thornton.p65 Carpal Tunnel Syndrome in ARL Libraries 9 9 Carpal Tunnel Syndrome in ARL Libraries Joyce K. Thornton Carpal tunnel syndrome (CTS), commonly found in manufacturing op- erations, is spreading from this traditional haunt to nontraditional set- tings. Libraries are one setting where employees are sustaining an in- creasing number of CTS injuries. This study reports the results of a survey of the libraries holding membership in the Association of Re- search Libraries. Based on information obtained via a questionnaire, the study reports the incidences of CTS and the measures libraries are taking to cope with this pervasive health condition. Repeated comments from respondents also are included. This article concludes by listing recommendations to help reduce carpal tunnel syndrome. Joyce K. Thornton is Executive Assistant to the Dean and Director of Libraries at Texas A&M University; e-mail: jkthorn@tamu.edu. surgery. If not currently at your library, carpal tunnel syndrome is on its way. Carpal Tunnel Syndrome Described Rapid continual motion or rapid repeti- tive motion can cause injuries to the body. These injuries are known collectively as repetitive strain injuries (RSIs), repeated trauma disorders (RTDs), or cumulative trauma disorders (CTDs). The terms re- fer to the group of musculoskeletal dis- orders involving injuries to the tendon, tendon sheaths, and related bones; and the muscles, ligaments, and nerves of the hands, wrists, elbows, arms, shoulders, neck, back, or legs.2 One CTD, carpal tun- nel syndrome (CTS), has reached epi- demic proportions and has been called the technological disease of the �90s. Of- ten CTS is caused by repetitive motion and is common in occupations that re- quire repetitive use of the hands, such as keyboard use. Kate Montgomery de- he computer �s presence is so pervasive in our lives today that we hardly notice it. It is a very rare occasion when a person�s life and occupation are not in some way affected by computers. Librar- ies are no exception. Computers have become indispensable tools in library culture because they are effective and efficient in serving the library�s needs, but recent information suggests that computer operations may cause pain, create emotional stress, and diminish the quality of work life for users. Com- puters simplify jobs into smaller, more repetitive tasks so that people can work faster and longer while produc- ing more�but at what price?1 As staff pound away on the keyboard rapidly and continually, it in turn is pounding them. This repetitive pounding can lead to debilitating pain, hours of physical therapy, and in many cases 10 College & Research Libraries January 1997 FIGURE 1 Growth in Number of Cumulative Trauma Disorders Cases Source: U.S. Department of Labor, Bureau of Statistics, BLS Reports on Survey of Occupational Injuries and Illness. scribes CTS as entrapment and compres- sion of the median nerve because of structural, muscular, and postural mis- alignment. It is brought on by the over- worked, overstrained muscles of the arms and hands, resulting in a loss of nerve conductivity leading to muscle- strength problems.3 According to the Bu- reau of Labor Statistics, CTDs are grow- ing far more rapidly than other work-related problems (see figure 1). The 302,400 CTD cases reported in the United States in 1993 were 165 percent higher than those reported in 1988. In 1996, the Occupational Safety and Health Admin- istration (OSHA) provided a more spe- cific breakdown of CTD injuries, includ- ing type of CTD. These reports also suggest that CTDs are spreading from their traditional haunts in manufacturing and are affect- ing increasing numbers of workers in offices, retail stores, and other nonfactory settings.4 CTS is the most commonly re- ported of the CTDs, and recent informa- tion suggests that libraries are one set- ting where employees are sustaining an increasing number of CTS injuries. Thomas suggests that the condition may affect both hands or only one hand, but the symptoms are usually greater in the dominant hand.5 Some library posi- tions require workers to hold a sustained posture as they carry out the same tasks again and again. Many jobs focus the entire workday into one or two small sets of muscles that hold or repeat a motion all day. The amount of time these muscles and tendons spend under tension re- duces their blood supply, thereby contrib- uting to CTS.6 CTS and related repetitive stress injuries are removing employees from their jobs and requiring hours of re- habilitation therapy and sometimes