Friday, September 18, 2009

Back and Neck Pain is More serious than HIV

Urban Neck Syndrome; New killer Disease of Spine

Dr S Bakhtiar Choudhary was awarded this year with “SIR Ardeshir Dalal Memorial Award the highest award in occupational health in India” by Indian Association of Occupational Health for the discovery of a New Urban disease of spine which leads to severe pain to serious complications. This page gives you some idea about the study


In near future, Neck and Back pain will push all other serious diseases aside; because treatment of these painful syndromes demand lot of bed rest and people do not have time. Neck pain is one of the commonest conditions treated by primary physician to tertiary hospitals. Numbers of Occupations produce mild neck pain to disabling conditions which need surgical treatment. They often end with either surgery or dumping grounds of pain killers. We have collected the data on neck pain and back pain among urban population past 18 years in three different centres mostly of urban origin.


We have studied and treated 13,590 persons. Many were students (12-16y), house wives (26-45y), working women (25-45y), mining executives (34-42y), mining labour (33-50y), computer professionals (24-36 y), dentists (26-36y), journalists (26-38y) and drivers (21-40y). These subjects were clinically examined during direct consultations, during workshops and routine examination. Their workplaces were screened for ergonomic errors; Posture and movements of neck were studied. X-ray examination and MRI studies were conducted. The life-style factors such as exercise habits, sleep, body composition and performance related to work were also recorded. Bed-rest, physical therapy, posture and ergonomic correction, conditioning exercises were advised to these subjects.


Our study revealed 14% of students, 26% of house wives, 32% of working women, 11% of mining executives, 16% of mining labour, 34% of IT professionals, 26% of dentists, 23% of drivers, reported with severe neck pain. Small numbers had restricted movements, vertigo and radiculopathy (radiating pain to hands and chest). Investigations revealed SSS (Straight Spine Syndrome), changes in cervical discs and early cervical spondylosis.

Life style:

These people who had these symptoms had sedentary life (91%), Obesity (26%), less sleep (51%), contributing to their existing problems. Many affected professionals were good performers (62%).

What is the cause of This New urban neck Syndrome?

This syndrome results from many complex factors acting on the spine. The alignment, strength and functional ability of the spine get’s compromised. In this busy world we are unaware of our posture and ergonomics during Activities of Daily Living and professional pursuits. Some of the causes shown here are like

· Drinking water with bottle by extending neck many times a day.

· Watching television from bed with many pillows behind the neck

· Excess computer use without right ergonomics

· Excess TV viewing from wrong angles and wrong heights

· Excess driving

· Faulty ergonomics at workplace

· No exercise habits

· Wrong exercises

· No breakfast

· Habitual faulty postures during reading and domestic jobs

This is a very common problem in every third person; based on symptoms, recovery and complications, urban neck syndrome are classified in III stages. During I and II stages we can easily reverse the process of damage but III stage is always associated with may serious problems.

Wrong Advice:

All neck pains are treated with

· Label as spondylosis even in young people

· Removal of pillow

· Expensive investigations

· Wearing of cervical collar wrongly

· Pain killer medicine over use

· Yoga exercises practised wrongly

Unfortunately all these lead to no relief but sometimes worsen the situation.


Neck problems are noticed among many occupations which lead to Pain, absenteeism, poor motivation and emerged as new disease of urban life. People are ignorant about domestic and workplace ergonomics. I have made categories depending on their degree of risk. Good neck care, regular exercise and nutritional habits, early treatment may prevent this occupational epidemic. Comprehensive support can prevent expensive and difficult surgeries. However in very serious and long standing conditions we do need surgery after a good conservative trial. Physicians should pay more attention for serious management and education to people.

Note: dear friends please let me know if you find such problems in anybody; same thing can occur in the lower back also. Do not hesitate to contact me

Hyderabad Spine clinics

Tel: +91-9849136940

Sunday, October 21, 2007

Dear reader,
Please read this study of last one decade of 15000 IT professionalsin India by Prof. Dr. S Bakhtiar Choudhary a renowned Sports medicine Specialist from Hyderabad, INDIA.

