Work 36 (2010) 2737 27

DOI 10.3233/WOR-2010-1004
IOS Press

Effects of intermittent stretching exercises at

work on musculoskeletal pain associated with
the use of a personal computer and the
influence of media on outcomes
Allen H. Marangoni
Department of Physical Therapy, Wheeling Jesuit University, 316 Washington Ave, Wheeling, WV 26003, USA
Tel.: +1 304 243 2372; Fax: +1 304 243 2432; E-mail: amaran@wju.edu; ahmarangoni@comcast.net

Received 31 July 2008

Accepted 7 January 2009

Abstract. Objective: The objective of this study was to evaluate the effects of regular stretching exercises on pain associated
with working at a computer workstation, and to ascertain whether the type of media used for exercise instruction had an effect on
outcomes.
Participants: Sixty-eight volunteers were divided into three equivalent groups. All of the subjects worked at computers for
prolonged periods of time and reported that their pain had been a source of distress for at least three weeks prior to the intake
evaluation.
Methods: A pretest-posttest-control group design with cluster randomization was used to evaluate the effect of a stretching
program on pain. Thirty-six different stretches were performed by the subjects for 1517 work days. Two intervention groups
were directed to stretch once every six minutes. One group (n = 22) was reminded to stretch via a computer program, the second
group (n = 23) by using a hard copy version of the stretches with pictures and written instructions, and a third group received no
intervention.
Results: ANOVA analysis found a significant reduction in pain of 72% (p < 0.001) for the computer-generated stretching
program, and of 64% (p < 0.001) using the hardcopy version of the intervention. The control group had an increase in pain of
1%.
Conclusions: Both software and hard copy stretching interventions contributed to a decrease in pain without making any changes
to workstation ergonomics and there was no significant statistical difference in the outcomes of either intervention. The subjective
evaluation of pain using both visual analog scales and a newly created pain spot assessment technique yielded similar results.

Keywords: Occupational disease, carpal tunnel syndrome, muscle spasm, computer, assessment, visual analog scale, media

1. Introduction tion strategies and intervention effectiveness as priority

The association between the use of personal comput-
ers and symptoms of musculoskeletal disorders (MSD)
has been well established in the current literature un-
der a variety of names [2,7,16,25,30,38,44,47,50]. The
National Occupational Research Agenda has identified
pain of the upper extremities with associated preven-
areas [42].
The risk factors associated with MSD while work-
ing at a computer include being seated, repetitive or
rapid work, length of time spent at the computer, lack
of support for the extremities, non-neutral body posi-
tions, inactivity, lack of rest breaks, poor workstation
ergonomics, insufficient recovery time, static muscle
loading, age, poor physical, mental or social condi-

