Musculoskeletal disorders and telework

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Liesbeth Daenen, Idewe (External Service for Prevention and Protection at Work), Leuven, Belgium, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium, Pain in Motion International Research Group, Brussels, Belgium, Erik Van den Hoof, Idewe (External Service for Prevention and Protection at Work), Leuven, Belgium, Lode Godderis, Idewe (External Service for Prevention and Protection at Work), Leuven, Belgium, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium

Introduction

Short introduction to telework

Telework is defined as the use of information and communication technologies (ICTs), such as smartphones, tablets, laptops and desktop computers, for work that is performed outside the employer’s premises[1]. This article focuses on working from home, referred to as home-based telework.

In 2020, telework exploded to an estimate of almost 40% of people employed in the European Union who started teleworking fulltime as a result of the pandemic[2]. Telework has become a highly important instrument in the fight against the COVID-19 pandemic. This gave a substantial boost to the already upward trend of teleworking in the past years. The share of employees in the European Union who works at least sometimes from home increased from 8,1% in 2011 to 18,7% in 2020[3], mainly due to increasing mobility problems (e.g. traffic jams), search for a better work-life balance and increased flexibility requirements for organisations.

Short introduction to the main MSDs risk factors related to telework

Home-based teleworking has potential advantages such as gain in time or less stress by not commuting, better work-life balance, higher productivity and improved concentration. However, the increase in prolonged sitting and sedentary behaviour combined to poor ergonomics of the home workstation and social isolation from colleagues may have a negative impact on worker’s health and may contribute to the development or exacerbation of musculoskeletal disorders (MSDs). MSDs, mostly experienced at the low back, neck, shoulders, arms, hands and wrists, are one of the most important causes of musculoskeletal pain and discomfort, work disability and long-term sickness absence among workers who spend several hours a day working with a computer. They are multifactorial in origin and related to ergonomic, work organisation, environmental as well as psychosocial factors.[4][5][6][7][8]

Teleworking, which often implies prolonged use of ICT and Visual Display Units, is associated with extended periods of continuous working, an increased rate of continuous sitting and awkward body postures due to poor ergonomic workstations (i.e. well-known work-related risk factors for MSDs)[9]. In light of the increasing spread of teleworking, which is likely to maintain even after the COVID-19 pandemic, it is crucial to identify MSDs risk factors related to telework and to address them preventively / proactively[10].

This article aims at describing the main work-related MSDs risk factors related to telework and presenting preventive / protective recommendations and approaches to address them.

Presentation of the main work-related MSDs risk factors related to telework

Physical work demands as well as psychosocial and organisational factors related to telework play an important (and probably interacting) role in the development or exacerbation of MSDs.

Workstation ergonomics and related body postures

Computer work, as home-based telework usually involves, contains repetitive movements that are mostly performed in a sustained static, mainly seated, position. This can result in MSDs, particularly when it is accompanied by poor ergonomics[9][11][12][13]. Many teleworkers use laptop computers and makeshift home workstations, that result in non-neutral body postures and, hence, increased musculoskeletal complaints[14][15]. Inappropriate location of the screen, keyboard or mouse and lack of forearm support lead to discomfort and muscle loading of the upper extremity and back[7][12][16].

Work environment

There is evidence that work environmental factors such as being disturbed by glare or reflection, draught, noise and poor air quality are related to MSDs at the neck and shoulder[7][12][16]. Although environmental demands are given due consideration in an office design, in home-based teleworking this attention is likely to fail.

Sedentary behaviour and physical activity

Home-based teleworking involves longer periods of sitting with fewer work interruptions than in the office[17]. This in combination with poor ergonomic workstations may lead to an increase in MSDs[6][18][19][20][21]. The lack of movement during sitting leads to a higher load on the vertebral discs and reduces circulation of the blood and the supply of oxygen to the muscles. However, evidence concerning the direct link between prolonged sitting and MSDs remains inconclusive. Because of the multifactorial nature, MSDs are only partially linked to sitting behaviour itself.