sur- gery.7 Current automation practices that call for extensive use of computers, coupled with the application of antici- pated new technologies essential to li- Carpal Tunnel Syndrome in ARL Libraries 11 brary operations, are requiring adminis- trators to assess CTS problems in the or- ganization and to provide ways of pre- venting and reducing this sometimes crippling disease. Literature Survey Medical, corporate, and government publications are replete with articles on CTS, repetitive stress, and repetitive mo- tion injuries. However, a search of library literature reveals few articles on CTS in libraries. Ricks has defined CTS, and de- scribed its causes and treatments. He con- cludes that as libraries implement new technologies, the risk of developing CTS among employees will increase.8 LaRue has looked at health hazards (including repetitive strain injuries) surrounding the use of video display terminals. He cau- tions that RSI is not to be taken lightly and that CTS is costly, thus prevention is far better and cheaper than the cure.9 In 1990, James M. Kusack surveyed fifty-eight large public libraries to find out whether public library employees were affected with CTS as much as news- paper or telephone company employees were.10 Of the thirty-eight libraries re- sponding to his survey, seventeen re- ported one or more employees with CTS (one of which reported nine cases) and twenty-one said they were unaware of any injured employees in their libraries. Forty-nine injuries were reported, six of which required surgery and one of which required steroid injections. Most required time off the job or the use of braces. Kusack found that all categories of em- ployees were affected�thirty-four cases were support staff and three were librar- ians. Thirteen of the forty-nine injured spent more than 50 percent of their time at keyboards or computer workstations, and three of those injured spent less than 10 percent of their time at a keyboard. This library reported that it could not trace its three cases specifically to library- related work because the three injured persons spent only 10 percent of their time at keyboards. Eight of the reported cases were among circulation clerks who were responsible for sensitizing and de- sensitizing library materials. Kusack re- ports that the nature of the work and the amount of time spent on a single task are contributing factors for potential injury. Other factors include incorrect worksta- tion design and poor work methods. Related articles include Richard Eissenger and Thomas W. Ricks�s discus- sion of how a large academic library was coping with repetitive-motion injuries.11 Eissenger and Ricks surveyed members of a library staff to find out the number of work-related injuries in the library and to establish the level of the staff �s con- cerns about and knowledge of repetitive- motion injuries. The researchers con- cluded that new technologies will con- tinue to be implemented by librarians who must be aware of the potential prob- lems that come with them. The authors think that working within a cooperative rather than an adversarial environment can allow the fullest use of these new technologies, where productivity and a healthy environment can exist together. Teri Switzer has outlined a six-step cost- effective ergonomics program developed at Colorado State University.12 She con- cludes that the key elements to a success- ful ergonomics program are creating a sense of ownership and helping staff to realize that their well-being is important. Prevention is an important management tool in the fight against carpal tunnel syn- drome. An article by Elizabeth N. Steinhagen and Carolyn J. Mueller discusses ergo- nomics from the catalog librarian�s per- spective.13 The authors reemphasize the fact that �little is found in the literature� Eight of the reported cases were among circulation clerks who were responsible for sensitizing and desensitizing library materials. 