BRIEF OBSERVATIONS
Prevalence of Upper
Extremity Musculoskeletal
Disorders in College
Students
Jeffrey N. Katz, MD, MS, Benjamin C. Amick III, PhD,
Barbara B. Carroll, EdD, Christine Hollis, MPH, MPS,
Anne H. Fossel, Christopher M. Coley, MD
U
pper extremity musculoskeletal disorders are the
fastest growing source of disability in the US work-
place (1,2), affecting workers of all ages, including
those less than 25 years old (3). Computer work for 4 or
more hours per day doubles the risk of these disorders (4).
The association of upper extremity disorders with pro-
longed computer work and their emergence in younger
workers (3) suggest that college students may also be at risk.
METHODS
As part of an annual survey in 1998 among senior under-
graduates at a private university, who were required to
complete the survey to receive graduation tickets, stu-
dents were asked: “Do you experience pain, numbness,
tingling or other discomfort in your hands, wrists or arms
when you use a computer?” Students were given five pos-
sible responses: (1) “No, never”; (2) “Yes, if I use the
computer for several hours at a time”; (3) “Yes, if I use the
computer for an hour or so”; (4) “Yes, even if I just use the
computer for a few minutes”; and (5) “Yes, with virtually
all activities.” The last three responses were combined to
yield a three-level variable: never experience symptoms,
experience symptoms if use the computer for several
hours at a time, and experience symptoms if use the com-
puter for an hour or less. We examined associations be-
tween this variable and potential determinants of symp-
toms with Mantel-Haenszel chi-square tests for trend.
Other items on the survey that we hypothesized to be
associated with symptom reporting or hand and wrist
activities included the student’s sex, academic concentra-
tion, residential house (more than 98% of seniors lived in
one of 12 residential communities termed “houses”),
hours of computer use each week, and participation in
intercollegiate athletics.
Correlates of symptoms at P ⬍0.05 in univariate anal-
yses, including individual houses and concentrations that
met this level of statistical significance, were included in a
multivariate logistic regression model. The dependent
variable was a dichotomous indicator designating
586 䉷2000 by Excerpta Medica, Inc.
All rights reserved.
whether the student had any computer-associated upper
extremity symptoms versus never had such symptoms.
Analyses were conducted using SAS (edition 6.03, Cary,
North Carolina).
RESULTS
Of the 1,601 students (96% of the class) who responded to
the survey, 57 (3.6%) did not complete the item on upper
extremity symptoms. Of the remaining 1,544 students, 720
(47%) reported that they never had symptoms, 630 (41%)
that they had symptoms after several hours of computer use,
106 (6.9%) that they had symptoms after computing for 1
hour or less, 49 (3.2%) that they had symptoms after com-
puting for a few minutes, and 39 (2.5%) that they had symp-
toms with virtually all activities.
Each variable in Table 1 was significantly associated
with a greater prevalence of symptoms in univariate anal-
yses and was included in the multivariate model. Inde-
pendent correlates of symptoms included female sex
(odds ratio [OR] ⫽ 1.6, 95% confidence interval [CI]: 1.3
to 1.9), computer science concentration (OR ⫽ 2.2, 95%
CI: 1.1 to 4.3), and more than 20 hours per week comput-
ing (OR ⫽ 1.4, 95% CI: 1.1 to 1.9). History concentration
was associated with lower prevalence (OR ⫽ 0.5, 95% CI:
0.3 to 0.8), as was participation in intercollegiate athletics
(OR ⫽ 0.6, 95% CI: 0.5 to 0.7). Interactions between
hours of computing and computer science and history
concentrations, between sex and these concentrations,
and between sex and hours of computing were not statis-
tically significant (P ⬎0.3 for each interaction).
DISCUSSION
More than half of the undergraduates at this university re-
ported having upper extremity symptoms while using the
computer, and 1 in 8 reported symptoms after computing
for an hour or less. More than 1.7 million Americans attend
undergraduate institutions annually (5); thus if our results
apply nationwide, about 800,000 undergraduates in the
United States have upper extremity symptoms, including
200,000 with frequent symptoms.
To place these findings in perspective, 7% of US adults
report shoulder symptoms occurring on most days for at
least a month, and 3% report wrist symptoms (6). In
workplace settings, 22% of computer-intensive workers
in a telecommunications firm (7) and 20% at a major
newspaper (8) had moderate or severe upper extremity
pain occurring at least once per month or for longer than
a week. While variations in case definitions preclude di-
rect comparisons, these previous results suggest that our
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 Upper Extremity Musculoskeletal Disorders in College Students/Katz et al

Table 1. Univariate Associations between Selected Characteristics and Self-Reported Upper