1051-9815/10/$27.50 2010 IOS Press and the authors. All rights reserved
28 A.H. Marangoni / Effects of stretching exercise
tions, pressure on blood vessels and nerves, pain-spasm
cycles, stress on bone and connective tissues, working
without variety in physical movements, and others [4,
17,19,28,4446].
Specific types of ergonomic interventions were sug-
gested to offset the injury attributed to the personal
computer; however, since body types, posture, work-
ing habits and personal preferences differed with each
individual, the interventions were often found to be in-
effective [13,26,29,51]. The literature addressing the
component parts of a computer workstation failed to
identify workstation and computer hardware as the sole
cause or cure of the related MSD [2,8,22,33,34].
Clerical workers and female computer operators
were found to have the highest incidence of symptoms
caused by static muscular work [6,10,14]. Electromyo-
graphy (EMG) studies demonstrated that a five-minute
break each hour decreased pain in a data entry popula-
tion, that there was an association between contracted
muscles and pain, and that computer users were often
unaware of sustained muscle contractions while seated
at their workstations. These sustained contractions of-
ten extended into the rest periods and may have been the
cause of vasoconstriction in the affected muscles [14,
20,28,43].
At 5 and 10 percent of maximal voluntary contrac-
tion (MVC) the biceps muscle was found to have an
initial decrease in oxygen concentrations that returned
to baseline after 6 minutes and demonstrated muscle
fatigue after 10 minutes. Other studies found that fore-
arm tissue oxygenation decreased significantly during
isometric muscle contraction of as little as 5 percent of
the MVC when held for one minute and that decreased
tissue oxygenation was associate with an increase in
muscle fatigue [12,39,40].
Software programs have been used to compare mini-
breaks every 5 minutes, to mini-breaks with exercise
every 35 minutes but did not demonstrate an effect on
the frequency and severity of complaints from com-
puter users [51]. Other studies have demonstrated that
resistance and stretching exercises during the work day
yielded a decrease in subjective reports of discomfort
but no changes in the pain impact as measured via a
visual analog scale (VAS) [30]. Improvements in pain
have been also been noted after weekends away from
work, and muscle massage [3,43].
For those using interventions to address symptoms
while seated at a computer it may be important to know
if the type of media used to teach stretching techniques
is key to the outcomes. While the use of media is an
integral part of learning in todays society,professionals
often give instructions to clients in a written form. The
effects of media on learning have been argued for many
years. One side argues that while media may improve
motivation, it is only a vehicle, while others point out
that media allows for time to learn, reduces errors and
can increase retention [5,9,15,18,27,32,41].
In summary, the specific causes of pain in those who
use computers were not evident in the literature and are
most likely multifactorial. Extended time at a computer
was associated with an increase in pain which was likely
due to decreases in tissue oxygenation, and regional
blood flow. Additionally, no protocol for successfully
decreasing the MSD associated with computer use was
found [12,14,20,39,43].
2. Procedure
After Institutional Review Board approval was re-
ceived the study began with three equivalent groups
which were identified from a population of conve-
nience. A pretest-posttest-control group design with
cluster randomization was performed. Sixty-eight vol-
unteers formed three equivalent groups and were em-
ployed by either the university or by one of two federal-
ly funded programs which were located on the campus.
The university was located in the Appalachian region of
the United States. The average age of the subjects was
43 years, ranging from 21 to 62. Eighty-eight percent
(60) of the participants were female. All of the subjects
worked at computers for prolonged periods of time and
reported that their pain had been a source of distress for
at least three weeks prior to the intake evaluation.
Thirty-six stretches lasting 10 to 15 seconds each
were developed for this study by the researcher, a physi-
cal therapist, to address areas of potential muscle spasm
which were identified while observing subjects who
were working at computers. The stretches targeted
muscles of the neck, upper extremities, trunk, lower
extremities, eyes and breathing and were presented to
the subjects in one of two ways. In the first intervention
group (n = 22), a Computer Assisted Stretching Pro-
gram (CASP) was used. This program was developed
by the author for this study to guide the subjects through
stretches using a real time audio and video display on
the computer screen. If the subject was working on
a document, only the verbal instructions were heard
and the video remained hidden from the screen unless
called up. The CASP program played one stretch ev-
ery six minutes, by default, while the computer was
operating (see Figs 1, 2 and 3). Six minutes between
 A.H. Marangoni / Effects of stretching exercise 29

Fig. 1. The CASP program startup as it appeared on the video display.

Fig. 2. Selected clips of stretches used for the intervention.