Occupational Health problems related to
Computer users (Information Technology: IT);
A review of last decade


Prof. Maj. S. Bakhtiar Choudhary

Address: Hyderabad Spine Clinics
House no: 6-3-1089/1A, Gulmohar marg,
Opposite Villa Marie College
Rajbhavan Road-Hyderabad-500082
Tel: 09849136940,


Background: The computerisation of the workplace has increased tremendously last decade. This IT revolution has not only created more jobs but also led to increased incidence of RSI, CTD, and other MSD’s (Musculo skeletal disorders).
Methods: An investigation of various factors responsible for developing these problems and reviewing current research on emerging newer diseases was carried out to develop a strategic model.
Results: Review of studies on Indian IT professionals has revealed the prevalence of Straight spine syndrome, Sacroiliac joint pain and Early Isolated Diastolic Hypertension in addition to RSI & MSD’s. The attitude and lifestyle factors are important in modifying the intensity of the problem. Lack of clear diagnostic criteria delays timely management.
Conclusion: It is evident that these occupation-related painful problems likely to increase further unless, serious long term preventive approach is followed. An integrated approach aimed at improving the working posture, reduction in static load and positive interventions to reduce the influence of job-stress resulting in poor work performance.

Key words: RSI, Computers, Occupational health, Posture, job-stress

1. Introduction

Revolution in information technology (IT) is happening world wide with great pace. About 30% of the work force in developed and much more in the developing countries report with work related problems. Each year, 8% of working Dutch citizens take time off from work due to RSI (Repetitive Strain Injuries) symptoms 1. According to Canadian report 10% of Canadian young adults report with RSI 2. Health problems in computer users appear to be interrelated, and they are musculoskeletal ‘or’ musculo-tendinous, visual and stress related. India is becoming a hub of IT industry with large number of young people in it. One of the early studies on 200 subjects 3 revealed 40% - 50% of them suffer from fatigue, more than 40% MSD’s predominantly from neck & upper limb. Recent studies have also revealed peculiar incidence of Sacroiliac joint pain and systemic disease like early diastolic hypertension among Indian professionals. We have been following IT professionals (n = 14,300) past 7 years on occupational health status and it is felt that Indians (probably Asians) perceive differently to these work-related problems. I have tried to discuss these problems with an Indian perspective under the following headings.

1.1 RSI and related problems
These are attributable to (a) static loading or isometric contraction of muscles of neck, shoulder and arm to maintain position of function (b) dynamic loading ‘or’ repetitive movement of forearm and fingers to execute a task (c) force used to perform a task 4, 5. Great historians like Leonardo da Vinci, Ramazzini and many occupations like tea pluckers, battery wrapping jobs and telegraphers complained of RSI symptoms. WHO classified RSI under the group of ICD-9 (International Classification of Diseases)6. However Indian IT professionals don’t seem to suffer much from RSI of wrist & hand, on the contrary, CTS incidence is quiet high in the west.

1.2 Neck & Back

Relationship between the performance of work and the occurrence of neck pain is evident 7. The normal curvatures of the cervical and lumbar spines are essential for healthy function. During normal postural alignment, he external auditory meatus lines up directly over the acromioclavicaular joint. The average relative rotation angle found for C2-C3 was 7.59 degrees and was explained as being larger vertebrae and would naturally make up a larger portion of a circular lordosis in the cervical spine. Maintenance of cervical lordosis of 31°to 40° could be a clinical goal as a functional treatment 8. Neutral position, which is repeatable, is also known as self balance position of spine is less stressful 9. Wrong acquired postures in addition to habitual postures of professionals are responsible for neck pain. Forward head posture (FHP) which is observed in many Indian IT professionals found to be responsible for developing painful Straight Spine Syndrome 10 . Sitting for long hours disturbs the spinal mobility and increases the risk of FHP. FHP is a clinical entity and has been identified as an important factor for variety musculoskeletal syndromes 11. The lordotic cervical and lumbar spine are the basis of the spine’s ability to resist axial stressors; thus any reduction in cervical curve can results in a 50% reduction in the strength of the spine. Indian IT professionals face major painful situations during job as a result of FHP.

