impact of computer

7/28/2019 Impact of Computer

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Work 18 (2002) 249259 249IOS Press

The physical impact of computers and

electronic game use on children and

adolescents, a review of current literature

Robin Mary GillespieDepartment of Ergonomics and Biomechanics, New York University, 454 Fort Washington Avenue #66, New York,

NY 10033, USA

Tel.: +1 212 927 1283; E-mail: [email protected]

Received 24 November 2001

Accepted 3 January 2002

Abstract: Children using computers and electronic games may adopt the kinds of sustained and awkward postures that are

associated with musculoskeletal disorders in working adults. If they do, the physical demands of extensive use could lead to a

wide range of adverse effects on developing children, including visual, neurological and physical changes. This article reviews

the literature related to media use, ergonomics, epidemiology and pediatrics that address the physical impact of computer use

by children. The literature establishes that computer use is common, but does not demonstrate a causal or statistical association

with any physical disorders. Laboratory studies on vision, case reports of game-related tendonitis and ergonomic analyses of

classroom computers suggest that concern is warranted.

Keywords: Ergonomics, musculoskeletal disorder (MSD), pain, technology, video games

1. Introduction

Children and adolescents are increasingly engaged inactivities that simulate work demands known to causerepetitive strain injuries in working adults. From theearliest years, children use computers at home andschool. Nursery schools and commercial play spaces

advertise computer classes, computer games are pro-duced for every age and interest, and reference mate-rials are sold on CD-ROM. But desktop computers arenot the only way kids interact with computer technol-ogy. Notebook computers are issued to middle-schoolstudents. TV-based video games are found in 70% ofhouseholds with children [77]. Handheld games areused everywhere, including the playgroundand school.Given the widespread and increasing use of computersand electronic devices, it makes sense to ask if chil-dren use this technology in physically risky ways, andif they experience pains or clinical problems related tothat use.

Computer use at work has been implicated in the

development of musculoskeletal disorders. In adults,

using a computer keyboard at work is thought to be

associated with musculoskeletal symptoms and clinical

disorders in the upper extremities, neck and upper back

[59]. Posture, duration, frequency and force are the

exposure parameters of concern.

Children using computers and electronic games maywell adopt the kinds of sustained and awkward postures

that are associated with musculoskeletal disorders in

working adults. If they do, the physical demands of ex-

tensive use could lead to a wide range of adverse effects

on developing children, including visual, neurological

and physical changes. (Cognitive and behavioral ef-

fects are also possible; these are reviewed extensively

elsewhere [9,22,28,99].) Some researchers have sug-

gested that computers and games encouragemore awk-

ward postures or intense concentration in children than

TV watching or schoolwork do, indicating that chil-

1051-9815/02/$8.00 2002 IOS Press. All rights reserved


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250 R.M. Gillespie / The physical impact of computers and electronic game use

drens risk of musculoskeletal disorders may be greater

than in other sedentary activity [31].This article reviews the ergonomics, epidemiology

and clinical literature that begins to address the ques-

tions related to the physical impact of computer use by

children. It does not delve into the extensive literature

on the cognitive impact of computer use and only in

passing will describe the related literature of classroom

ergonomics. Although the question of why computers

and similar devices are used so extensively and inten-

sively is clearly germane to the issues of impact, health

effects and prevention, it is beyond the scope of this

article.

Five main research streams provide insight into the

impact of computer and electronic game use on chil-

dren.

Stream 1: Computer use literature describes the fre-

quency and duration of computer use as well as elec-

tronic games use, television watching and other related

activity.

Stream 2: Workstation research attempts to ana-

lyze the goodness of fit between children and computer

workstations, typically in the classroom.

Stream 3: Musculoskeletal symptoms research pro-

vides comparative rates of musculoskeletal disorders in

children.

Stream 4: Health effects research combines thesethree streams to investigate the link between physical

effects and computer use parameters of frequency, du-

ration, posture and ecology. Effects of interest typ-

ically include musculoskeletal pain, visual problems

and physiological changes.

Stream 5: Preventive measures research intervenes,

typically in the classroom, to change how computers

are set up and used, and measures the impact of the in-

tervention on changes in health outcomes or presumed

intermediary variables such as behavior. Ideally, it is

based on knowledge derived from all the preceding re-

search streams.