A recent study found that home-based teleworkers had longer sedentary behaviour and were less physically active during work time[17]. The more they telework, the more they would be sedentary and the less they would be physically active during work time. Results of a recent Spanish study demonstrated that teleworkers modified their physical activity habits (i.e. from occasional to frequent exercise and from aerobic to stretching and strength training) during COVID-19 pandemic[22]. At the same time, prevalence of musculoskeletal pain decreased during the time that they were working from home. Being physically active (> 30 minutes of moderate physical activity every day or >20 minutes of vigorous physical activity there days a week) seems to preserve from MSDs[7][11][23]; otherwise, employees who exercise less frequently are at higher risk[17][24]. However, health risks associated with sedentary behaviour cannot be fully compensated by physical exercise during leisure time.

Work organisation

Another risk factor of home-based teleworking is the blurred boundaries between work and home. Teleworkers tend to work longer hours at home in order to ensure that they meet or exceed supervisor’s expectations[25]. In addition, teleworkers have fewer opportunities to socialise with colleagues and thus don’t allow to take regular breaks.

Extended work hours associated with longer periods of sitting may result in an increased risk of MSDs.

Psychosocial factors

It is also important to consider the psychosocial risks of teleworking. Factors such as excessive workload, increased social isolation from colleagues, lack of face-to-face interaction and support, and anxiety can have an impact on workers’ wellbeing[10], which in turn can increase the risk of developing MSDs. Extent of teleworking is negatively associated with social support from colleagues and line managers[26], with a duration of more than 2.5 days a week as disadvantageous for co-workers’ relationships[27]. Lack of social support from colleagues and superiors, low autonomy, high job demands, and low job satisfaction seems to be related with an increased occurrence of MSDs[6][19][20][28][29]. In addition, the omnipresence of the work and the feeling of living in the ‘office’ day and night may provoke stress, and hence cause MSDs among home-based teleworkers[14].

On the other hand, positive psychosocial aspects of home-based teleworking (e.g. greater autonomy and higher job satisfaction) would have a beneficial effect on health problems such as MSDs and, potentially delay the onset of symptoms.

Preventive / protective approaches to address MSDs risk factors related to telework

Workplace risk assessment to reduce and manage MSDs risk factors

A workplace risk assessment, including participation of the teleworkers as well as the management[30], should be the first step in preventing and addressing MSDs risk factors related to telework. Besides providing information that is important to take the next steps towards an action plan, it creates awareness among teleworkers and the management. A good way to actively involve workers in risk assessment and identifying MSDs, workplace hazards and solutions is via the interactive methods of body mapping and hazard mapping[31]. The results of mapping, combined with data gathered by risk assessments using checklists or online tools, can give insight in teleworkers’ home-based workplace (i.e. design and ergonomics, work environment, work organisation, mental well-being and sedentary behaviour) and related MSDs and, hence, guide preventive and protective measures and focused multidisciplinary solutions and interventions.

Adapt the work to the individual

Workplace design and ergonomics at home

Teleworkers do not always have the same resources and possibilities at home than they do at the office. To make the home office a comfortable and healthy workplace, here are some tips[32]. An appropriate workstation should at least include:

Office chair

The office chair is preferably adjustable in height, back rest, seat depth, arm rests and dynamic tilt (to create movement) (corresponding to standard EN 1335). For a neutral sitting posture, make sure that the chair is correctly adjusted[33][34].

If the chair is non-adjustable:

  • adapt the seat height so that the hips are slightly higher than the knees and the thighs are sloped slightly downwards. If the seat is too low, use a cushion (or two). That helps to maintain a comfortable body posture (with the back natural aligned)
  • ensure that the feet are in good contact with the floor. If this is not the case, take a stable object and place it under the feet to improve contact with the floor.
  • use an additional support (e.g. thin cushion) behind the lower back, when the lower back is not well-supported.

