Computer-generated Headache Brachiocephalgia at First Byte" Myron M. LaBAN,’ MD AND JosePH R. MEERSCHAERT, MD ‘Twenty-four women employed as computer operators were evaluated for ‘complaints of occipital headaches, as well as neck and shoulder pain. Although the symptoms were highly variable with respect to duration, intensity and distribution, they were mutually consistent in that they started or intensified with the resumption of the work week. The patients varied in age from 25 to 58 with a median average of 48 years. Fifteen demonstrated radiographic evidence of cervical degenerative disc disease and in an additional four, electromyo- graphic evidence of cervical root compromise was present. Multiple precipitat- ing factors were identified in Monday's headache including the predisposing, presence of unrecognized impairment of visual acuity in 4 and cervical radicu- lopathy in 16. Mechanically, prolonged postural cervical hyperextension fre- quently combined with repetitive head rotation appeared to trigger the discom- fort complaints. Undue elevation of the CRT screen, prolonged copying of laterally displaced hard copy, the wearing of bifocals, as well as seating either excessively soft or with a tendency to pitch the operator forward were identified as additional aggravating factors. The rapidly proliferating number of computer video display terminals (VDTs) in the work place hhas been accompanied by increasing health. and safety concerns as they relate to optimal producti ity. At present, 15 million VDTs are in use in the United States and this number is expected to reach 100 million by the year 2000. It has been estimated that 10-14 million employees in the United States and Canada, one-half of whom are women of child- bearing age, spend a least part of their working day in front of VDTs. Individually and/or organized as special interest groups, operators have voiced their concerns about the possible health hazards related to the VDT. The complaints have been multivaried Gg. 1) including visceral discomfort, musculoskel- etal symptoms of headache, neck, shoulder and chest discomfort as well as backache, wrist and forearm pain. Fears of birth defects and other repro- ductive disorders secondary to radiation exposure have also been expressed. To the contrary all sci- entific studies in this regard have demonstrated that in all spectra of VDT radiation there is no biological fisk compared with normal environmental exposure. ‘To date, most of the somatic complaints have been ‘see 115 ojesu-ons00 09/0 ‘cs ou oF Praca Mere Rear {Copygh © 1939 by Mians ine ey Words: Brachocephalia, cerca radiculopathy, comptes "From the Department of Physical Medicine and Rehabita tig, Willam Beaumont Hospital, Royal Ook, Michigan "ro whom all corespondence and requests for reprints should ‘be addresed at: Department of Physical Medicine and Rehab tation, Wim Beaumont Hesptay 3601 W. Thiteen Mile Rd, Royal Oak, MI 48072, ae attributed to ergonomic factors as they relate to ‘concomitant personal health problems, computer design, hard copy positioning and poor furniture design. In those special instances where psychoso- ‘ial disorders are prominent, a reduction in stress may require frequent work breaks and improve- ments in management/employee relations. Twenty-four women employed as computer opera- tors were evaluated for neck and shoulder pain complaints. Multiple precipitating factors were iden- tified as causal factors and were evaluated with respect to their individual and combined contribu- tion to the patient's symptoms of brachiocephalgia. A therapeutic approach employing both physical treatment and modification of the work environ- ment are described, METHODS AND RESULTS ‘Twenty four female VDT operators were evalu- ‘ated by both authors with referral complaints of headache and neck as well as shoulder and chest pain. In all instances, their status as computer op- ‘erators was obtained as part of a vocational history. ‘Their ages varied from 25-58 with a median age of 48, Their symptoms of occipital headache and as- sociated skeletal-muscular pain were striking by their temporal relationship to the work week; exac- erbating on Monday with an improvement on the ‘weekends, Headache in four patients was described as having symptoms of pain in the greater occipital nerve distribution associated with local tenderness at the occipital notch, and/or the perception of scalp “numbness or burning.”