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

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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.

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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).

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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.

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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)

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