1.3 Ergonomics and Back pain

Indian professionals vary tremendously in their anthropometric data; hence it is difficult to achieve sound ergonomics in workplace. Backache in young subjects is frequently due to lack of back support, tall & short subjects do not understand the ergonomic adjustments needed. In the absence of footrest for short people (stature < 160cm) always suffered low back pain during our observations12. FHP places greater stress on thoracic and lumbo cervical spine creating paraspinal muscular spasm

1.4 Visual Impairment

Work related visual complaints (asthenopia) in IT professionals were reported all over the world. Commonest being red-eye syndrome / dry-eye syndrome in young professionals and they usually overcome. VDT (Visual display terminals) cause disturbances in accommodation, more with small sized font but better than conventional hard copy work 13. Heavy computer users predominantly young population were shown to be significantly associated with frequency doubling technology (FDT-VFA) visual field abnormalities and computer users with myopia pose increased risk of VFA, possibly related to glaucoma 14. The luminance can greatly influence the visual fatigue of VDT users.
A general tendency towards visual complaints for LCD, TFT (liquid crystal display with thin film transistor) than for CRT (cathode ray tube) and surrounding luminance decreased the accommodation amplitude 15. Visual symptoms can be grouped as
a) Simple eye strain which recovers with little awareness and care
b) Asthenopia; severe visual fatigue resulting from ocular muscles and the neck posture.
c) Accommodation disturbances and with pre-existing myopia if present, can increase the risk of glaucoma.
Subjects complaining of eyestrain varied from one organisation to other. In one organisation 38% complained, but in another 21.2% and depends up on many factors.

1.5 Stress related to work

IT professionals face continuous stress due to job dead lines supplemented by environmental & domestic stressors. Stress results from an imbalance between resources and demands including self imposed ones. During stressful situations, concentration, awareness on posture, dexterity during work and many neuro-physiological changes occur in the body leading to drop in work performance. Many young subjects lack positive lifestyle factors leading to early obesity (41%), poor physical fitness (66%), and poor dietary habits increase the risk of stress related problems in them 16. Stress induced shoulder and neck pain is not necessarily associated with elevated trapezius muscle activity in one study 17. Computer work related stress is influenced by complex factors such as the purpose of computer use, the environment, the equipment and the continuous duration of users 18.

1.6 Early Hypertension
Early hypertension in young individuals is not uncommon in India. Recent study has indicated that young IT professionals face early hypertension; Sixteen percent had moderately raised isolated diastolic rise in blood pressure, 48% had HDL <>240 mg/dl, 80% had LDL > 180mg/dl. About 26% of them were overweight and 14% had grade-I obesity with abnormal waist to hip ratios. Eighty percent do not exercise, 38% skip breakfast and 17% consume > 5cups of coffee / day 19. This unique rise in isolated diastolic blood pressure indicates clearly early cardiovascular reactivity a serious risk due to stress and lifestyle factors.
1.7 Sacroiliac joint pain
Backache occurs as a result of many factors; but recently many senior professionals suffered from back pain emerging from sacroiliac joint. About 165 (11% of 1500 employees) had SIJ pain. Ninety percent of them had job experience of more than 7 years20.

2. Discussion
Apart from IT occupations, even in private life, an increasingly long duration of computer use is observed among every generation. Current review of studies and our experience of working with IT professionals and other occupations involving prolonged computer use since 1997 till date have revealed many observations. RSI and related MDS’s are highly prevalent in Indian computer professionals and comparable with west. Pain, discomfort and partial dysfunction reported when they are engaged in repetitive and forceful jobs ‘or’ when they assume prolonged static ‘or’ awkward postures. According to Browne et al, the important aspect of RSI depends upon the degree of severity; stage Three of RSI where weakness, pain and fatigue even at rest results in serious loss of work performance. The two important risk factors are
Physical risk factors: substantial amount of working time at a computer in a poor arrangement i.e. lack of footrest, unsupported back, incorrect chair, wrongly arranged desktop heights with awkward posture can increase risk of developing RSI. Workplace organisational risk factors: working without breaks, tight deadlines, unclear job roles and poor workplace social support increase the risk for them. However carpal tunnel syndrome (CTS) and other wrist & hand related RSI do not occur frequently in Asian IT professionals when compared to west. Neck is a major crush for Indian professional. There is essentially minimal or no muscular activity needed to support the head; a forward head posture incurs from increased dorsal spinal kyphosis places this head, ahead of the centre of the gravity increasing the static loading of the neck as well as shoulder muscles. Abnormal stress occurs in the facets, disc and supporting tissues when normal motion of the spine is impaired. Spinal biomechanical stability requires an optimal lordotic structure.
Potential stress to the anterior longitudinal ligament in upper cervical spine and posterior longitudinal ligament in lower cervical spine develops to forward head posture thus decrease in the relative rotation angle in the upper cervical spine. Many painful conditions result during FHP i.e. Muscle tension and fatigue, narrowing of intervertebral foramina in upper cervical spine and thus leading to impingement in blood vessels and nerve roots; Tight levators will lead to impingement in cervical plexus, tight upper trapezius will cause impingement in greater occipital nerve and hence cause head ache, TM joint pain from faulty head, neck, and mandible alignment and facial muscle tension. In a study of 277 lateral cervical x-rays, patients have shown lordosis of 20° or less were more likely to have carcinogenic symptoms significantly (p <0.0001)21.>7 years of experience); this has led to serious back pain due to sacroilitis as a cause of persistent pain observed in our studies. Long sitting hours had high correlation with SIJ pain. Use of computers might influence physical and mental health problems such as blood pressure and mood disturbance 24, 25.