2. Research Stream 1: Patterns of computer use

Many children already use computers intensively, at

school and play. Home use of games and CD-ROMs

can occupy even very young children for hours, as do

television-based video games and hand-held toys. Par-

ents, receiving the message that children who dont use

computerswill miss out on academic and work success,

encourage computer games and learning activities.

Media use has changed dramatically in the past ten

years. The Longitudinal Study of American Youthfound thatonlyone in fifty kidsin 1990used a computer

outside of class for ten or more hours during a school

year [79]. Just five years ago, research on childrens

computer use characterized significant classroom com-

puter use as more than ten times per subject in the

school year [71]. Now researchers are asking about

daily use, about minutes or hours per day, and about

several different types of media interfaces [77,90,104,

105].

Several major surveys catalog computer use in the

home and at school. According to the annual Current

Population Survey of the US Census Bureau, in 2000

89.6% of children aged 6 to17 hadaccess to a computer,

65% at home and 80% at school [61]. Just three years

earlier, 74% of children had some access to a com-

puter, 50% at home and 70.8% at school [60]. In 2000,

the NPR/Kaiser Family Foundation survey found that

78% of telephone survey respondents had a computer

at home [80].

The Media in the Home annual telephone survey

characterizes duration of home use as well as ac-

cess [104]. According the results for 2000, seventy

percent of families with children between 2 and 17

have computers and 68% have video games. Based

on parent reports, the average child uses a computerfor 34 minutes a day, the Internet for 14 minutes and

a video game for 33 minutes. Screen media use for

all children, including television, videotapes, Internet,

computer and games, exceeds four and a half hours. At

281 minutes per day, this is up 21 minutes from the pre-

vious year. Predictably, media use increases with age,

although video game use does not increase between the

611 and 1217 age groups. VCR use decreases with

age. Parents report that adolescents spend 164 minutes

daily on computers, Internet and video games and an-

other 195 minutes watching television and videotapes,

for a total of six hours of screen exposure.

The Kaiser Family Foundation reports from class-

room survey results that in 2000, children spent an av-

erage of five hours and 29 minutes on all media com-

bined (including music and reading) [77]. Nine per-

cent of all children use a computer for more than an

hour a day, and 8% play video games for more than

an hour. In a related telephone survey, 57% of these

children used the computer almost daily. (One caveat

about generalizingthis result is that the next level of use

offered to respondents was about once a week, which

clearly could inflate the apparent use. This group was

also notably higher in access and use than others sur-


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R.M. Gillespie / The physical impact of computers and electronic game use 251

veyed.) Averaging over all children reduces the appar-

ent load of computer use, of course. Among computerusers aged 818, average daily use was 101 minutes.

The 1999 Media in the Home survey provided evidence

that heavy media users are heavier across the board,

with computers and electronic games being added to

television watching rather than replacing it [90].

A national survey of childrens electronic media use

in 1997 analyzed 24-hour time use diaries from 2902

children aged 0 to 12 [105]. Only 25% reported video

game use. In contrast, in the NPR/Kaiser telephone

survey in 2000, 82% of all children report using video

or computer games, and 35% of all children did so

almost daily [80].

Electronic media use changes with age, and is af-

fected by other demographic characteristics (compre-

hensively reviewed by Wartella and by Behrman [9,

99]). Although in 1996 younger children were more

likely to report at least weekly computer use (74% of

4th graders compared to 50% of 11th graders), older

children reported more daily use (9% of 4th graders

compared to 16% of 8th graders and 18% of 11th

graders) [58]. Through early childhood, video and

computer game use increases with age [38]. Computer

game use decreases by early adolescence [16]. More

older children than younger use video games, but there

was no age effect on amount of use [105]. Girls andboys have similar access to computers, but typicallyuse

computers slightly differently [60,105]. Within each

age group, boys were significantly more likely to use

video games; this sex difference is confirmed in other

studies, which also indicate that the content and genre

of preferred games differed by sex [16].

As with access, income and ethnicity affect use [80].

People with lower incomes have less access in both

arenas, although the disparity is less at school than

at home. Lower SES children spend more time with

videotapes and TV. However, in households with com-

puters the rates of Internet and computer use are not

different between income groups. In the Kaiser Fam-

ily Foundation survey, the race inequities are reversed

among computer users: Hispanic and Black children

who do have access to computers spend more time at

it (109 minutes for Hispanic, 94 for Black and 80 for

White) [77]. Economic disparities for computer own-

ership did not change appreciably between 1997 and

2000.

