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Ergonomics
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Musculoskeletal disorders among visual display

terminal workers: individual, ergonomic, and work
organizational factors
a a b c a
U. BERGQVIST , E. WOLGAST , B. NILSSON & M. VOSS
a
Department of Neuromedicine , National Institute of Occupational Health , Solna, S-171
84, Sweden
b
Department of Physiotherapy , Uppsala College of Health and Caring Sciences , Uppsala,
S-751 85, Sweden
c
Department of Applied Work Physiology , National Institute of Occupational Health , Solna,
S-171 84, Sweden
Published online: 28 Mar 2007.

To cite this article: U. BERGQVIST , E. WOLGAST , B. NILSSON & M. VOSS (1995) Musculoskeletal disorders among visual
display terminal workers: individual, ergonomic, and work organizational factors, Ergonomics, 38:4, 763-776, DOI:
10.1080/00140139508925148

To link to this article: http://dx.doi.org/10.1080/00140139508925148

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 ERGONOMICS, 1995,vOL.38, No.4, 763-776

Musculoskeletal disorders among visual display terminal

workers: individual, ergonomic, and work organizational
factors

U. BERGQVIST,I E. WOLGAST,1,2 B. NILSSON,3 and M. voss'

'Department of Neuromedicine, National Institute of Occupational Health,
S-17l 84 Solna, Sweden
"Oepartment of Physiotherapy, Uppsala College of Health and Caring Sciences,
S-75l 85 Uppsala, Sweden
30epartment of Applied Work Physiology, National Institute of Occupational
Downloaded by [National Taiwan University] at 23:22 08 January 2015

Health, S-171 84 Solna, Sweden, Currently at SAAB-SCANIA, POBox 603,

S- I51 27 Sodertalje, Sweden
Keywords: Musculoskeletal disorders; Visual display terminals; Individual
factors; Work organization; Ergonomic factors,
A number of individual, ergonomic, and organizational factors of presumed
importance for the occurrence of musculoskeletal disorders were investigated in a
group of 260 visual display terminal (VDT) workers. The cross-sectional study
utilized medical and workplace investigations as well as questionnaires, The results
were subjected to a multivariate analysis in order to find the major factors associated
with various upper-body muscular problems. Several such factors were identified
for each investigated type of musculoskeletal problem. Some were related to the
individual: age, gender, woman with children at home, use of spectacles, smoking,
stomach-related stress reactions, and negative affectivity. Organizational variables
of importance were opportunities for flexible rest breaks, extreme peer contacts, task
flexibility. and overtime, Identified ergonomic variables were static work posture,
hand position, use of lower arm support, repeated work movements, and keyboard
or VDT vertical position.

1. Introduction
Considerable attention has been paid to the possibility that working with a visual display
terminal (VDT) leads to various upper-body musculoskeletal problems. 'VDT work and
health' is a longitudinal study of a cohort of office workers in Stockholm, Sweden, that
started in 1981. As part of this study, a cross-sectional investigation was carried out in
1987, with data being obtained from questionnaires, a physiotherapist's examinations,
and workplace investigations. The aim was to investigate associations between
musculoskeletal problems and various factors relating to both the individual and to
ergonomic and organizational conditions at the workplace. The study group was
restricted to VDT users only.

2. Study group and methods

2.1. The investigated group and data acquisition
The 1981 cohort of 535 office workers has already been described (Bergqvist et al. 1992,
Knave et al. 1985). The 353 individuals remaining in the cohort in 1987 were given
the opportunity to fill in a questionnaire on perceived musculoskeletal discomforts,
individual, and work organizational factors, with a response rate of 92%. Based on this
questionnaire, 260 current VDT users were identified, 76% of whom were women.
Common types of VDT jobs involved extensive numerical input, data acquisition-
0014-0139195 $10,00 e 1995 Taylor & Francis Ltd,
 764 U. Bergqvist et al.