We have also observed that raised early isolated diastolic blood pressure is due to many factors and the hypothesis based on poor physiological adjustment in sedentary IT professionals. The study by Huang GD & Fenerstein on 248 marines clearly suggest that job redesign and interventions which address a workers work style during increased work demands may help reduce the likelihood of musculoskeletal symptoms and \ or their intensity 26. Deverence JJ and colleagues have suggested the importance of focusing on psychosocial work factors along with physical work factors when undertaking ergonomic intervention strategies 27. Another study investigated 721 workers to indicate that psychological factors at work may predict musculoskeletal pain 28.

3. Conclusion
Emerging research suggests that IT industry has many occupational hazards, which can be prevented effectively. Despite development in office-automation with modern gadgets like voice software, flicker, radiation, glare free monitors, air conditioned environments, man-machine-environment relationship need to be balanced. Many modern equipment do provide adequate feedback which is outside the range of conditions in which human perceptual system evolved. In the last decade, common man faced cardiovascular diseases, diabetes and cancer; but the next decade we have to face the challenges of IT related MSD’s and stress related medical problems. In Indian context, problems have been perceived differently. Individuals & organisations should develop Occupational wellness programmes with a multi-disciplinary approach and more controlled studies are needed by occupational physicians.

4. Recommendations

As number of young aspirants perceiving IT job should develop complete awareness of problems related to job, competitive nature of IT industry may leave no time to regulate exercise and other life style factors. Colleges should incorporate ergonomic awareness, postural awareness and the most important regular physical exercise and stress coping skills in the education curriculum. Organisation staffed with computer users should encourage frequent breaks during work and compulsory vacations in order to improve their work performance. Effective time management will help the professionals to develop these healthy occupational habits. Special attention should be paid towards neck pain and related problems and emerging early hypertension. Occupational physicians should initiate more close controlled studies as Indian Professionals face peculiar problems and preventive approach is the best for IT related medical problems.

5. References

1. Bongers PM, de Vet HC and Blatter BM. Repetitive Strain Injury (RSI): Occurrence, aetiology, therapy and prevention. Ned Tijdschr Genceskd 2002 (Oct) 19; 146(42); 1969-70.

2. Statistics Canada. Canadian Community Health Survey. Health reports. August 12, 2003; 14 (4)

3. Choudhary S. Bakhtiar, Suneetha S: Can we prevent Occupational stress in Computer Professional? Ind J Occu Env Med 2000 March Vol 4(1);4-6.

4. Browne CD, Nolan BM and Faithfull DK: Occupational repetition strain injuries. Med J Aust 1984; March 17: 329-332.

5. Ferguson D: The ‘New’ industrial epidemic. Med J Aust 1984March; 17: 318-319.

6. NOHSC (National Occupational Health and Safety Commission): RSI Committee Report and Model Code of Practice, Canberra: Australian Government Publishing Service, 1986; 7.

7. Buckle PW, Devereux JJ. The nature of work-related neck and upper limb musculoskeletal disorders. Appl Ergon 2002 May; 33 (3): 207-17.