Office desk

Make sure that the desk is large enough (preferably complying with standard EN 527) and there is sufficient legroom. Try to consider at least a depth of 80cm and a thickness less than 5cm.

If the height of the desk is adjustable, adapt the height to elbow height (note that the shoulders are relaxed). Before doing that, make sure of a correct body posture while sitting (see office chair).

If the desk height is non-adjustable:

  • The desk is too high: raise the sitting height of the chair (e.g. by using cushions in case of a non-adjustable chair) so that the elbows are at the same height as the desk.
  • The desk is too low: raise the desk height (e.g. by using blocks) so that the elbows are at the same height as the desk. But keep it stable and safe.

Create an orderly desk. Remove unnecessary objects. A desk cluttered with documents and office materials prevents working in an ergonomic manner.

Monitor

To avoid muscle strain at the neck and shoulder, it is important to position the screen at the correct height (i.e. at eye level or just below)[35]. Therefore, use a laptop stand or, if not available, a box or a stack of books to the exact height. Preferably, use an external screen (that is large enough, at least 19inch). When using two screens, place them in a V-shape directly in front of you (by using both screens equally) or the primary screen directly in front and the secondary screen on one side of you (by using one screen more than the other). Place the screen(s) at the correct height and an arm’s length from the eyes.

To avoid eye fatigue, use the 20-20-20 rule (i.e. look every 20 minutes for at least 20 seconds at a distance of at least 20 feet)[36]. Besides this, increase readability by using full width of screen, non-colors[37] (e.g. dark font on light background) and sufficiently large font size and line spacing. For wearers of spectacles, computer glasses[38] could be appropriate to focus the eyes on a computer screen.

Mouse and keyboard

While working on the laptop, it is recommended to use an external mouse and keyboard. This allows to adopt a more comfortable body posture and prevents muscle strain at the neck and shoulder.

Preferably use a flat keyboard (or fold in the keyboard feet). Position the keyboard directly in front of the correctly positioned screen (see tips above), approximately 5-10cm from the edge of the desk. Place the mouse as close as possible to the keyboard. Correctly use the mouse[39]. Make sure that the arm is well supported by the desk (or armrest) and that the side of the hand rests on the desk. Avoid resting the hand on the mouse while not using it. Reduce mouse clicks by using keyboard short cuts where possible. A vertical or roller mouse could be appropriate for employees suffering from MSDs at the neck, shoulder, elbow or wrist.

Document stand

Use a document stand when typing up notes or text from paper documents. It helps to maintain a neutral posture at the neck and back. Position the document stand behind the (external) keyboard and beneath the monitor, directly between the monitor and keyboard. Arrange it at a slight angle (approximately 45°) so that the documents are clearly legible. In case of touch typing, place the document stand at the same height and distance as the monitor (so the eyes do not have to focus each time and the neck remain in a comfortable position).

Work environment at home

Lighting

Adequate lighting (preferable a minimum of 500 lux) is also important at the home office[40]. Avoid extreme light contrasts (e.g. working in a dark room while staring at the screen, the screen surrounded by dark walls) and prevent glare from sunlight or bright lighting on the screen. Therefore, sit across the window (do not sit with the face or back to the window) and use blinds if necessary.

Air and temperature

Open windows and doors regularly, e.g. before starting the teleworking day or when taking a break.

The optimum temperature for computer work is between 22°C and 24,5°C depending on the season[41]. Adjust clothing to the temperature of the workplace. Dress in such a way that easily put on or take off a layer if it is too hot or too cold.

Background noise

It is appropriate to work in a separate room to minimise interference from music, television, housemates, etc. Make good arrangements with housemates, especially when concentration tasks need to be performed. In addition, a noise reducing headset may be helpful to attenuate annoying background noise. Preferably also place the printer in a different room.

Plants

Brighten up the home office with flowers and plants, as they improve air quality, concentration, creativity and productivity and, help to reduce noise and stress levels[42].