In summary, most children and adolescents in the

United States do use computers and electronic games

regularly. Although levels are not the same as that for

computer users who are at risk of work-related upper

extremity problems, the overall burden of computer

and electronic device use is large. Combined mediause estimates approach a working day, with keyboard

use alone accounting for up to three hours. Newer

technologies may add to the physical load. Curiously,

none of the research reviewed here characterizes hand-

held game use separately from other games. The recent

introduction of small text messaging devices, which

can be used everywhere and anytime, may create an

additional hand stress that warrants consideration.

3. Research Stream 2: Workstations

The setting as well as the duration and frequency

of computer use is important in characterizing risk.

Typically, research has focussed on the classroom. An

extensive literature has been produced about school

furniture in the past 10 years by researchers around the

world. Mismatches between schoolroom furniture and

children have been shown in the height and design of

desks and chairs [1,49,51,68]. The interested reader

should refer to a review by Yeats [106], as well as

additional research and policy articles [20,37,47,53,63,

88,89,96,97].

Much less has been published about computer work-

stations for children. Available evidence suggests that,like schoolroom furniture, typical computer worksta-

tions at school are not well suited to most children.

Concern about the physical demands of computersused

at school was expressed as early as 1980 by French re-

searchers who evaluated the impact of VDT use on fa-

tigue in technical high school students [18]. The team

also evaluated visual fatigue [30,32]. No effect was

identified except in some students with existing visual

problems. Despite their lack of findings, due in part

to their small sample sizes and short exposure times,

Cantineauwarned that younger children, and especially

those most enthusiastic about use, may still be at risk

of adverse physical effects from computer use [19].

In the past decade, teams around the world de-

scribed similar concerns. In 1997, the Fifth Inter-

national Scientific Conference on Work with Display

Units in Tokyo included seven papers on childrens use

of computers or screen devices. Knave reported that

the rapid increasing use of computers in schools had

not let to evidence of related musculoskeletal disor-

ders [46]. Researchers in Sweden, Japan and Italy an-

nounced a project to evaluate how computers are used

in schools and whether ergonomic concept are consid-

ered [11]. The survey was distributed to administra-


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tors in school districts around the world, including the

United States; results are not yet available. Jonnsondiscussed Swedish work regulations and their relation-

ship to computer use at school [42], and Johansson

and others described a project to address the school

computer work environment, including the integration

of multimedia [41]. Three papers, described below,

explored the visual effects of computer use. As re-

ported by Saito [82], extensive Japanese research activ-

ities also include classroom workstation analysis and

furniture.

Researchers have documented that children typically

do not fit available workstations at school. Using a

modified RULA analysis of 95 children aged 8.511.5,

Oates reported that none of the children were able to

use the computer according to accepted postural rec-

ommendations [66]. The subjects total RULA scores

were either of some concern (61%) or indicated pos-

tural risk (39%). The legs, wrist and neck were con-

sidered at particular risk, largely because of too-high

monitors, keyboards and chairs. Oates compared ob-

served workstation dimensions to those recommended

by Wilson [102], finding that no school workstations

could be considered adequate. (It must be noted that

Wilsons guidelines were based on monitor height and

postural recommendations that may be somewhat out-

dated, as well as anthropometric data produced morethan thirty years ago. This does not negate Oates find-

ings, and may in fact give them more weight. For ex-

ample, setting the monitor center at eye level is gen-

erally accepted to be too high [17,98], which means

that Wilsons conversions to childrens dimensions are

probably not correct. Thus the workstations observed

by Oates may be even farther from ideal.

Browns dissertation study of 1063 workstations in

14 public schools also showed that sound ergonomic

principles were not integrated into school computer

classroom design and furniture selection [14]. He

found that all keyboards and monitors were too high,

and no equipment was adjustable. Other parameters of

seating and workspace met guidelines at some grade

levels. Like Wilson, Brown relied on possibly outdated

sources to establish acceptable standards and develop

recommendations, suggesting that the problems may

be worse than he reports.

Noro and others [64] report a huge mismatch be-

tween children and available workstations: tables and

chairs are too big, and input devices do not match hand

and arm sizes. They also point out that the human

factors dimension is also a bad match: most school

computer use includes more than one child, yet there is

no attempt to use multiple control devices or adjust the

workstation. (The teachers need to view the childsscreen without strain is also important. This relates to

Williams concerns about computer-related pain symp-

toms experienced by teachers [101].)