8. Harrison DD, Janik TJ, Troyanivich SJ, Holland B. Comparisons of lordotic cervical spine curvatures to theoretical model of the static sagittal cervical spine. Spine 1996; 21:667-75.

9. Saudham A. Repeatability of head positive recordings from lateral cephalometric radiographs British J Orthodontics 1988;15:157- 62.

10. Choudhary S. Bakhtiar, Suneetha S. Deb PS: Forward head posture is
the cause of Straight Spine Syndrome in many professionals, Ind J Ocu
Env Med 2000 Sept; Vol 4,(3); 122-124.

11. Memell JM. The Musculoskeletal system:Differential Diagnosis from symptoms and physical signs. Gaithersburg, Maryland: Aspen Publishers, Inc, 1992, PP 126-133.

12. Maj. Choudhary S. Bakhtiar, Sapur Suneetha, Rao Vijay. Conservative approaches benefit occupation-related backaches in milk-vendors and goldsmiths. Ind J Ocu Env Med 2000 Sept Vol 6 (4); 186-188.

13. Kurimoto. S, Iwasaki T, Nomura T, Noro K, Yamamoto S. Influence of VDT work on eye accommodation. J UOEH 1983March 1; 5(1):101-10

14. Masayuki Tatemichi and Tadasshi Nakano et al. Possible association between heavy computer users and glaucomatous visual field abnormalities. A cross sectional study in Japanese workers. Journal of epidem and com health 2004; 58:1021-1027.

15. Wolska A, Swituha M, Luminance of the surround and visual fatigue of VDT operators. Int J Occup Saf Ergon 1999; 5(4): 553-81.

16. Bakhtiar Choudhary S, Vijaya Rao and Suneetha S Attitude Alters the Risk for Development of RSI in Software professionals. Ind J Ocu Env Med Vol 7, (1) 32-33.

17. Holte KA, Westgaard RH. Daytime trapezius muscle activity and shoulder-neck pain of service workers with work stress and low biomechanical exposure. Am J Ind Med 2002 May; 41(5): 393-405.

18. Sheedy JE. Vision problems at video display terminals; a survey of optometrists. J Am optom Assoc 1992; 63:687-92

19. Bakhtiar Choudhary S, Vijaya Rao and Adithya Shetty U. Early Hypertension in IT Professionals; Seniors Cardiovascular risk. Unpublished data. 2006.

20. Bakhtiar Choudhary S et al. Sacroiliac joint pain, a common cause of backache in experiences IT professionals. Unpublished data. 2007.

21. Jeb McAvinarey, Dan Schulz, Richard Bock, Deed E, Harrison DC and Burt Holland. Determining the Relationship Between Cervical Lordosis and Neck Complaints. J Manipulative Physiol Ther 2005 Mar; 28(3).

22. Misawa T, Shigeta S, Nojima S. Efeects of video games on visual function in children. Nippon Eiselgaku Zasshi 1991 Feb;45(6):1029-34.

23. Collins C, O’Meara D and Scott AB. Muscle strain during unrestrained human eye movements. Journal of Physiology. London 1975;245:351- 369

24. Tanaka T, Tamamoto S, Naro K, et al. The effects of VDT work on the regulation of hemodynamics compared with aging. Ergonomics 1989; 32:1595-605.

25. Smith MJ, Conway FT, Karsh BT. Occupational stress in human computer interaction. Ind Health 1999; 37 ;157-73.

26. Huang GD and Fenerstein M .Identifying work organisation targets for a work related musculoskeletal symptoms prevention programme. j occup Rehabilitation 2004 Mar;14(1) ; 13-30.

27. Deverux JJ , Viachonikolis IG, and Buckle PW. Epidemiological study to investigate potential interaction between physical and psychological factors at work that may increase the risk of symptoms of musculoskeletal disorder of the neck and upper limb. Occup Environ Med 2002 Apr;59 (m) ; 269-77.

28. Torp S,Riise Tand MoenBE. The impact of Psychological work factors on musculoskeletal pain; a prospective study. J Occup Environ Med 2001 Feb;43 (2):120-6.

(This paper was presented for Dr CKR Oration lecture in Chennai on 3 Feb 2007)