stretches was selected as the interval between exercises
for this study because it is the point at which oxygen
returns to base line in muscles being used at 5 and 10%
of MVC [12] and it adds 10 mini-breaks per hour that
interrupt static positioning associated with use of the
computer [30,43,51].
The second version of the intervention was called the
Facsimile Lesson with Instructional Pictures (FLIP).
This was a hard copy version of the CASP program
and was also developed by the researcher for this study.
The FLIP version incorporated selected still pictures
and words transcribed from the CASP version of the
program. These black and white pictures and text were
placed on a spiral stand from which they could be
flipped into place by the subject and followed the
same order as that of the CASP program. The FLIP
30 A.H. Marangoni / Effects of stretching exercise
Fig. 3. An example of one of the stretching exercises used for both the CASP and FlIP versions of the stretching interventions.
Fig. 4. The FLIP version of the stretching program.
version used a digital kitchen timer attached to the stand
which was pre-set to alarm every six minutes once it
was activated. The timer had to be restarted after each
stretching exercise by the subject (Fig. 4). Each person
was given a journal that was tethered to the computer
to record the amount of time that the intervention was
used each day. The subject was also asked to record
their pain level at the end of each work day and to note
if the program interfered with productivity. The third
group (n = 23) comprised the non-treatment control
group.
Subjects were recruited via a campus wide email
asking for volunteers who were experiencing pain that
they attributed to use of their computer. The random-
ization sequence was established by listing the order of
the date and time that the emails or phone calls were
received by the secretary and alternating the interven-
tions by assigning the CASP intervention to the first
caller (or group if more than one subject was located in
an office cluster), the FLIP intervention to the second
caller or group, and the control category to the next
caller who was isolated from anyone using an interven-
tion program. Recruitment of subjects was ongoing and
continued throughout the 4 months of data collection.
Inclusion criteria were that all subjects identified the
computer as one of the causes of pain which they had
experienced for at least three weeks prior to the begin-
ning of the study and the subject used the computer five
days a week. Exclusion criteria were prior dislocation
of an upper extremity, a health condition that may in-
terfere with the study (as reported by the subject and
discussed with the researcher) or current professional
treatment or medication for pain. Each subject used the
intervention for 15 work days unless the study comple-
tion date fell on a day which was preceded by time off,
in which case two days were added to negate the effect
of the time away from work.
After informed consent was established, the re-
searcher, a physical therapist, enrolled the participants
and conducted the intake evaluation. A picture was
taken of the subjects workstation, a series of intake
questions regarding subjective opinions about the work
environment and an objective ergonomic assessment of
the computer workstation was completed. The protocol
for assessment of individual workstation risk factors
was based upon consensus of authoritative input as pub-
lished in the evidence based literature (Appendix A), [1,
13,16,21,24,25,28,30,31,3437,48]. Using this evalu-
ation tool, one point was deducted for each problem
area identified. For example, if the keyboard was not
ergonomically designed, one point would be deducted
from the maximum score.
The next evaluation employed a standard body di-
agram where the subject designated areas of pain and
graded its intensity on 10 centimeter visual analog
scales (VAS) below the diagram. Subjects were asked
to evaluate the pain that they felt at the end of the work-
day and to mark the body image with sequential num-
bers to locate its position. The sum of the numbers
 A.H. Marangoni / Effects of stretching exercise 31

Fig. 5. Pain spots with random letters varying in size from one to ten centimeters in diameter.

Fig. 6. Pain spots displaying pain before and after intervention.

evaluating pain on the visual analog scales were added
to give a total pain index score. For example: if pain in
the low back was rated as a 2 and pain in the neck was
rated as a 4, the pain index would be 6.
The subject was then asked to select pain spots
to describe his or her pain. Pain Spot Assessment
(PSA) was a tool developed by the researcher that used
circles cut from thin Styrofoam sheets and varied in
size using whole numbers from one to ten centimeters.
They were placed in an eight by eleven inch shallow
tray for selection by the subject, and were identified by
random letters. Once the pain spots were selected
by the subject to represent their pain, they were taped
to the subjects clothing in the area where pain was
indicated, a picture was taken, and their positions were
recorded. The sum of the diameters of the pain spots
were measured in centimeters and added to determine
a pain spot index. (Figs 5 and 6).
Pain was categorized into the following areas: cervi-
cal (neck), right shoulder, left shoulder, mid-back, low-
back, lower extremity, right upper extremity (but not
hand or wrist), right hand or wrist, left upper extremity
(not hand or wrist pain), left hand or wrist, headache,
and other pain. This data was recorded at both intake
and outtake and was analyzed as a pain index via ANO-
VA and correlation analysis using SPSS. Subjects were
asked to avoid making any changes to personal exer-
cise programs or to their computer workstation for the
duration of the study.
Hypothesis: After using either the Computer As-
sisted Stretching Program (CASP) or Facsimile Lesson
with Instructional Pictures (FLIP) as an intervention
for 15 to 17 work days, there will be a significant re-
duction in the amount of pain associated with working
at a computer workstation.
3. Results
The 68 participants reported pain in the following
areas of the body upon initial evaluation, in order of
prominence: cervical (neck), right shoulder, left shoul-
der, mid back, low back, lower extremities, right up-
per extremity (not hand or wrist), right hand/wrist, left
32 A.H. Marangoni / Effects of stretching exercise