sometimes combined with limited numerical and text input-and extensive word
processing. All subjects were invited to attend a physiotherapeutic examination-97%
of the 260 VDT users participated. Subsequently, a worksite investigation was
conducted to assess the ergonomic situation at the workplace, with data on each
individual's most common work situation used in this analysis. Coverage was 88% of
the 260 VDT users. The physiotherapist had no information on work situations or
questionnaire responses, while the workplace investigators were unaware of question-
naire or examination results.
The 260 identified VDT users form the basis for the analysis reported here. The
numbers of individuals in specific analyses were, however, often reduced below this
number, due to the combination of participation rates given above, and incomplete
information on certain items.
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2.2. Effect measurements

From the standardized Nordic questionnaire (Kuorinka et al. 1987) the following
musculoskeletal discomfort endpoints were used (i) 'neck/shoulder discomforts': any
neck and/or shoulder discomforts over the last 12 months; (2) 'intense neck/shoulder
discomforts': as above, if they had occurred within the last seven days and interfered
with work; (3) 'back discomforts': any lower back discomforts over the last 12 months;
and (4) 'arm/hand discomforts': any elbow, wrist and/or hand discomforts over the last
12 months.
The physiotherapeutic examination included a short case history of aches, stiffness,
tiredness, paresthesia, and numbness in the neck, shoulders, elbows, and hands. Pains
and/or aches were recorded if these had been experienced for at least one week's
duration, or on at least 20 occasions during the previous year. Pains due to diabetes,
inflammatory joint diseases or traumata were excluded. Mobility, muscle function, and
muscular tenderness were examined. The active range of motion was measured, using
a compass goniometer (Myrin) for the neck, and functional tests for shoulder joints,
elbows, and hands. Muscle function tests for isometric manual resistance were
performed with the subject in a sitting posture. Muscles and muscular attachments in
the neck, shoulders, and arms were palpated, and pain noted. Specific criteria were
applied to make diagnoses, requiring three or more symptoms or signs (Wolgast 1989).
The following diagnostic endpoints were selected: (I) 'TNS (tension neck syndrome)
diagnosis': ache/pain in the neck; feeling of tiredness and stiffness in the neck; possible
headache; pain during movements; muscular tenderness; (2) 'cervical diagnoses' for
either cervical syndrome: ache/pain in the neck and arm; headache; decreased mobility
due to cervical pain during isometric contraction; often root symptoms such as
paresthesia or numbness, or cervical degenerative disease: ache/pain in the neck;
possibly headache; decreased mobility due to pain during movements; (3) 'shoulder
diagnoses': any diagnosis in the shoulder joint region; and (4) 'arm/hand diagnoses':
any diagnosis in the elbow, wrist and/or hand regions.

2.3. Individual, organizational, and ergonomic factors

All factors relating to the individual, to the work organization and to ergonomic
conditions which were included in the analysis are listed in figure 1.
Having children under 16 years at home was considered a factor only for women
(Bjorklund 1991), and accordingly, a variable describing this was defined ('woman with
children' vs others). 'Negative affectivity' corresponds to, 'anger, disgust, scorn, guilt,
 Musculoskeletal disorders among visual display terminal workers 765

Individual factors
I Attitudes andstress:
Negative affectivity •
Constitutional: Tiredness-related stress reac-
Age tions ..
Gender Stomach-related stress reac-
(High bodymass index a/) lions ..

Activities: Eye conditions:

Smoking Use orspectacles
Children at home bI Use of bifocal/progressive glasses

Organiz.ational factors Timeplanning andflexibility:

I
Work and work organization:
Limited or extensive
peer contacts ..
Routine workcI
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Limited rest break opportu-
nity·
Limited work task flexibility"
(Long VDT wort: passes)
Workload:
Frequent overtime

Limited organizational in- (High work pace *)

fluence .. (Overtime on short notice)