Extremity Symptoms with Computer Use
Response to Item on Upper Extremity
Symptoms
Yes, If Use Yes, If Use
Computer for Computer for
Several Hours at an Hour or P Value for
Characteristic* No, Never a Time Less Trend
Number (Percent)
Sex
Female 285 (41) 301 (43) 110 (16) 0.001
Male 430 (52) 322 (39) 80 (10)
Concentration
Computer science 13 (26) 24 (48) 13 (26) 0.001
History 45 (66) 20 (29) 3 (4) 0.001
Residence in house 1 62 (60) 34 (33) 8 (8) 0.002
Participate in intercollegiate athletics 284 (56) 174 (34) 48 (9) 0.0001
Self-reported computing (hours/
week)
ⱕ6 184 (56) 114 (35) 29 (9) 0.0001
7–12 264 (49) 212 (39) 68 (13)
13–20 115 (42) 129 (47) 30 (11)
ⱖ20 132 (38) 157 (45) 60 (17)
Total 720 (47) 630 (41) 194 (13) —
* History and computer science were the only two concentrations that were associated with symptom preva-
lence compared with other concentrations, and residential house 1 was the only residential house (of 12) that
had a symptom prevalence significantly different from the others.

finding that 12.6% of students had discomfort after com-
puting for less than an hour exceeds the estimated prev-
alence for the general population but is lower than the
estimated prevalence in some work sites.
Female sex, computer science concentration, and hours
of computing were associated with higher prevalence of
symptoms, whereas intercollegiate sports and a concentra-
tion in history appeared to be protective. These findings in-
dicate that there are a variety of risk factors for this condi-
tion, as suggested by others (9 –11). The finding that greater
exposure to computing is associated with higher symptom
prevalence is consistent with prior work (4). The effect of
athletics may reflect a protective influence of overall fitness.
The effect of certain academic concentrations, adjusted for
hours of computing, may reflect work style (eg, more
“binge” computing in computer science) or other personal
factors.
The survey did not include physical examination and
detailed clinical assessment, which would help establish
specific diagnoses, nor did it specify the time period in
which symptoms occurred. Although our response rate
was excellent, ensuring internal validity, this single-insti-
tution study should be confirmed in other colleges. Fi-
nally, future research should incorporate detailed mea-
sures of physical exposure and a broader range of poten-
tial determinants of symptoms.
An important, potentially preventable (12) public health
problem may be emerging on college campuses. If the ob-
served high prevalence of upper extremity disorders is con-
firmed, research on interventions for these disorders in stu-
dents should receive high priority. Longitudinal studies are
needed to delineate the natural history of these disorders,
and studies involving younger students may be worthwhile
to identify opportunities for intervention.
REFERENCES
1. Bernard BP, ed. Musculoskeletal Disorders and Workplace Factors.
Cincinnati, Ohio: National Institute for Occupational Safety and
Health, DHHS (NIOSH) Publication No. 97–141; 1997.
2. Annual Survey of Occupational Injuries, and Illnesses. Washington,
DC: Bureau of Labor Statistics, US Department of Labor; 1995.
3. Bureau of Labor Statistics. Selected (sprains, strains, tears; carpal
tunnel; tendonitis) natures by worker, and case characteristics. Ta-
ble 9. Occupational Safety and Health Data. Available at: www.
bls.gov/oshsum1.htm. Accessed April 1999.
4. Punnett L, Bergqvist U. Visual Display Unit Work and Upper Ex-
tremity Musculoskeletal Disorders: A Review of Epidemiological Find-
ings. National Institute for Working Life—Ergonomic Expert
Committee Document No 1. Solna, Sweden: Arbetslivsininstitutet;
1997.
5. National Center for Education Statistics. Higher education general
information survey: fall enrollment in colleges and universities,
Washington, DC: US Department of Education; 1997. Available at:
http://nces.ed.gov/pubs/digest97. Accessed April 1999.
6. Cunningham LS, Kelsey JL. Epidemiology of musculoskeletal im-
pairments and associated disability. Am J Publ Health. 1984;74:
574 –579.