68 Subjects complained
of pain associated with Self
Random assessment of
computer use lasting for Assignment to
at least three week prior workstation
CASP, FLIP, or and informed
to beginning the control group
intervention consent

Pain: 72% CASP Subjects

improvement N = 23 at intake,
N = 22 Workstation, VAS
INTERVENTION

and PSA
evaluations and
Pain: 64% FLIP Subjects instructions for
improvement N=24 at intake, daily journaling
N = 23 and use of
intervention
Control Subjects
Pain 1% N=23 at intake,
worse, N=23

CASP = Computer Assisted Stretching Program, FLIP = Facsimile Lesson with

Instructional Pictures, VAS= visual analog scale, PSA = pain spot assessment.
Intake and final subject numbers differ due to participant attrition.

Fig. 7. CASP = Computer Assisted Stretching Program, FLIP = Facsimile Lesson with Instructional Pictures, VAS = visual analog scale, PSA
= pain spot assessment. Intake and final subject numbers differ due to participant attrition.

Table 1
The frequency with which pain was
measured to the nearest millimeter to describe the pain,
reported at intake by the 68 partici- while the pain spots were graded as whole numbers
pants only one through ten centimeters.
Cervical (neck) = 72%, The two intervention and one control group were
Right shoulder = 44%, found to be equivalent when being assessed by the VAS
Left shoulder = 40%, as supported by an F value of 1.20 with a significance
Mid back = 40%,
Low back = 40%, of p = 0.30. Similarities were also supported by non-
Lower extremities = 13%, significance in the pair-wise comparisons of differences
RUE (not hand or wrist) = 13%, (ANOVA) for all groups as follows: computer /con-
Right hand/wrist = 35%,
trol, p = 0.68 computer/flip, p = 0.95, flip/control,
LUE (not hand or wrist) = 13%,
Left hand/wrist = 20%, p = 0.32. The 95 percent confidence interval further
Headache = 14%, supported the similarities.
Other areas = 4%. The mean values of the two intervention and the con-
trol groups using the pain spot evaluation tool also
upper extremity (not hand or wrist), left hand/wrist, supported equivalency with an F value of 1.27 and a sig-
headache, other areas (see Table 1). nificance of p = 0.29. Similarities were also supported
Evaluation of both the visual analog scale (VAS) and by the non-significant pair-wise comparisons (ANO-
the pain spot assessments (PSA) was completed using VA) for all groups as follows: CASP /control, p =
an ANOVA analysis before the intervention, after the 0.45; CASP/FLIP, p = 0.99; FLIP/control, p = 0.41.
intervention, and to compare the differences between The 95 percent confidence interval further supported
the mean values of the initial and final results. The pain the similarities (see Table 2).
index used for comparison was the average numerical The reduction in pain from the CASP intervention
sum of all of the reported pain attributed to working at was 73% using the VAS scale and 70% using the PSA
a personal computer by all of the subjects in each group tool. Reduction of pain reported from the FLIP subjects
(CASP, FLIP and Control). The visual analog scale was was 64% using the VAS and 62% using the PSA tool
 A.H. Marangoni / Effects of stretching exercise 33

Table 2
ANOVA: pair wise comparison of group means for cumulative pain index before the
intervention was applied as measured by visual analog scale
Tamhane
Mean 95% Confidence Interval
(I) (J) Difference (I-J) Sig. Lower bound Upper bound
computer control 2.25 0.68 3.26 7.77
flip control 3.34 0.32 8.59 1.89
flip computer 1.09 0.95 4.68 6.87

Table 3
ANOVA comparison of group mean differences for pain from intake to end of
intervention as evaluated by VAS
Tamhan
Mean 95% Confidence
(I) (J) Difference (I-J) Sig. Lower bound Upper bound
computer control 10.80 0.000 6.12 15.50
flip control 10.30 0.000 14.48 6.14
flip computer .050 0.994 5.81 4.81

16
15

14
13
12
Pain index, mean

11

10
9
8
7
6
5
4
3
2

computer control flip

Test Group
Fig. 8. Mean value of pain index before the Intervention as measured by VAS. Computer = Computer Assissted Stretching Program.