In a laboratory setting, Laeser [48] provided ev-

idence that changing the keyboard angle improves

RULA scores and encourages 6th and 8th grade chil-

dren to work longer at a typing task.

Harris and Straker [34] documented that children in

three private Australian schools using laptops provided

by their schools maintained potentially stressful pos-

tures. Only 34% of laptop time was spent at a desk.

Other postures described included lying prone, sittingon the floor and sitting with the computer in the lap.

Average daily use in the past month was 3.2 hours in

219 predominantly female (87%) children aged 10 to

17; the highest total daily use reported was 15 hours.

Themean longest single period of use was 102minutes.

The physical impact of this will be described later. In

related research, Zandvleit and Straker, investigating

the relationship between psychosocial and physical fac-

tors in the classroom, revealed a potentially complex

association among computer and workspace factors and

psychosocial factors such as task orientation [107].

The ergonomic demands of computer use are prob-

ably even greater at home, where computers used by

the whole family are set up in conditions not optimal

for adults and without consideration for smaller peo-

ple. Children sit unsupported, with feet dangling,necks

tilted to view monitors too high for most adults, reach-

ing out and up for pointing devices andkeyboards. And

home is where children spend most of their computer

time as well as use electronic games. As yet, no data

on home computer use ergonomics has been published.

Based on this literature, and on most observations,

children and adolescents are not using computers in

ideal circumstances. However, little is known about

the ecology of use in these settings, such as how oftenchildren take breaks or what variety of postures they

adopt. Evidence aboutthe ergonomicdemands of other

electronic device use is not present in the literature, ex-

cept for visual demands research described below [56,

82,83].

The question remains, what impact do the observed

use patterns and postural demands have on the muscu-

loskeletal health and development of child and adoles-

cent users of computers and electronic devices? An as-

sessment of the baseline rates of symptoms and clinical

problems is necessary before this can be determined.


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4. Research Stream 3: Musculoskeletal symptoms

rates

Baseline rates must be taken into account when plan-

ning and analyzing studies of association between ex-

posures and symptoms. Clinical musculoskeletal syn-

dromes in children are rare in the absence of structural

abnormalities, trauma or obvious excessive use such

as competitive sports or dance performance [3,52,74,

85]. Low back pain, which has been investigated ex-

tensively, is seen in about 1520% of adolescents every

year [7,31,33,67,75].

Research on the overall rate of musculoskeletal pain

in the general population of children and adolescent

has producedwidely varyingprevalence estimates. Ac-

cording to Mikkelsson, 32.1% of Finnish children in

their sample reported weekly musculoskeletal pain not

due to injuries [55]. Eggers review describes estimates

of 5%20% for weekly musculoskeletal pain, 10%

30% for headaches [27]. Musculoskeletal pain was re-

ported by only 2.2% in this southeastern US sample,

in part because cases were defined as those experienc-

ing symptoms more than 3 times per week for the past

three months. Bru asked his 8th grade Norwegian sub-

jects about muscle tension, lower back pain and neck

or shoulder pain; 9.5% report at least one severe mus-

culoskeletal symptom [15]. Neck or shoulder pain wasreported by more than 40%, with 13% reportingmoder-

ate or severe complaints. Perquin and others found that

pain is a common experience in their survey population

of more than 5000 children in the Netherlands [73]:

53.7% of all of all children aged 0 to 18 experienced

pain in the previous three months, with 25% having

symptoms lasting more than three months according

to parent or self reports. Among older children and

adolescents (818 years), about 15% of girls and 7%

of boys report severe chronic pain. Evaluating 1000

clinic visits in an urban general practice, de Inocen-

cio found that 6.1% were attributable to musculoskele-

tal complaints related to trauma (30%), developmental

problems (18%) and overuse syndromes (28%) [23].

Generally, girls report more symptoms than boys do,

and symptoms increase with age.

Thus, musculoskeletal pain is common in children

and adolescents, although as yet tendonitis and other

clinical syndromes are not. This will make evaluating

the impact of computers and electronic games difficult.

Because pain is commonly reported by children and

adolescents, an increase in symptoms related to com-

puter use may be difficult to identify at the population

level unless it is quite large.