12 College & Research Libraries January 1997 on how, or whether, librarians are ad- dressing ergonomic concerns. They de- veloped a questionnaire to obtain data, focusing on the catalog librarian in 185 medium-sized academic libraries, on the amount and types of cataloging being done, and on the availability of ergo- nomic options. The authors concluded that as online public access catalogs be- come more prevalent, catalog librarians are expected to become more frequent users of computers, leading to concerns about physiological effects of computer use and greater availability of ergonomic furniture and other remedies. This sur- vey is the first attempt at reporting on how a group of academic libraries is cop- ing with CTS. Methodology This author �s interest in carpal tunnel syndrome in academic libraries stems from being employed in a large academic library with a collection of 2.1 million volumes where over a five-year period (1990�95), twenty-seven (13.5%) of the two hundred employees were diagnosed with, or showed symptoms of, CTS; two (1%) required surgery and eight (4%) wear wrist braces for therapeutic reasons. The goals of this study of CTS among libraries that are ARL members are to: (1) determine the number of reported cases of CTS, (2) learn what measures these libraries are taking to alleviate this affliction, (3) provide information on the positions most affected, (4) find out if the amount of time spent at keyboards or computer workstations influences the number of cases, and (5) ascertain whether changes are being made in per- sonnel policies because of CTS. A com- ments section and a request for pertinent information were included on the survey. To obtain information, a short ques- tionnaire was formulated and mailed to the 119 ARL directors in November 1995. To increase the number of surveys re- ceived, a reminder was faxed to the sixty nonresponding libraries in January ex- tending the deadline to February 15, 1996. Ultimately, seventy-six libraries (64%) responded, including seven of the eleven nonuniversity libraries. Four of the sev- enty-six responding libraries did not TABLE 1 CTS Incidence Rate No. of Total Diagnosed % of Staff Library Staff CTS Cases Affected 1 215 4 1.9% 2 282 3 1.1 3 229 0 0.0 4 95 0 0.0 5 110 1 0.9 6 200 2 1.0 7 500 50 10.0* 8 509 3 0.6 9 129 0 0.0 10 245 5 2.0* 11 300 7 2.3* 12 338 10 3.0* 13 205 2 1.0 14 111 3 2.7 15 125 3 2.4 16 137 2 1.5 17 398 10 2.5* 18 210 5 2.4* 19 170 9 5.3 20 165 4 2.4 21 150 3 2.0* 22 160 0 0.0 23 187 3 1.6 24 124 5 4.0* 25 262 1 0.4 26 204 6 2.9 27 417 50 12.0 28 140 1 0.7 29 109 8 7.3 30 275 27 9.8* 31 187 5 2.7 32 278 UA 0.0 33 200 10 5.0 34 435 7 1.6 35 250 9 3.6* 36 114 1 0.9 cont. Carpal Tunnel Syndrome in ARL Libraries 13 complete the survey for various reasons including: requested information not col- lected, insufficient staff to answer all sur- vey requests, and library policies restrict- ing responses to surveys. Seventy-two li- braries completed the survey. Findings One of the goals of the study was to learn the number of cases of CTS, thus the first question asked for the total size of the staff to calculate the reported incidence rate of CTS for each library. Size of staff (excluding students) ranged from 66 to 535 (see table 1). The second question asked for the number of staff who had reported incidences of carpal tunnel syn- drome. Respondents were instructed to give an estimate if a precise number could not be given. One library reported having no procedure for providing this informa- tion; nine libraries reported no CTS inju- ries; and twenty-one libraries (29%) pro- vided estimates ranging from one to fifty injuries per library. One library that pro- vided an estimate said that CTS is occur- ring but because medical and claims policy exclude the unit from being in- volved, only self-reporting is available. Two libraries reporting estimates stated that some complaints came from staff who also had repetitive hand movement from recreational or outside interests. In all, forty-one libraries reported a total of 277 injuries. One library of 500 employees estimated that 10 percent of the staff suffered from CTS; another li- brary with 201 employees reported twenty-seven injuries; a third reported fifty injuries in the past five to six years; and a fourth reported twenty-nine cases within a staff of 176. In reporting the number of staff receiv- ing medical treatment for CTS, fourteen libraries reported estimates ranging from three to fifty cases per library, and three libraries said that the information was unavailable (although one of these said that it had an increasing number of em- ployees out on medical leave). Two librar- ies reported that the number was un- known. One library did not respond to this question. Two libraries said that the question was not applicable. Seven librar- TABLE 1 cont. CTS Incidence Rate No. of Total Diagnosed % of Staff Library Staff CTS Cases Affected 37 432 1 0.2% 38 125 0 0.0 39 255 1 0.4 40 170 15 8.8* 41 181 12 6.6* 42 283 2 0.7 43 180 1 0.6 44 146 5 3.4* 45 66 0 0.0 46 380 5 1.3* 47 116 7 6.0 48 210 4 1.9 49 272 1 0.4 50 421 18 4.3* 51 230 4 1.7 52 145 0 0.0 53 110 1 0.9 54 514 10 1.9* 55 368 6 1.6 56 535 4 0.6 57 75 7 9.3* 58 115 8 7.0 59 201 27 13.4 60 151 1 0.7 61 124 4 3.2 62 208 10 4.8* 63 216 0 0.0 64 380 5 1.3* 65 176 29 16.5 66 91 3 3.3 67 423 23 5.4 68 165 11 6.7 69 213 3 1.4* 70 227 10 4.4 71 143 8 5.6* 72 157 4 2.5 Total 16,463 509 3.1 *Estimates provided by libraries. 