(in all cases p < 0.001). There was an increase in
pain reported from the control subjects of 1% using
both the VAS and the PSA (See Table 3, Figs 7, 8 and
9). The differences in the percent of improvement for
the CASP and FLIP interventions were not found to be
significant.
When a Pearsons Correlation comparing length of
time the interventions were used during the 15 days of
intervention with the reduction in pain the correlation
was found to be r = 0.48, (p < 0.001). When the VAS
for pain was compared with the ergonomic grade of the
workstation at intake, r = () 0.042, (p = 0.73) for
VAS.
The VAS assessment tool was compared to the PSA
tool using Pearsons Correlations to compare the nu-
merical sum of the pain indices reported by each of
the 68 subjects. The pre-intervention VAS to PSA tool
resulted in an r = 0.75 (p < 0.001); post intervention
VAS when compared with the PSA resulted in an r =
0.86 (p < 0.001) and the difference in the pre and post
VAS to the PSA resulted in an r = 0.76 (p < 0.001).
The following are noteworthy comments from the pre
34
14
Mean pain index after (by VAS)
12
10
computer
Fig. 9. Mean value of pain index after intervention Computer = Computer assisted stretching program intervention.
and post qualitative surveys and daily journals: Thirty
percent of the treatment groups (CASP and FLIP) re-
ported that they had no pain at the end of the 15-days of
intervention. Seventy eight percent of the participants
rated the ergonomics of his or her workstation as bad.
The study subjects rated poor ergonomics as the pri-
mary reason that they had pain in both the pre and post
intervention groups. This was followed by no breaks.
The most common comments in the daily logs were
that the stretching feels good (13 times), and that the
program has helped (12 times). No comments were
made regarding work productivity being affected.
4. Discussion
The data analysis supported a statistically significant
decrease in pain when evaluated by both the VAS and
PSA evaluation tools for both the CASP and the FLIP
intervention groups and the hypothesis was supported.
Reduction in symptoms as measured by the VAS tool
was 74% for the CASP group and 64% for the FLIP
group. The non-treatment control group was one per-
cent worse at the end of the three-week period. When
the mean values of the FLIP and CASP groups
were compared, however, there was no significant dif-
ference in two treatment outcomes.
The favorable effects may have been due to the in-
tervention alone, that someone was acknowledging the
subjects complaints or may have been due to the friend-
A.H. Marangoni / Effects of stretching exercise
control flip
ly voice and smiling face incorporated in the computer
program. With the similarity in outcomes of the two
types of media (computer vs. hard copy) there should
have been a difference in outcomes if there was a me-
dia affect and there was not.
The same physical therapist performed the intake and
outtake evaluations and that may have brought about
some unintentional bias. Analysis of the pre and post
intervention results was deferred until all of the data
for the study were collected, and the initial assessment
was not consulted for the outtake evaluation. Since
the participants were using visual analog scales and
random pain spots, bias should have been buffered, but
remained a possibility.
Eighty-eight percent of the subjects in this study
were female. This may have been influenced by several
factors. All of the secretaries and most of the clerical
workers in this population of convenience were women
and therefore more likely to be exposed to the offend-
ing stimulus. In other populations studied, when all
conditions were equal, females who were working with
computers were found to have a significantly higher in-
cidence of neck and shoulder disorders when compared
with their male counterparts [6,23,49].
Ergonomics should not have played a role in the
outcomes since the workstations were not altered or
changed either before or during the time that the sub-
jects were taking part in the study. This was confirmed
by before and after pictures. In areas where more than
one subject was using the intervention, group support
 A.H. Marangoni / Effects of stretching exercise
may have been a factor in the outcomes, but similarly
positive results were demonstrated in both the isolated
and the group situations.
In the case of the pain spot assessments, the evalu-
ation tool was not as sensitive as the VAS. However, no
significant differences were seen in the pair-wise com-
parisons of the means of the pre/ post intervention or
control groups. In addition, the Pearsons Correlation
supported a similarity between the VAS and the PSA
evaluation tools of between r = 0.76 and .86.
The stretching interventions appeared to be effective
in decreasing pain even though seated work, awkward
positions, overuse, poor ergonomics, poor posture, age,
