................................................................................ Error! Bookmark not defined. Figure 4.13 Percentage of participants whose answers differed on Question 53b... ................................................................................ Error! Bookmark not defined. Figure 4.14 Change in scores from Baseline to Time 2 for the combined groups for Question 58f ............................................................ Error! Bookmark not defined. Figure 4.15 Percentage Change in scores from Baseline to Time 2 for the experimental and control groups for Question 59 .... Error! Bookmark not defined. Figure 4.16 Percentage of participants whose answers differed on Question 60k?. ................................................................................ Error! Bookmark not defined. Figure 4.17 Percentage of participants whose answers differed on Question 60l?.. .............................................................................. ..Error! Bookmark not defined. Figure 4.18 Percentage Change in scores from baseline to Time 2 for the combined groups for Question 61a .......................................... Error! Bookmark not defined. Figure 4.19 Change in scores from baseline to Time 2 for combined groups for Question 64b ........................................................... Error! Bookmark not defined. OPERATIONAL DEFINITIONS 1. Repetitive strain injury (RSI) - cumulative chronic upper extremity pain, for which no alternative diagnosis is made and which is related (but not limited to) highly repetitive movements, movements at extremes of reach, static muscle loading, awkward sustained positions and overuse (Sanders, 2004, van Tulder, Malmivaara and Koes, 2007) RSI are characteristically shown to have a slow insidious onset with initial localised pain, which becomes diffuse. (Palmer, 2003.) 2. Tenosynovitis and Tendonitis ? Inflammation of one or more tendon sheaths or one or more tendons. As the above are difficult to discern clinically without thorough examination (and have the same treatment) they were collectively termed tenosynovitis in this research. (Palmer, 2003) 3. Compression Neuropathy ? Entrapment in a specific anatomical area where nerves pass under restrictive pulleys or retinaculae. Sensory fibres are more readily and quickly affected than motor fibres. Symptoms (proximal or distal to the compression) may be vague, however may include one or more of the following: pain, numbness, weakness and tingling. (Kasch, 2002) For the purposes of this study the following characteristics of RSI were accepted: ? multifactorial causes, ? mechanical and physiological mechanisms are involved, ? a relationship to the duration and intensity of work exists, and ? work cycle and environment have an impact.(Sanders, 2004) 4. Work Related Upper Limb Disorders Type I WRULD ? These have clearly defined and localised symptomology, diagnoses and treatments. They include: carpal tunnel syndrome, lateral epicondylitis and De Quervain?s tenosynovitis Type II WRULD ? Non traumatic upper limb pain with poorly defined symptoms and causation are included in this class. They incorporate the regional pain syndromes. (Povlsen and Rose, 2008) 5. Ergonomics Ergonomics can be described as the interface between an individual, their work task/job, the work environment and the tools they utilise to perform the task at hand. It should take into account the individual (physical characteristics and capabilities), the task and the work environment. Ergonomics as used by Occupational Health practitioners involves the study of the work and the individual fit. It must include the study of the organisation?s social, economic, political and legislative environment. Work organisation i.e. psychosocial work place risk factors as well as physical work place risk factors must be considered as well as the individual. (Sanders, 2004) 6. Point Prevalence Point prevalence is not defined by a time interval and is therefore not a rate. It may be defined as the number of cases of a disease that exist in a defined population at a specified point in time. (Mann, 2003) ABBREVIATIONS CTD ? Cumulative Trauma Disorders EU ? European Union IOD - Injury On Duty MSD ? Musculoskeletal Disorders NIOSH - National Institute for Occupational Safety and Health OCD ?Occupational Cervico-brachial Disorders OOS ? Occupational Overuse Syndrome RSI ? Repetitive Strain Injury SASHT ? South African Society of Hand Therapists SLE ? Systemic Lupus Erythematous UE ? Upper Extremity UL ? Upper Limb UED - Upper Extremity Disorders ULD ? Upper Limb Disorders USA ? United States of America VAS ? Visual Analogue Scale WRULDS - Work Related Upper Limb Disorders WRMSDS - Work Related Musculoskeletal Disorders WCA ?Workman?s Compensation Act