Sedentary behaviour at home

Three pieces of advice should be taken into account to have a positive effect on employees’ mental and physical health: 1) sit less hours a day, 2) change posture as much as possible, 3) be aware of a good sitting posture.

The key is the combination of these three pieces of advice. Focusing on only one of these will not be sufficient to achieve a beneficial health effect. In addition, physical activity and exercising outside the home office hours is at least equally important. Here are some tips to move more and reduce sedentary behaviour during the home-based workday.

  • Start the day with a short walk or a quick workout (e.g. yoga, stretching, strength exercises, …).
  • Alternate between tasks and change posture at least every hour by standing up, taking a (coffee) break, going to the toilet, etc.
  • Regularly stand up during online meetings or walk during phone calls.
  • Alternate between sitting (no more than one hour) and standing (no more than 30 minutes) work. Ideally, use a sit-stand desk. If not available, position the laptop on a platform on the table or a cabinet.
  • Use the stairs regularly. For instance, go to the toilet on a different floor from the home desk.
  • Lunch break is the ideal time for a walk, 15 minutes of exercise, garden work or other outdoor activities.
  • Create movement while sitting, e.g. by activating the dynamic seat of the office chair or stretch and lean back from time to time.
  • Be physically active for at least 30 minutes a day at a moderate intensity, e.g. brisk walking, cycling at a speed of at least 15 km/h, garden work, playing double tennis. It is not necessary to be physically active for 30 consecutive minutes. The total active time can be split into periods of exercise lasting at least 10 minutes each.
  • Regularly do some quick exercises to improve blood circulation and release muscle tension[43]:
    • Turn your head to the left and right.
    • Tilt your head forward and gently shake your head from side to side.
    • Let your arms and shoulders hang loosely.
    • Then lean your shoulders towards your feet.
    • Roll your shoulders backwards and then forwards.
    • Extend your arms forward to shoulder height. Put your hands together (with palms facing outward) and stretch your arms.
    • Spread out your arms sideways and backwards.
    • Plant your heels on the floor and raise your toes.
    • Plant your toes on the floor and raise your heels

Since the detrimental effects of sitting cannot be fully compensated by exercise in leisure time, it is recommended to do some short workouts during the workday (regularly some short exercises is more beneficial than one longer session).

There are currently several online tools and apps available (e.g. break reminders, office work-outs, …) that remind workers to take a break or do some exercises every 30 minutes.

Work organisation at home

When working from home, the boundaries between work and home become more blurred. Here are some practical tips to improve work-life balance while working from home:

  • Provide a separate home-office where you can work without being disturbed. This helps to maintain a clear separation between work and home. Make good arrangements with your partner and children.
  • Schedule the workday (including lunch and short breaks). Start each day by noting the goals and track your progress. If necessary, adjust daily goals according current circumstances and work rhythm.
  • Respect ‘normal’ office working hours.
  • Take care of a good routine: get up and start at the same time as you would for a ‘normal’ workday. End the workday, for example by taking a walk.
  • Make plans for the after-work hours. If you have to be somewhere at the end of the workday, it is more likely that you log off and stop working.
  • Set up an out-of-office and a good voicemail during holidays.

Psychosocial factors at home

Job support (i.e. social support, autonomy, decision-making) is an important element for employees’ psychosocial and physical health. Job satisfaction increases when employees feel sufficiently guided and supported during their (tele)work[26].

Here are some practical tips to reduce MSD-related psychosocial risk factors of teleworking.

Social isolation / social support

Stay connected with colleagues and supervisor by scheduling regular phone calls or virtual meetings. This helps to keep them informed of what you’re working on and maintain positive relationships. Tell them when you like them to help you. Otherwise, express your appreciation and in turn help colleagues when necessary.

Team meetings are best alternated with one-on-one talks with colleagues and supervisor.

Make time for informal talks and hearing friendly voices. Reserve the first part of the meeting for a check-in, to discuss how everyone is doing and talk about non-work-related issues. Take virtual coffee breaks with colleagues.

Provide teleworking buddies that allow employees to voice their concerns and potential difficulties to be detected more quickly.