®184. LABAN AND MEERSCHAERT ‘Am. J. Phys, Med. Rehabil Figure 1. A computer operator with undue strain and much pain Cervical and shoulder pain were the most com- ‘mon complaints in the remaining 18 patients, Again, symptoms as well as signs were highly variable, Sixteen demonstrated foraminal closure signs of cer- vial radiculopathy associated with patterns of cer- vical root myotome weakness on manual muscle testing, All three of the patients with concomitant chest or breast pain had C; root patterns of weak- ness. Four had electromyographic abnormalities cor- responding to their levels of clinical abnormality, Dysesthetic complaints of hand and finger numb- rness or “tingling” corresponded to the patterns of myotome weakness except in a singular instance where a suspected latent carpal tunnel syndrome was confirmed by electrodiagnostic study. In the remaining seven patients, skeletal muscular symp- toms were predominant including localized tender- ness in the trapezius within some instances of pal- pable myofascial nodules. Additionally, three had pain over the subdeltoid bursa and one over the bicipital notch. ‘None of the patients in the series had significant antecedent or concomitant medical problems. Fif- teen had roentgenographic evidence of cervical spine osteoarthritis. In three patients with clinical radicular symptoms, a trial of cervical traction ther- apy after thermal therapy was successful in easing the clinical complaints. Ice massage, ultrasound, cer- vical mobilization including massage and localized steroid/xylocaine injections were utilized singularly and in combination to manage the primary com- plaints of skeletal muscle discomfort, Eighteen of the patients had a good to excellent response to therapy while six improved with treat- ‘ment but experienced only marginal relief of symp- toms, Four patients with ocular symptoms related to uncorrected refraction errors were later accommo- dated with appropriate lens prescriptions. Ten patients worked as data entry VDT operators, while the remainder did general clerical work with computers. All had access to computers and com- puter furniture with adjustable features. Work schedules were flexible and all of the operators were comfortable with the demands of their individual ‘work situations. DISCUSSION The predisposition to neuromuscular and skeletal auscle comphints of VDT operator is undoubtedly mullfaceted and is most often related fo the inter. action between on-going physial problems. and general ergonomic and visual factors: Degenerative isc disease ofthe cervical spine with concomitant osteoarthritis of the zygopophyseal joints can pre~ dispose to complaints of neck pain often with asso- Giated radicular discomfort. Prolonged neck hyper extension, particularly when associated with repeti- five rotation, unduly burdens thee articulations and enhances the potential for discomfort. Seating that i 'too soft or falls to support the thighs tends to pitch the patient too far forward and induces pos- {ural alterations that tend to increase both the cer Veal and lumbar lodosis. lard copy that 5 not at the level of the VDT screen or dopaced {00 far Isterally of ata variable distance from the operator can serve 10 further exacesbate the clikal com Plnints by producing excessive degrees of rotation Ind repetive neck hyperextension ‘Operators vision with respect t0 acuity, accom- modation and the wearing of glasses introduce other factors that individually or jointly can also produce neck pain. After the age of 40, accommodation fs Oen limited but can be adequately corrected with prescription lenses, VDT operators who find that {heir spectacles are excellent for normal reading distances at ~0.2 m may not focus clearly ona VDF screen distances often in exess of © 5 ,BfocalsVol. 68, No. 4, August 1989 and multfocals complicate this scenario even fur- ther, With bifocals, objects are best seen at chest level or below and at distances approaching 30-45 cm. If, however, as is often the case, the VDT screen is at face level or higher and in some instances at an excessive distance, the operator is forced to lean over or hold her’ head at an extended angle to present a comfortable focal distance. In time this position can provoke neck and shoulder pain.