14 College & Research Libraries January 1997 ies reported that none of the staff had received medical treatment. Forty-three libraries reported that 322 employees re- ceived medical treatment, including twenty-two who had surgery and seven who received therapy. Several libraries that provided an estimated number of in- cidences of CTS were able to report ex- act numbers for those staff who received medical treatment. The fourth question solicited informa- tion on job titles and percent of time spent using keyboards or sensitizing/desensi- tizing equipment. Fourteen libraries did not answer this question. Five libraries reported job titles, but not percent of time spent at keyboards. Figure 2 shows the average percentage of the workweek each category of personnel spent using computer keyboards. Group E, which in- cluded computer support specialists, database managers, programmers, heads of automation, and system heads, spent a large part of the workweek (83%) us- ing keyboards. The nonlibrarian profes- sional group (group C) used a keyboard 58 percent of the time. This group in- cluded administrative assistants, execu- tive assistants, staff assistants, newslet- ter editors, and development officers. Library technicians, library assistants, and library specialists (group G) were the third heaviest users of keyboards, spend- ing an average of 45 percent of their workweek at keyboards. Interestingly, the secretaries group (group F) and the nonadministrative librarians in group B reported similar computer use (42% and 40%, respectively). The library adminis- trators, which included library directors, archivists, and department heads, used a keyboard an average of 33 percent of the workweek. Individuals classified as clerks, photocopy staff, and mail room clerks (group D) reported a keyboard fre- quency of 37 percent. Forty-three libraries reported that 322 employees received medical treatment, including twenty-two who had surgery and seven who received therapy. FIGURE 2 Average Time Spent Using Computers A. Lib. Admin. B. Other Lib. G. Lib. Assts.E. Comp. Staff F. Secretaries C. Other Prof. D. Gen. Staff Carpal Tunnel Syndrome in ARL Libraries 15 For comparison purposes, figure 3 provides the percentage of the total cases of CTS that fall within each category. It should be noted that group G included 52 percent (individual) of the CTS cases. Thus, libraries would do well to include this particular staff in any educational or preventive program. Regarding the measures libraries had undertaken to eliminate, prevent, and provide relief for CTS, respondents were asked to check all items that applied. Sixty-five libraries bought adjustable er- gonomic chairs, some in response to CTS problems. Several libraries that reported no cases of CTS purchased ergonomic chairs anyway. Forty-five libraries pur- chased ergonomic desks/workstations, thirty-two purchased ergonomic key- boards, and fifty-one purchased other supporting equipment such as wrist rests, footrests, and keyboard shelves, mostly on a case-by-case basis. Forty-two libraries provide training in the use of ergonomic chairs/workstation, and forty routinely provide training on preventive measures, whereas some provide train- ing as requested. Twenty libraries pro- vide training exercises to develop flex- ibility and strength in vulnerable areas. Fourteen libraries actually changed their personnel policy to allow more frequent breaks; others have achieved the same ef- fects informally by encouraging staff to take frequent breaks. The response for varying tasks seemed to follow the same pattern as taking more frequent breaks. Job rotation was informal and left up to the discretion of the department head. Other noted changes included: (1) educating employees and sharing re- sponsibility for prevention, (2) changing heights of work surfaces/retrofitting ex- isting desks and tables, (3) including er- gonomics as a part of new staff orienta- tion, (4) creating active ergonomic com- mittees or teams, (5) establishing tasks forces to review the literature and de- velop training sessions, (6) developing a light-duty program (work not involving heavy computer use), (7) outlining pro- cedures to follow in case of injury, (8) try- ing a combination of solutions as circum- stances dictate, and (9) evaluating staff for potential problems. One library said that it was in the middle of evaluating its central technical services unit of more than 100 employees, and had found that 20 percent are at high risk and 80 percent are at varying levels of risk. These find- FIGURE 3 Percent of Total Cases in Each Job Category 16 College & Research Libraries January 1997 ings have led this library to embark on a �program of education of employees plus shared responsibility for preven- tion.