Ergonomic factors
I.
Position:
Static work posture
Nonuse of lower arm support
Hand in non-neutral position
Extremehand positions
(Extreme back position)
(Extreme neck position)
(Prolonged work wilh non-sup-
ported extended ann)
Table and chair:
Insufficient leg space at table
Insufficienttable work surfaces
(Height difference table-elbow)
(Nonadjustable table)
(LQwchair comfort *)
(Wide work zone widlh)
Work movements:
Repeated movements with risk
of tiredness
(Repeated arm/hand work,
twisting CIC.)
VDT utilities:
Height difference keyboard-
elbow
High visual angle to VDT
Specular glare present on VDT
Spreadof screen, keyboard
and documents
Keyboard type
(Configurationof screen,
keyboardand documents *)
(VDT positional adjustability)
(Need and use of wrist support *)

Figure I. Individual, organizational, and ergonomic factors evaluated in the analysis; items in
parenthesis = factors not selected for multivariate analysis; bold items = factors retained in a
final multivariate model.
• = summary indices based on a number of items
aJ from the physiotherapist's examination
bl combined with gender (women) in the analysis
cl from the worksite investigation interview

fearfulness, and depression', and has been suggested to influence reporting of

discomforts (Chen and Spector 1991, Vassend 1989, Watson and Pennebaker 1989).
'Tiredness-related stress reactions' included responses such as 'psychological
tiredness' 'inability to relax', etc. 'Stomach-related stress reactions' were those
indicating an 'upset stomach' (Aronsson et al. 1992).
For 'peer contacts', limited or very extensive contacts with fellow workers were
jointly compared with moderate contacts, based on the a priori suggestion that either
extreme might be a stress factor. (Limited or very extensive contacts were also
separately analysed a posteriori; see figure 4.) 'Organizational influence' was based on
'ability to take initiative', 'self-development at work', 'ability to influence planning',
etc. 'Rest break opportunity' was (primarily) the ability to take unscheduled breaks.
'Work task flexibility' refers to the ability to 'shift work task to another day',
'availability of several tasks', 'choice of when to use the VDT', etc. 'Work pace'
 766 U. Bergqvist et al.

includes 'demands for concentration', 'time pressure', 'inability to take a breather', etc.
(Aronsson et al. 1992).
'Static work posture' compared those with only one main work posture (sitting or
standing) with those who varied their posture. 'Extreme hand positions' were flexion,
extension, and ulnar deviation. The height differences between table or keyboard and
the elbow were measured with the worker sitting in hislher normal posture. 'Chair
comfort' was based on adjustability of back support and chair height, and possibility
of comfortable turning or rolling. 'Visual angle to VDT' was the angle between the
horizontal and the line from the eyes in normal position to the middle of the screen.
The presence of specular glare was evaluated by the investigator in the operator's
position.
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2.4. Analysis outline

Prevalences of various musculoskeletal effect measures were tabulated (table I).
Relevant factors were those considered a priori as potential causal or aggravating
factors in relation to a specific effect measure. Univariate associations between each
effect measure and (its) relevant factors were tabulated, and then adjusted, if necessary,
for confounding by individual factors (age, gender, etc.). Individual, organizational or
ergonomic factors still showing an association after this adjustment-according to
specific criteria based both on effect size and precision-were included in multivariate
logistic regression models I in order to estimate the effect of each factor when controlling
for the other factors. A further reduction of factors were made within these multivariate
models, and a final model for each effect measure was obtained, which included the
most prominent factors.
By definition, a confounder of a relationship between a factor and an effect can not
be an intermediate variable in the causal path between the two (Rothman 1986). Thus,
to treat stress reactions as possible confounders of associations between organizational
factors and muscular problems is questionable. For this reason, separate multivariate
models were used when evaluating the confounding influences of organizational factors
and stress reactions. Interactions were examined where such were anticipated a priori.
When the aim was to describe interactions, stress reactions and organizational factors
could be included in the same model.
Estimates of univariate (crude) and stratum-specific odds ratios and their 95%
precision-based confidence intervals were computed. Adjusted odds ratios (summaries
across strata) were obtained with the logit estimator and precision-based confidence
limits (Kleinbaum et al. 1982, SAS Users Guide 1985). Unconditional maximum
likelihood estimates were obtained from the multivariate logistic regression analysis.
The analyses were conducted using the FREQ and CATMOD procedures in the SAS
System (SAS Users Guide 1985). Linear trends in odds ratios (figure 2) were calculated
as described by Rothman (1986).