** To sustain the advantages of binocular vision as an operator fixates on the VDT screen, the linked neurological functions of accommodation, conver- gence, myosis, depression-of-gaze reflexly inter- react. To the extent that these movements efficiently interrelate, energy expenditure is reduced and fa- tigue is minimized. To perform near-work visual tasks, where the fixation target is both close and elevated, the depression-of-gaze component can be volitionally overridden. In this circumstance, the eye muscles work harder in an effort to restore and maintain the “visual vertical.” This effortis increased with convergence, and convergence itself increased by clevation-of-gaze in a sustained effort to preserve singular binocular vision in the vertical axis. Over time, the contractive and torsional efforts of the individual ocular muscles to maintain a near point ‘of fixation can become fatiguing and uncomfortable to the observer. Subjective comfort can be regained when convergence and depression-of-gaze are com- bined and facilitated by either initially positioning the VDT screen a least 35~40° below the horizontal plane or by reflexly extending the occiput on the Shoulders. This position permits viewing the visual target in a relatively depressed position-of-gaze at a preferred downward slope of the line of sight at an angle from 15-302 Tin an extended neck position, particularly when the VDT operator has concomitant cervical degen- erative dsc disease, repetitive rotational movements of the head on the shoulders can contribute to increased discomfort from the cervical zygopophy- seal joints. Current patterns of computer usage fre- quently require relatively large (30-45°) eye move- ments to continually reposition the screen/key- bboard/copy-viewing area targets onto the visual fovea, These large angular differences requiring re- petitive reixations can be minimized by placing the copy-viewing area along the visual midline and also at an angle of 35~40° below the primary horizontal plane.’ ‘Although operator work sight lines are being re- defined, computer manufacturers are also redesign- ing monitors, Keyboards and computers as well as software to make them more facile and efficient to use. Computer furniture design too is also changing to meet the comfort requirements of the VDT oper- ators. This process is being accelerated by healthcare legislation requiring that all computer work stations be provided with adjustable chairs and tables. The COMPUTER-GENERATED HEADACHE 185 chair should permit the operator to sit with thighs fully supported and paralel tothe floor. The seat should be sufficiently firm as not to foster lumbar hyperlordonis, The Backrest should be adjustable with respect to height and contour, ‘The hands Should rest comfortably on the keyboard with the elbows at 90° and the arms supported. Whether this poston is achieved by chat” adjustments ot by Srlizing a desk vith the Keyboard postoned on & drop-down tray is 2 matter of opertor preference ‘The VDT screen should be placed on an adjustable stand with the hard copy inimediatly adjacent and at the same level. The lop ofthe monitor should be positioned just below the operator's eyes.’ To mini- Inize both visual and skeletal-muscular complaints, the user's fine of sight should be maintained at an angle ~20-30° below eye level, Various stresses in the wotk environment can increase musculoskeletal discomfort and are also recognized as potential inclting agents. Cervical my fascial symptoms can be exacerbated by tasks 1e- auiing prolonged positioning in one position partic larly when the assigned tsk require precise rep- ettion and is electrically monitored by Supervisors as is the case with many VDT operator affected With “ob stress" In these instances, itis generally agreed that “it the nature of the fask which im. poses the stress notthe VDT per ses Systems tht bre “user friendly” and employers who provide for intermittent rest periods tallzed tothe length and the intensity of the assigned task ise have both been recommended to minimize stess atthe work station. The adoption of appropriate sight lines and the acquisition of adjustable computer furnishings can also contribute fo a reduction in anwiety produc. ing cyberphobia or fear of automation and new technology.” Medical intervention to deal with con- Siig complains of headache as well as neck and shoulder pain remains appropriate when the symp- toms continue to resist ergonomic accommodation. [REFERENCES 1. American Metical Association Counc on Scientific Affair Hlalh effect of vdeo diopay terminals. JAMA 1987257:1808- 1512 2. Clever Lit Hazards for heslth cate workers. Anny Reo Public Heth 1988-273-209, 3. Dain Sj, McCarthy AK. Chan-Ling T: Symptoms sn VOU ‘operators. Am J Optam Physiol Opt 198865:162-167 ' Parssinen ©, Kirjonen J, Sart KME Wearing of spectacles and occurrence of ocular symptoms in clase workin different (orupations Scand Soe Med 1987159103. 3" Grant Als The computer user syndrome, J Amt Optom Assoc 1987356:892-901 6, Miler NR Clinical Newo-Opthalmoiogy, ed 4. 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