� When asked for the items found to be most helpful in alleviating CTS, the two items listed most frequently were ergonomic chairs and wrist rests/pads. The seventh question asked for the number of employees shifted to other jobs because of CTS and to what jobs they were shifted. Several libraries said that employees have the opportunity to job share where computers are not needed. Several indicated that some employees were shifted on a temporary basis when warranted. One library reported one employee on leave waiting for the results of surgery. One person was shifted from typing to answering the phone�head- sets were provided. One was shifted from photocopying to equipment mainte- nance, and one to a branch library where time at a keyboard was reduced dramati- cally. One person was shifted to several different jobs/areas and special projects were designed to find a suitable match. Some employees were temporarily shifted to light-duty work. One was shifted from shelving to payroll; and a stack assistant was placed on modified assignment, progressively reintroducing the regular assignment with instruction, assistance, and close monitoring by the head of the institution�s Environmental Safety and Health Office. One person was promoted from a billing clerk to a pro- fessional position, one was shifted from a circulation clerk to a branch library as- sistant, and one was shifted from admin- istrative assistant to library assistant. Responses to the eighth question show that twelve employees resigned due to CTS. Of these, workmen�s com- pensation benefits had expired for two individuals and no alternate position could be found. Two other received dis- ability retirement, and four were listed as medically separated. The ninth question asked if external help was used in conducting ergonomic training or other programs, and respon- dents were asked to describe the type of assistance used. Surprisingly, thirteen li- braries with no reported incidences of CTS brought in assistance, whereas only six libraries with no incidences of CTS did nothing. A total of thirty-three librar- ies used assistance from within the insti- tution, including personnel from the university�s environmental, safety, ergo- nomics, safety and health, personnel, and risk management offices. Thirteen librar- ies used local specialists including occu- pational and physical therapists, nurses, or trainers. Other types of assistance in- cluded an accident investigator and a consultant. Four libraries used library staff, ergonomic committees, or task forces using published materials, videos, etc. Three did not say what type of assis- tance was used. One library did not an- swer the question. Six libraries used more than one type of assistance. The last section of the study question- naire asked for comments on any of the questions. The major comments in- cluded: � the belief that CTS is underreported; � the helpfulness of ergonomic train- ing and review; � the evolving definition of ergonom- ics; � the lack of assistance and special funding to enable libraries to implement university-mandated occupational injury prevention programs; � the need for a better means of re- porting CTS; � the seriousness of CTS; � the pleasure for staff that library ad- ministration is encouraging them to learn more about preventing work-related in- juries; Thirteen libraries used local specialists including occupational and physical therapists, nurses, or trainers. Carpal Tunnel Syndrome in ARL Libraries 17 � the need for a general survey of com- puter-related complaints by long-term users; � the need for reasonable accommo- dations to alleviate the problem; � reluctance of some staff to report CTS injuries because they have not seen a doctor or do not want this information in their files. Conclusions The data collected in this study show that there is cause for concern about carpal tunnel syndrome injuries in academic li- braries. It shows a need for administra- tors to take immediate action to prevent and reduce the potential for