3. Results
3.1. Prevalence of muscular problems
The occurrences of questionnaire-reported muscular problems were fairly high in the
 Musculoskeletal disorders among visual display terminal workers 767

Table I. Prevalence of musculoskeletal problems among VDT workers, as ascertained by

questionnaire and a physiotherapist's examination

All Women Men

Cases Prevalence Cases Prevalence Cases Prevalence

Discomforts reported in the questionnaire

Neck/shoulder
discomfort, n = 247 )52 61·5% 119 63·0% 33 56·9%
Intensive neck/shoulder
discomforts. n = 247 18 7·3% IS 7·9% 3 5·2%
Back discomforts, n = 240 99 41·3% 75 40·8% 24 42·9%
Arm/hand discomforts, n = 241 72 29·9% 56 30-4% 16 28·1%
Diagnosesfrom physiotherapist's examination
TNS diagnosis, n = 252 55 21·8% 47 24·6% 8 13·)%
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Cervical diagnoses, n = 252 59 23·4% 47 24·6% 12 19·7%

Shoulder diagnoses, n = 252 30 11·9% 28 14·7% 2 3·3%
Arm/hand diagnoses, n = 252 22 8·7% 21 11·0% I )·6%

study group, with the most common locations being in the neck, shoulder, and lower
back regions (see table I). With the exception of TNS and cervical diagnoses, the
prevalences of specific diagnoses were low. The differences between men and women
were fairly small in the questionnaire data, in contrast to the physiotherapist's data.

3.2. Univariate associations between various factors and muscle problems.

Associations were found between several musculoskeletal problems and gender,
woman with children at home, age, and stomach-related stress reactions. Some effects
were also associated with use of spectacles or tiredness-related stress reactions and
smoking. Negative affectivity was only associated with neck/shoulder discomforts.
Associations emerged between a number of organizational factors and various
musculoskeletal problems. For limited rest break opportunities and peer contacts,
increased odds ratios were found for the majority of the musculoskeletal problem
endpoints. Substantial increases in odds ratios were also found for limited work task
flexibility and shoulder diagnoses, and for occurrence of frequent overtime and
armlhand discomforts. Limited organizational influence appeared also to be associated
with discomforts, but the precisions of these estimates were low.
Neck/shoulder discomforts were associated with static work posture, insufficient
table space, and with keyboard and VDT in a high position. This last factor was also
associated with intense neck/shoulder discomforts. Insufficient table space was
associated with TNS diagnosis. Specular glare was associated with cervical diagnoses.
No VDT user who could vary between sitting and standing was given a shoulder
diagnosis. Non-neutral or extreme hand positions were associated with armIhand
discomforts. Of extreme hand positions, ulnar deviations appeared to be potent in terms
of discomforts-all individuals with ulnar deviations reported discomforts, but the
small number of such subjects (only two of whom were VDT users) precluded any
separate analysis. Armlhand diagnoses were associated with non-use of lower arm
supports, and use of high profile keyboards. For lower back discomforts, only the factor
'insufficient leg space' appeared to be of interest.
 768 U. Bergqvist et al.