de-conditioning, stress on bone and connective tissues,
behavioral issues, and general work environment were
not changed. The only changes were the use of periodic
stretching exercises as directed by an impersonal media
and the attention given to complaints of pain. Since
several studies have given attention to their subjects
and used computer programs to encourage breaks from
work, without similar positive results, this may also not
be an issue. What did change was that a variety of
stretches was introduced in a timely manner. This may
have prevented static muscle loading, decreased blood
flow to the area and the associated muscle spasms [11
13,17,20,39,40,43,51].
Seventy-eight percent of the participants in this study
subjectively rated the ergonomics of their workstation
as bad. After the post intervention evaluations were
completed for all subjects in a given area of the cam-
pus, the researcher suggested ergonomic changes for
the participants workstations. Of 20 participants with
adjustable keyboard heights and angles, none of the
subjects knew how to use the adjustment knobs that
were an integral part of the keyboard. This remains
in agreement with the findings of Alexander who re-
ported that seventy-four percent of 404 office-support
employees were not aware of the ergonomic changes
that could be made at their workstations [2].
This intervention was used for a total of three weeks
with each subject. Long term assessments were not
done. The outcomes of this research suggest a possible
treatment regime that may address the acute phase of
pain, while long term outcomes are unknown.
Eighty-eight percent of the participants were white
females from Appalachia. The external application of
the program shows promise,but will need to be repeated
with a larger, more representative population.
When comparing the specific areas of pain identified
by the subjects in this study with other studies, the
findings were similar [2,11]. While subjects were asked
35
to comment on any interference in work productivity
that the stretching programs might have caused, none
was reported. Some did complain that the kitchen timer
on the FLIP version of the stretches was too loud and
that was modified by placing a piece of tape over the
speaker on the device to decrease the volume.
5. Conclusions
When subjects were reminded to perform stretch-
es once every 6 minutes while seated at a computer
workstation, associated pain was significantly reduced.
The type of media used to prompt stretching while at
the computer was not related to a significant difference
in outcomes. Pain Spot Assessments may be a re-
liable tool for evaluating pain. A study that extends
the stretching protocol to a larger population with an
extended follow-up is recommended.
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Appendix A: Workstation evaluation
Subject # Picture # Date
Workstation and picture evaluation: A 17-point scale
for evaluation of computer workstations and pictures.
One point is to be deducted for each problem area
detected. References that support the use of each item
in the protocol follow the statements.
1. Keyboard type is ergonomic [13,21,28,48]
2. The mouse is held using a neutral position of the
wrist [21,28,35]
3. Top of computer screen is at the level of the eyes
(within 15 degrees) [13,21,25,28,35,36]
4. Chair height is adjustable [21,28,35]
5. There is space between back of knees and front
edge of chair [13,21,34,35]
37
6. There are supportive arms on chair [13,21,28]
7. The back on the chair is supportive [13,21,24,
3436]
8. The back of the chair adjustable [13,21,24,28,
35]
9. There is a lumbar support [13,21,35]
10. Elbow angle is 70-90 degrees when hands are
on keyboard [21,24,28,35,36]
11. Elbows are supported when using the key-
board [12,13,16,21]
12. Elbows are supported when using the mouse [13,
16,21,30,31]
13. Wrist angle is within 10 degrees of neutral when
using the keyboard [13,21,28,34,35,48]
14. The feet touch on floor [13,21,28,34,35]
15. A 7090 degree angles of the knees, and 90
degree angle of the buttocks is evident when
seated at the workstation [13,21,28,34,35]
16. There is a document holder at eye level [13,21,
28,35,36]
17. Glasses do not alter the neck position from neu-
tral when using the computer [1,21,24,28,34,35]
This protocol for assessment of individual worksta-
tion risk factors was based upon consensus of the fol-
lowing authoritative input as published in the following
literature [1,13,16,21,24,25,28,30,31,3437,48].
Copyright of Work is the property of IOS Press and its content may not be copied or emailed to multiple sites or
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Copyright of Work is the property of IOS Press and its content may not be copied or emailed to multiple sites or
posted to a listserv without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.