5. Research Stream 4: Health effects of computer

and electronic games use

So what is the evidence that computer use is as-

sociated with physical symptoms? Computers might

produce visual, cognitive, neurological, behavioral or

physical changes in developing children. The variety

of behavioral and cognitive changes currently being in-

vestigated have been extensively reported on and re-

viewed, notably by Wartella and by Shields [86,99].

The current discussion will be limited to physical ef-

fects potentially associated with computer use.

Blisters caused by control devices have been re-

ported [103] and in 2000 led to a settlement between

Nintendo and the New York state attorney general re-

quiring the company to provide protective gloves to

users of one product version [24,62]. In 1998, the US

Consumer Product Safety Commission reported that

almost 10,000 emergency room visits were attributable

to computers(equipment and electronic games); half of

these events involved people under 24 [21]. Whether

these were acute or chronic problems is not clear.

Epileptic seizures were probably the earliest health

effect attributed to computer game use [35,43]. Video

games are not thought to cause epilepsy but can initi-

ate seizures in a vulnerable subpopulation of epileptics.

Video game use, like television viewing, may be asso-ciated with excess weight [78]. Other effects poten-

tially linked to computer use include nausea, headache,

fatigue and fever seen in a set of heavy computer

game users in Japan [94]. None of this research estab-

lishes that computers cause significant health risks. In

contrast, Segal measured cardiac and metabolism re-

sponses, similar to the effects of mild exercise, in chil-

dren using video games. The changes were not enough

to suggest any health advantage [84].

Visual demands at young ages are thought to con-

tribute to myopia [6,69,70,95]. The visual demand of

computer use may be even greater in countries with

complex written characters [82]. Could computer use

have a similar effect? Researchers in Japan have shown

that childrens vision is affected by electronic game use.

The blurry target of small handheld games produces

a greater accommodative load than larger computer

screens or cartoon drawings [83]. Although this study

of young children was too short to demonstrate a per-

sistent effect, the authors speculate that this exposure

may lead to myopia. Miyao and others demonstrated

transient changes in accommodation and increases in

myopia with video game play in older children [56].

Marumoto and others observed that increased neck an-


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gle reduces viewing distance and possibly contributes

to deficits in accommodation; they believe that theirfindings are relevant to computer monitor use as well

as the reading task they measure [54]. Based on re-

search indicating that virtual reality viewing leads to

visual disturbance in adults, Rushton and Riddell posit

that early exposure may adversely influence the devel-

opment of the visual system in children [81].

What about musculoskeletal disorders such as ten-

donitis or nerve compression? A growing body of ev-

idence implicates school furniture size and design in

back pain and other physical symptoms in children [49,

51,53,68,106]. Because computers invite sustained

postures and intense concentration, the strain related

to inadequate design, limited adjustability and lack of

training may be greater than in other school activities.

The most immediate impact is likely to be strain and

pain in soft tissues, which can be early signs of serious

health problems such as tendonitis and carpal tunnel

syndrome.

Recent articles and professional discussions indi-

cate that heavy computer users risk repetitive strain in

late adolescence and early adulthood. Musculoskeletal

problems that affected career plans were reported in

college journalism students almost ten years ago [40].

An informal survey paper published on the Internet

supports this concern: students showed high rates ofpain they attributed to computer use, however the asso-

ciation with time spent on a computer was not signifi-

cant [72].

In a survey of 1601 college seniors, increasing time

spent on the computer was significantly associated with

increasedreporting of musculoskeletal painand clinical

syndromes (p value for trend = 0.0001) [44]. Students

reporting more than 20 hours weekly computer use

were 40% more likely to experience symptoms (Odds

ratio = 1.4, 95% CI: 1.1 to 1.9). As is typical in this

literature, women were more likely than men to report

symptoms. Fifty-three percent of all students reported

some computer-related symptoms.

Little is known about the epidemiological or phys-

ical ergonomics relating to younger people who use

computers or other devices. Knave has stated that

despite concerns no pattern of symptoms related to

computer use had been observed [45,46]. In the

Harris paper described earlier, 60% percent of sub-

jects reported discomfort using or carrying their lap-

top computers [34]. Significant relationships be-

tween symptoms and exposures were found only for

type of laptop (symptoms experienced while carrying,

2 = 65, p = 0.0001), school location (also while

carrying, 2 = 63.58, p = 0.0001) and school year

(level of symptoms, 2

= 15.75, p = 0.0275), not formaximum or mean daily use.