Oddsratio for

D =~~~:er
(11=190)

/ ~~~~-
/
IOdhtio.
forelll:h I do<dUeomforu

'0
category

/ • ..... Odd> ratiofor

andda-
rom'011,(_189)

-, ' " ~= ~r
m[ans
-~""
~"""d

2.0
-, / -L~=h catego-
'Yo'
andrange

"',.....
m
"""
1.0
/ 1\ Budine, odds
ra!io... 1.0
Downloaded by [National Taiwan University] at 23:22 08 January 2015

1\
/ Keyboard po-I
lition above
elbow, em
0.0
-10 0 +10

Figure 2. Odds ratios for discomforts in the neck/shoulder and in the annIhand regions in
relation to the vertical position of keyboards (home row) above elbow. Multivariate odds ratios
are shown for four categories of keyboard positions, with the category having the lowest
discomfort occurrence used as the baseline. Linear trends between the odds ratios and the
keyboard height are also shown. In each category, the average height was used in these
calculations. The estimated slope of the trend for neck/shoulder discomforts is 0·18 ( - 0·03;
+ 0·40)/cm, suggesting an increase in the odds ratios of 0·18 for each em increase in keyboard
position. The estimated slope of the trend for arrnlhand discomforts is - 0·15 (- 0·33;
+ O·04)/cm, i.e., an increase in the odds ratio of 0·15 for each ern decrease in keyboard position.
The higher than + 7·5 cm category was not used in these calculations. implying that these
estimated increases should not be extended to situations where the keyboard is elevated higher
than some 7 cm above the elbow.

3.3. Multivariate models of individual, organizational, and ergonomic factors

The final models from the multivariate analysis aimed at reducing confounding are
shown in table 2. As discussed above, stomach and tiredness reactions were kept in a
separate model from organizational factors. For neck/shoulder discomforts, stomach
reactions were kept in a second model with negative affectivity and age, since these
two latter factors did not influence the impact of other factors when included in the first
model, i.e., they were not confounders in that model.
The linear trends of the multivariate models suggested that the odds ratio for neck
shoulder discomforts increased by 0·18 and that of armIhand discomforts decreased by
0·15 for each cm increase in keyboard vertical placement (figure 2).
A few interactions were noted. Individuals with both stomach reactions and repeated
work movements had an odds ratio of 5·8 (1·9-17·6) for intense neck/shoulder
discomforts compared to those with none or only one of these conditions (n = 217). The
combined presence of limited rest break opportunity and non-use of lower arm support
produced an odds ratio for annlhand diagnoses of 10·1 (2·4-43·2) compared with others
(see figure 3, n = 205).
For several endpoints, indications of interactions between peer contacts and
stomach reactions were found; individuals with both factors present had an odds ratio
for TNS diagnosis of 4· 7 (1·4-16·3; n = 181, see figure 4), for shoulder diagnoses 8·1
(3·2-21·9; n = 250) and for armIhand discomforts 8·2 (2·8-23·9; n = 240).
 Downloaded by [National Taiwan University] at 23:22 08 January 2015

Table 2. Models indicating factors with the strongest independent influence on neck, shoulder, hand, and back problems.
~
to
Muscle l::
"C
problem Factors retained in the model, with odds ratio and 95% confidence interval
~
Neck/shoulder = Ltd rest break Static work Too highly * Stomach Negative Age below "
discomfort opportunity posture placed keyboard * reactions affectivity 40 ""§:.
n= 181' 2·7 4·\ 3·1 * 3·5 2·0 2·1 !::
to
n = 210> (1·2-5·9) (0·9-18·3) (1·3-7·2) (1·5-8·2) (1·0-4·2) (1·1-4·2) <::>
*
Intensive = Stomach Repeated work Too highly
a.
"o:l
neck/shoulder reactions movements placed VDT l:l
discomfort, 5·4 3·6 7·4 s
<::>
n = 187 (1·6-17·6) (0·4-29·6) (0·9-60·3)
~
Tension neck = Woman without Woman with Ltd rest break Too highly -e
1;;'
syndrome children children opportunity placed keyboard l::
l:l
n = 186 2·0 6·4 7·4 4·4
(0·7-5·6) (1·9-21·5) (3·1-17·4) (1·1-17·6) !::
-
i3
Cervical = Age above Use of Static work Presence of * Stomach Tiredness ~
diagnoses 40 spectacles posture specular glare * reactions reactions
n = 166' 2·7 4·0 5·1 1·9 * 3·9 1·9
2 (1.0-7-2) (2·0-7·7) (1·0-3·5)
"~
II = 250 (1·3-12·5) (0·6-42·5) (0·9-4·2) * S·
l:l
Any shoulder = Woman Ltd rest break Low task * Stomach ~
-
diagnoses opportunity flexibility reactions <::>
* >1-
n ee 227' 7·1 3·3 3·2 * 4·8
n = 250 2 (1·6-32·2) (1·4-7·9) (1·2-8·5) * (2·1-10·7) "o:l

