CONFERENCE: Occupational health
Grace Szeto provides an exclusive look into her conference keynote presentation ‘Heads-down tribe—effects of smartphone use on neck pain in different age groups’.
What is the first thing you do when you wake up in the morning and the last thing before you fall asleep at night? The answer is likely to be ‘look at my phone’.
Our lives have been fundamentally reshaped by the accessibility and pervasive influence of smart technologies. Since the first iPhone launched in 2007, smart devices have become all but ubiquitous. The terms ‘heads-down tribe’ and ‘smartphone zombies’ can now be found in Wikipedia and the dictionary. The rapid development of electronic products has led to different sizes and weights of touchscreen devices, but two common practices have not changed: the device is either held in the hand or on the lap, with a static-flexed neck posture, and the device is used for long durations—two to eight, or even 10 hours per day depending on the country (Xie et al 2017). One consequence is an increasingly sedentary lifestyle and lack of exercise, which may have an overall adverse health impact.
As physiotherapists, every day we face patients with aches and pains related to the use of electronic devices. Many of those who suffer from neck pain report frequent use of mobile devices while keeping the neck in a flexed posture for long periods. The problem of static-neck-flexion posture has been studied extensively in similar contexts. For example, our research team has documented an association between flexed neck posture and increased muscle activity in people who spend long hours typing on keyboards (Szeto et al 2005) and texting on mobile phones (Xie et al 2016). This association is mainly found in those with chronic neck pain and not in the pain-free controls, therefore supporting the important role of altered motor control being a mechanism contributing to the development of chronic neck pain.
Physiotherapists are strong advocates of good spinal posture and we often advise people to correct their ‘poking chin’ posture—more formally known as the forward head posture (FHP). While using a mobile device, FHP is most common during periods of intense concentration. In these moments, mobile users unconsciously poke their chins forward, resulting in increased upper cervical spine extension and lower cervical spine flexion. Greater neck flexion angles have been demonstrated to increase the compressive loading in the cervical spine (Vasavada et al 2015), and it is associated with increased muscle activity in the cervical erector spinae and upper trapezius muscles (Szeto et al 2005, Ning et al, 2015).
Therefore, when physiotherapists treat patients with chronic neck pain (and other related problems), we should include these questions in the subjective assessment: How much time do you spend on (1) a computer or (2) a mobile device each day? In what position do you usually hold your smartphone or tablet computer?
Do you text with one or two hands on your mobile device? During the objective examination, the therapist might also ask the patient to demonstrate their usual posture when viewing and/or texting with their mobile devices. This mode of questioning can be useful in identifying the patient’s physical problems and designing appropriate intervention programs.
Additionally, recent research suggests that providing arm support and back rest during the use of mobile devices can help to improve posture and reduce muscle activity.
This is consistent with the established ergonomic guidelines for computer use, that providing forearm support during keyboard work can help to reduce the workload of the neck and shoulder muscles, especially the upper trapezius. These findings are further supported by research we conducted using biofeedback to enhance relaxation of the upper trapezius (Ma et al 2011), with better reduction of pain and improved muscle activation after six weeks of biofeedback, compared to active exercise and electrotherapy treatment.
With the increasing influence of mobile technology in our daily lives, physiotherapists play an essential role in educating the general public on the appropriate use of electronic devices. We cannot stop people from using smart devices, but we can advise them to take care when using these devices in order to encourage sustainable, healthy behaviours and avoid adverse health effects.
Consider offering the following essential, take-home points to your patients:
- avoid prolonged static posture—vary your posture and position of your smart device at regular intervals
- take at least a five minute break for every hour of use of electronic devices; this includes all different forms of computers and mobile devices. Take your eyes off the screen, stand up and walk around
- vary the way you hold the phone or the way you text. Alternate between using the thumbs and the fingers
- tilt up the screen to avoid bending the neck down to more than 60 degrees
- support your arms when using mobile devices to relieve the load on your shoulder muscles
- perform stretching exercises for your neck and upper limb muscles
- maintain your fitness by performing regular exercise at moderate-to-vigorous intensity.
In short, by providing suitable advice to our clients, physiotherapists can enhance the pleasure and reduce the pain associated with using electronic devices.
Ma C, Szeto GPY, Wu S, Lin C, Li L, Yan T. 2011. Comparing the effectiveness of biofeedback versus active exercise and passive treatment on work-related musculoskeletal disorders: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation 92 (June), 849-858.
Ning X, Huang Y, Hu B, Nimbarte AD. 2015. Neck kinematics and muscle activity during mobile device operations. International Journal of Industrial Ergonomics 48, 10–15.
Szeto GPY, Straker LM, O’Sullivan PB. 2005. A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work – 1. Neck and shoulder muscle recruitment patterns. Manual Therapy 10, 270-280.
Xie Y, Szeto GPY, Dai J, Madeleine P. 2016. A Comparison of Muscle Activity in Using Touchscreen Smartphone among Young People with and without Chronic Neck-Shoulder Pain. Ergonomics 59(1), 61-72.
Xie Y, Szeto GPY, Dai J. 2017. Prevalence and risk factors associated with musculoskeletal complaints among users of mobile handheld devices: a systematic review. Applied Ergonomics, 59, 132-142.
Vasavada AN, Nevins DD, Monda SM, Hughes E, Lin DC. 2015. Gravitational demand on the neck musculature during tablet computer use. Ergonomics 58, 990–1004.
Professor Grace Szeto is a professor and physiotherapy program leader at the School of Medical and Health Sciences, Tung Wah College, Hong Kong.
Q&A: Jodi Oakman answers a few questions about her presentation on musculoskeletal disorders.
What projects are you currently working on to improve people’s occupational health?
My projects are focused on the influence of the work environment on people’s health and wellbeing. My key interest is in investigating how we create sustainable work environments to enable people to stay at work for as long they want to continue working. I am working on training occupational health professionals in using our risk management tool: A Participative Hazard Identification and Risk Management Toolkit (APHRIM). This toolkit takes a comprehensive approach to the assessment of the physical and psychosocial work environment to identify what are the key hazards associated with the development of musculoskeletal disorders. APHIRM has been developed and tested for over a decade, and we are excited to offer the tool through an online platform for people to use in their workplaces to reduce the risk of musculoskeletal disorders: aphirm.org.au.
Can you tell us a bit about what you will be addressing in your conference presentation?
Musculoskeletal disorders (MSD) are the largest occupational health and safety problem in Australia. My presentation will outline the key gaps in the current approaches used in workplaces to manage this complex problem. I will then propose how we should approach the MSD problem and argue the case for a different way in which to manage MSDs.
What do you hope attendees of your presentation will come away with?
I hope that attendees find the presentation challenges them to think differently about their current practices in the management of MSDs and to consider how they might make changes to improve the effectiveness of their practice in this area.
Finally, I would like people to feel like they have been presented with some knowledge in where to go to find out more about risk management of MSDs. I hope those who come along also leave with some questions. A good presentation should challenge your current ideas and thinking. My hope is to raise debate and encourage people to use evidence to support their practice in occupational health, rather than relying on traditional approaches that may not be supported by contemporary evidence.
Associate Professor Jodi Oakman is a Doctor of Philosophy and leads the Centre for Ergonomics and Human Factors at La Trobe University. Her PhD examined the organisational influences on employees’ retirement intentions.
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