Straker describes a related study comparing symp-

toms experienced by children while reading, writing,

using a laptop computer, using a desktop computer and

watching television [92]. One group of children (age

11) rarely used computers and the other (age 12) used

laptops throughout their school curriculum. 82% of the

laptop group reported discomfort associated with lap-

top use, more twice the rate for reading or for desktop

computer use in either age group. No statistical asso-

ciation with use is reported. In the same paper, Straker

describes motion analysis and EMG research investi-

gating postural demands in computer use and reading.

Early results indicate that different media use causes

distinct physical stress, but the musculoskeletal risks

have not yet been evaluated.

Physicians in Japan describe 19 patients with muscu-

loskeletal symptoms they attribute to excessive play-

ing of home computer games [94]. Trapezius stiffness

and elevated scapula, on the non-dominant side, were

common in this group. Elimination of computer games

resolved symptoms in all patients.

Children also spend large amounts of time using

hand-held games, video games or text messaging. As

yet, no published research has evaluated the muscu-loskeletal impact of electronic games or other elec-

tronicdevices on school-aged children and adolescents.

These activities may differ in their effects on children

because of different postural demands, use habits or

even cognitive or behavioral effects.

Physicians quoted in the popular press attribute mus-

culoskeletal disorders in their pediatric population to

computers and electronic games, but the musculoskele-

tal effects of video games have not been extensively

investigated. Individual case reports of childhood ten-

donitis caused by game use have been reported in the

medical literature, in adults [12,76] as well as chil-

dren [13,22,50,87]. Perhaps the most striking is also

the most recent. Macgregor describes an eleven-year-

old patient who developed severe pain in his left (dom-

inant) hand and arm between getting a video game at

Christmas and returning to school in January. Symp-

toms resolved completely when he took a week off the

game.

Although the available evidence is anecdotal, the

widespread recognition of the phrases Nintendo

thumb and nintendinitis in the world of electronic

games provides support for the suspicion that pain

symptoms attributable to game use are common. Nin-


7/11


tendo thumb is defined as repetitive strain intrigue

clicking perpetual users of the basic push-button con-trollers . . . Also known as numb thumb [4]. The med-

ical world may be slow to recognize the phenomenon

but the people who use the equipment seem to know it

well.

Related ergonomics evidence supports the need for

further research: Television and TV video game use has

been implicated in back pain in children, with game use

a more significant factor [31]. Because computers and

games seem to encourage more sustained postures and

intense concentrationthan TV watching or schoolwork,

the strain related to their use is likely to be greater than

in other activities.

It has been recognized that some adverse effects of

computer or game use might stem from the displace-

ment of other healthier activities [84,93]. Increasing

computer use occurs along with a secular trend of less

physical activity and decreasing physical education in

school, and these trends are replicated in children as

they get older [2,5,26,57]. Thus, the relative effects of

changes in physical activity and computer use may be

difficult to characterize.

6. Research Stream 5: Preventive measures

Children using these adult tools are provided with

few of the protections against injury that are required

at work. Chairs and tables may be scaled to the general

age of the students, but they are rarely adjustable [14,

64,66]. Keyboards and copy are not positioned with er-

gonomic considerations in mind. Although some mod-

ified keyboard and pointing devices are available, the

ergonomic evidence supporting them has not been re-

ported and they are not widely used. Children are not

taught the appropriate postures to reduce musculoskele-

tal and visual strain. Breaks and exercises are not re-

quired. Even the extensive guidelines on technology in

schools developed by teachers organizations and the

Office of Educational Technology of the US Depart-

ment of Education do not address ergonomics [39].

A major problem for researchers as well as educa-

tors and parents is that there is no accepted standard

for how childrens workstations should be set up, what

work/rest cycles they should follow or what equipment

should be modified for their use. An early attempt to

provide guidance for setting up computer workstations

was produced in 1991 [102]; some of its limitations are

discussed above. Other recommendations are available

on the Web [8,29,100]. Typically, these guidelines are

well grounded in current ergonomic knowledge as de-

rived from adults, extrapolated to children at variousages. Unfortunately, some popular advice sites are pro-

duced without a sound understanding of ergonomics

and some promote exercises or equipment without ap-

parent research support. None is yet based on child-

specific epidemiology or intervention research. An ad-

ditional problem is that most available anthropometri-

cal data does not reflect the changing population, al-

though newer data is being collected and has been mas-

terfully catalogued by Norris and Wilson [65,91].