Other tips to prevent the feeling of being isolated can be found here.

Workload

Take a critical look at the own contribution: define priorities and be assertive (e.g. say "no" if you are already busy). Do not ignore the high pace of work. In case of (persistent) high workload, make an appointment to talk about with your supervisor.

Take enough breaks during the day in order to break up periods of intense work, and do not skip lunch break. Go off-line! Do you sometimes forget to take a break? Consider the Pomodoro technique. That is a time management method that prescribes working in blocks of 25 minutes, with 5 minutes break between the blocks.

Focus on one task and avoid distraction by working in a quiet room, put on a headphone and close mailbox. Inform colleagues that you are not “available” for a while.

Autonomy

Make sure that teleworkers get the confidence and experience that they can work autonomously. Therefore, a clear framework of agreements that is drawn up in participation of the employee is recommended. Make arrangements on which tasks can be carried out at home (e.g. tasks that require concentration and a quite work environment), availability and report on the progress of the tasks.

Recommendations for the employer

Training for teleworkers provided

Suitable, ergonomic equipment and adjustable furniture does not necessarily guarantee adequate use and, hence prevention of MSDs. It is equally important to invest in technical assistance and training that help the teleworker to make optimal use of the dynamic workstation and stay vital throughout the teleworking day. Employees must be made aware of the value and possibilities of the workplace before they are prepared to make optimum use of it. Besides this, training on healthy (de)connecting, merit of a healthy work environment and regularly moving and changing posture during the workday may be valuable too.

Adequate education and training create awareness on MSDs risk factors related to telework and how to deal with it among teleworkers and their supervisors[44][45]. Education and training play an important role in the prevention and management of MSDs, but only when it is part of a general prevention strategy focused on the reduction of health-related risks at the workplace.

Tips for line managers/supervisors

Also the role of the supervisor or (team) manager is of great value here. Some practical advices they can take into account to support employees in preventing and proactively addressing MSDs risks related to telework:

  • Stay in connection. Regular individual contacts allow supervisors to be informed about teleworkers’ workload, needs and concerns and their work progress and, allow them to help if needed. Regular team meetings help to ensure uniform information flows to all employees and to keep in touch with the relationship between the employees.
  • Provide ergonomic equipment such as laptops, external mouses, keyboards, screens, etc.
  • Provide technical support and guidance on how to set up an effective home workstation.
  • Promote physical activity and regular exercise by encouraging employees to take part in active breaks and short work-outs during online meetings.
  • Make, in consultation with the employees, clear agreements about the results that they are expected to achieve, hours of accessibility, how to monitor progress and report results, etc.
  • Engage in dialogue with employees on healthy de-connection. What are their needs? What do they expect? What do you expect? Tell also what you do not expect. Explain the right to de-connect (e.g. taking breaks, working in low-stimulus environment, switch off mailbox after working hours, …). Give them tools.
  • Provide training opportunities for both teleworkers and supervisors.

Telework policy

Make use of a clear telework policy with necessary attention to the physical, ergonomic and psychosocial aspects and risk factors of teleworking. Agreements on accessibility, ergonomic equipment, healthy (de)connecting, expected output and results, informing and supporting employees, ratio home versus office work (e.g. based on tasks that need to be carried out and employee’s individual needs, i.e. activity-based/human-based working), etc. are laid down in a telework policy.

Conclusion

Teleworking has gained importance in recent years. Although home-based teleworking has potential advantages, it could also be detrimental to teleworkers’ health and contribute to the development or exacerbation of MSDs. A risk assessment of the home workplace should be the first step in addressing MSDs risk factors related to telework. A multidisciplinary approach including preventive actions to optimise workplace ergonomics and environment, reduce sedentary behaviour, improve work-life balance and psychosocial hazards such as social isolation and high workload should be the next step. In addition, creating awareness among teleworkers and supervisors, providing education and training and establishing a clear telework policy are essential as well.

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Contributors

Palmer