November 2000 THE AMERICAN JOURNAL OF MEDICINE威 Volume 109 587

 Aminotransferase Levels in Obesity and Type 2 Diabetes/Erbey et al
7. Hales TR, Sauter SL, Peterson MR, et al. Musculoskeletal disorders
among visual display terminal users in a telecommunications com-
pany. Ergonomics. 1994;37:1603–1621.
8. Polanyi MFD, Cole DC, Beaton DE, et al. Upper limb work-related
musculoskeletal disorders among newspaper employees: cross-sec-
tional survey results. Am J Indust Med. 1997;32:620 – 628.
9. Bongers PM, de Winter CR, Kompier MAJ, Hildebrandt VH. Psy-
chosocial factors at work and musculoskeletal disease. Scand J Work
Environ Health. 1993;19:297–312.
10. Amick BC III, Swanson NG, Chang H. Office technology and mus-
culoskeletal disorders: building an ecological model for the origins
of musculoskeletal injuries and their consequences. Occup Med
State Art Rev. 1999;14(1):97–122.
11. Bernard B, Sauter S, Fine LJ, et al. Job task and psychosocial risk
factors for work-related musculoskeletal disorders among newspa-
per employees. Scand J Work Environ Health. 1994;20:417– 426.
12. Galinsky TL, Swanson NG, Sauter SL, et al. A field study of supple-
mentary rest breaks for data entry operators. Ergonomics. 2000;43:
622– 638.
From the Robert B. Brigham Multipurpose Arthritis and Musculoskeletal
Diseases Center (JNK, AHF), Division of Rheumatology, Immunology and
Allergy, Brigham and Women’s Hospital, Boston, Massachusetts; the Uni-
versity of Texas at Houston School of Public Health (BCA), Houston,
Texas, and the Institute for Work and Health, Toronto, Ontario, Canada;
Harvard College (BBC), Harvard University Health Services (CH, CMC),
Cambridge, Massachusetts; and Harvard Medical School (JNK, CMC),
Boston, Massachusetts.
Supported by the Harvard University Provost’s Fund for Interfaculty
Collaboration and the Robert B. Brigham Multipurpose Arthritis and
Musculoskeletal Diseases Center (AR 36301).
Correspondence should be addressed to Jeffrey N. Katz, MD, MS, Divi-
sion of Rheumatology, Immunology and Allergy, Brigham and Women’s
Hospital, 75 Francis Street, B-3, Boston, Massachusetts 02115.
Manuscript submitted February 24, 2000, and accepted in revised
form June 23, 2000.
Prevalence of Abnormal
Serum Alanine
Aminotransferase Levels in
Obese Patients and Patients
with Type 2 Diabetes
John R. Erbey, PhD, Cheryl Silberman, PhD,
Eva Lydick, PhD
T
he severe hepatotoxicity associated with a member
of the thiazoladinedione class of oral hypoglyce-
mic agents has focused attention on hepatic func-
tion in patients with type 2 diabetes and on the medica-
tions that they take (1,2), but there is much that is not yet
known about the clinical importance of elevations in the
markers of hepatic damage and associated rates of hepatic
failure. Serum aminotransferase levels, especially the ala-
588 November 2000 THE AMERICAN JOURNAL OF MEDICINE威 Volume 109
nine aminotransferase level, are commonly used in test-
ing for liver injury (3). Diabetes mellitus and obesity have
been associated with mild asymptomatic elevations in the
serum levels of these enzymes (4 – 6). The background
rate of abnormalities is not well understood, and eleva-
tions in patients with diabetes are often attributed to fatty
infiltration of the liver (7– 8).
Recently, an analysis of the Hispanic Health and Nu-
trition Examination Survey reported that abnormal ala-
nine aminotransferase levels were significantly more
common in Mexican Americans with diabetes as com-
pared with their nondiabetic counterparts (9). The odds
of having an elevated alanine aminotransferase level were
approximately threefold greater for those with diabetes
(9), although the association between diabetes and an el-
evated aminotransferase level was not quite statistically
significant.
To determine the prevalence of elevated alanine ami-
notransferase levels in a larger, more generalizable sam-
ple, we used national data from the Third National
Health and Nutrition Examination Survey (NHANES
III).
METHODS
The survey was conducted between 1988 and 1994 by the
National Center for Health Statistics and the Centers for
Disease Control and Prevention. It consisted of house-
hold interviews and physical examinations in a nationally
representative sample of the noninstitutionalized popu-
lation in the United States. The sample was based on a
stratified, multistage probability cluster sampling design
that oversampled African Americans and Mexican Amer-
icans.
A total of 18,825 persons 20 years of age or older were
included in the analysis. Demographic information in-
cluded age, sex, race, education, marital status, alcohol
consumption, medical history (including physician-
diagnosed diabetes), and medication usage. The physical
examination included anthropometric measures and lab-
oratory evaluations, including serum glucose and alanine
aminotransferase levels and tests of hepatitis serology.
Diabetes was defined as a self-report of physician-di-
agnosed diabetes or a fasting plasma glucose level ⱖ126
mg/dL (American Diabetes Association criteria). Type 2
diabetes was defined as a diagnosis after 30 years of age
and the absence of insulin usage within the first 2 years
after diagnosis of diabetes. Persons with type 1 diabetes
and gestational diabetes were excluded from the analysis.
Elevation in the serum alanine aminotransferase level
was handled as a categorical variable for descriptive anal-
yses and as a dichotomous variable for logistic regression
analyses. The categorical split was defined as normal
(ⱕ43 U/L), one to two times normal (44 to 86 U/L), two