Several research groups have begun intervention

studies in classrooms. Bennett describes a project to

retrofit classrooms and provide training for teachers,

administrators, computer technicians, students and par-

ents [10]. Hedge reports on the Get Techfit project

which focuses on the role of students in the evalua-

tion and correction of ergonomics hazards [36]. Jo-

hansson has announced a similar project using inter-

active media [41]. The need to involve students as

field ergonomists is a theme in all this work. However,

no controlled intervention comparing musculoskeletal

symptoms in intervention and control groups has been

reported on. Until baseline measures of risk have been

established, evaluating the impact of ergonomics inter-

ventions will be difficult.

Conclusion

Giving the current research results, it remains possi-

blethat computer andelectronicgameuse poses muscu-

loskeletal risks for young users. Case reports of game-

related tendonitis and ergonomic analyses of classroom

computers suggest that concern is warranted. With the

expansion of the Internet and home computer use, any

problems caused by computers can be expected to ac-

celerate in the next few years, as they have in the work-

place following the introduction of computers. Anec-

dotal clinical reports and informal observation confirm

that this activity has caused pain in some children.

However no published research has established a sta-

tistically significant association between computer use

and physical symptoms or clinical syndromes in chil-

dren or adolescents. No posture, frequency or duration

of use has been identified that poses a clear risk or,

conversely, can be accepted as safe.

Because the contributors to musculoskeletal health

and development are diverse and complex, it is impor-

tant to begin with an understanding of the epidemiol-

ogy of computer use and musculoskeletal symptoms.


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A cross-sectional analysis of current rates of use and

the association with musculoskeletal symptoms is anessential first step. A longitudinal evaluation of phys-

ical development as it relates to computer use is also

necessary. Research will need to take into account the

baseline levels of symptoms reporting, by gender, age,

and possibly ethnicity, especially as computer use and

otheractivities are alsoaffectedby these characteristics.

Additional confounders, negative or positive, should

be evaluated. These could include levels of physical

activity or general fitness which might protect against

musculoskeletal injuries by enhancing aerobic health,

or competitive sports or dance performance which are

associated with increased musculoskeletal problems in

adolescents [25]. Adolescents work could contribute

to cumulative trauma, and health issues such as over-

weight, trauma or diabetes could affect symptoms de-

velopment or reporting.

Another important research consideration is whether

markers for increased comfort or health are the same

in children as in adults. For example, Laeser consid-

ered that longer work periods indicate improved com-

fort, however whether working longer is an appropriate

marker for improved comfort in children has not been

established. Is pain a good indicator of musculoskele-

tal problems in this population, and if so how can re-

searchers distinguish transient or trauma-related symp-toms from the effects of computer use? If we insist on

established clinical syndromes as the best indicator of

musculoskeletal problems, the role of pediatricians in

defining, observing and diagnosing problems related to

computer or game use will need to be examined.

Perhaps most important to understanding the impact

of computers and other devices on children and ado-

lescents is a comprehensive ecological description of

how they use these things. What is the ergonomic en-

vironment at home, while playing games, when using

notebook computers? What postures and movements

are adopted? How long are activities or postures main-

tained? What do children do that might in fact be pro-

tective stand up, share tasks, work in spurts, for ex-

ample? And what makes them feel more comfortable?

Adults may be able to learn about better computer use

behavior and conditions from children.

As computers and related devices become ubiquitous

and essential aspects of home, school and work life,

there will not be a better time to investigate their impact

and develop plans to limit or prevent possible adverse

effects. A timely investigation and programmatic re-

sponse may head off a potential epidemic. Understand-

ing the impact of computer use in children will also

allow the development of programs to teach healthy

computer use habits that may reduce problems of sub-sequent workplace exposure. It will contribute to the

designof better equipmentand softwareand, if need be,

improve clinical diagnosis and treatment. Childrens

use of computers may be a rare example of a public

health hazard that can be nipped in the bud.

Acknowledgements

I would like to thank Dr. Margareta Nordin,

Med.Dr.Sci., CIE, Director of the Graduate Program

of Ergonomics and Biomechanics (ERBI) at New YorkUniversity and Dr. Manny Halpern, PhD, CPE, for

their ongoing support of and contribution to my re-

search and to the Children and Keyboard Ergonomics

(CAKE) Project.

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