injury. The health of all employees must be a top priority�financial constraints must not be used as an excuse to do nothing or to do very little. Continued extensive use of comput- ers and new technologies essential to li- brary operations will heighten the prob- lem. Measures must be in place to coun- teract the consequences. Administrators must take a close look at how jobs are structured. The more narrowly a job is defined (only computer input), the more likely it is that staff will develop CTS. Diversifying jobs may result in fewer cases. Prevention is the best approach to combat CTS. Purchasing ergonomic fur- niture and peripherals, promoting changes in job habits, and educating employees through well-designed ergo- nomic programs are the keys to main- taining a healthy, productive work envi- ronment. The results show that in many instances, the library should use exter- nal help in implementing ergonomic pro- grams. A further implication of the study is that other library tasks, including the handling of materials, photocopying, and outside activities may contribute to CTS. Administrators must take respon- sibility for reducing or removing the en- vironmental factors that contribute to this serious health condition. Recommendations The author recommends that libraries: � immediately implement a proactive ongoing ergonomics program; � solicit input from staff when devel- oping solutions for ergonomic problems; � provide guidelines for reporting CTS; � bring in external help from other agencies on the campus or elsewhere; � stress preventive measures and edu- cation in the fight against CTS; � immediately investigate ergonomic problems; � provide diverse tasks for heavy com- puter users; � periodically view the web sites ad- dressing various aspects of CTS. Computers in libraries are here to stay. Technology, especially those technologies calling for extensive computer use, will continue to transform the library work- place. With this transformation, there will likely be a considerable surge in the num- ber of CTS cases. As we use technology to enhance the capabilities of our human resources, we must take measures to pro- vide a safe and comfortable work envi- ronment for our employees. Additional Areas of Study To ascertain the full impact of carpal tun- nel syndrome in the workplace, other areas should be studied. There exists a need to research the indirect cost of CTS including loss of productivity, absentee- ism, cost for workers taking over for in- jured staff, and time lost for medical ap- pointments, therapy, and surgery/ recovery. These costs may reveal the ur- gent need for libraries to take more ac- tive measures in helping to prevent and eliminate CTS. Surely prevention is less costly than the alternatives. A second area for study is the number of workmen�s compensation and insur- ance claims being filed for CTS. This study could show more precise incidence rates for various job categories or departments. This would reveal high-risk areas�areas that would need frequent monitoring. 18 College & Research Libraries January 1997 Notes 1. Thomas W. Ricks, �What, Exactly, Is Carpal Tunnel Syndrome?� College & Research Libraries News 53 (Mar. 1992): 164�65. 2. Robert E. Thomas et al, �A Computer-Aided Algorithm for Evaluating Thermogram of the Hand,� Computers and Industrial Engineering 26 (July 1994): 501�09. 3. Kate Montgomery, �The Body Is Not a Robot,� Sportstouch CTS article, available at http: //www.sportstouch.com/art.html. 4. U. S. Department of Labor, Bureau of Labor Statistics, �Repetitive Tasks Loosen Some Work- ers� Grip on Safety and Health,� Issues in Labor Statistics, Summary 94�9 (Aug. 1994): 1. 5. Thomas et al, �A Computer-Aided Algorithm,� 501. 6. �Repetitive Strain Disorders,� RSIFAQ, available at http://www.impaccusa.com/impacc9b. html. 7. James M. Kusack, �The Light at the End of the Carpal Tunnel,� Library Journal 115 (July 1990): 56�59. 8. Ricks, �What, Exactly, Is Carpal Tunnel Syndrome?� 165. 9. James LaRue, �Terminal Illnesses,� Wilson Library Bulletin 66 (Sept. 1991): 85�88. 10. Kusack, �The Light at the End of the Carpal Tunnel,� 56�59. 11. Richard Eissenger and Thomas W. Ricks, �Coping with Repetitive-Motion Injuries in a Large Academic Library,� College & Research Libraries News 53 (Mar. 1992): 161�62. 12. Teri Switzer, �Ergonomics: An Ounce of Prevention,� College & Research Libraries News 56 (May 1995): 314, 316�17. 13. Elizabeth N. Steinhagen and Carolyn J. Mueller, �Ergonomics and the Catalog Librarian,� Technical Services Quarterly 9, no. 4 (1992): 29�37.