.....
0-
lD
 Downloaded by [National Taiwan University] at 23:22 08 January 2015

-.I
-.I
o

Table 2.-Continued.

Muscle
problem Factors retained in the model, with odds ratio and 95% confidence interval

Arrn/hand Extreme peer Extensive Hand in non- Low keyboard * Stomach

discomforts contacts overtime neutral position placement * reactions
n = 181 2·1 2·2 3·8 2·0 * 3·8
(1·1--4·1) (1·2--4·4) (I ·0--15·0) (0·9--4·5) * (2·0--7·3) ~
b:l
Any arrn/hand Age above Woman with Smoking Extreme peer Ltd rest break Non-use of * Stomach "
~
diagnoses 40 children contacts opportunity lower arm support * reactions -<:l
-e
n= 206 1 2·4 5·2 4·7 4·5 2·7 2·7 * 3·4 <;;.
~
n = 25<Y (0·6-10·3) (1·2-22·8) (1·4-16·0) (1·3-15·5) (0·8-9·1) (0·9-8·3) * (1·3-8·4)
!l
Lower back Stomach Insufficient e!.
discomforts reactions leg space
n =208 2·4 2·2
(I ·2--4·8) (1·2--4·1)

For each endpoint, the factors included in the final multivariate model(s) are identified. Each factor's odds ratio is adjusted for the possible
confounding of other factors in the same model. For some noted interactions between factors, see the text.
*delineates two models that were separately analysed (see text for justification); 1.2refer to the number of individuals in the first and the
second model, respectively; Ltd = limited.
 Musculoskeletal disorders among visual display terminal workers 771

Reference cate-
• gory (n=96.
oddsratio=I,O)
Downloaded by [National Taiwan University] at 23:22 08 January 2015

Figure 3. Odds ratios for annIhand diagnoses for different combinations of rest break
opportunity and use of lower arm support, The results were obtained by a multivariate model
(n ~ 205), which also included other factors from the final multivariate model in table 2. The
odds ratio reponed in the text (10·\; 2-4-43·2) was obtained for the group marked' * ',compared
to all other groups.

Reference ca-
• tegory (n= 76,
odds ratio =1.0)

IOddsl
'~
6.0

Figure. 4. Odds ratios for TNS diagnoses for different combinations of peer contacts and
stomach-related stress reactions. The results were obtained by a multivariate model (n ~ lSI),
which also included the factors from the final model reponed on in table 2. The odds ratio reponed
in the text (4·7; 1·4-16·3) was obtained jointly for the two groups marked' * . when compared
with all other groups.

4. Discussion
4.1. Some methodological considerations
Classification of exposures at the time of the cross-sectional investigation may
misrepresent conditions as they existed at the time of the onset of musculoskeletal
problems. When attempting causal interpretations, a few such occasions were
suggested, e.g., reverse associations between shoulder diagnoses and table inadjustabil-
ity (OR = 0·29;.0·10-0·87), frequent overtime and cervical diagnoses (OR = 0-48;
0·23-0·99), and between chair comfort and back problems (OR = 0·64; 0·36-1·15). A
likely explanation for such findings is that the disorder led to certain adverse conditions
 772 U. Bergqvist et al.

being avoided or remedied-but the disorders remained. Such reverse associations have
been noted by others, and similar explanations have been proposed (Kemmlert et at.
1990).
We would advise some caution when generalizing from a lack of association for
a specific factor. Such a lack of association could be due to insufficient exposure to a
certain factor in the study group. The resulting imprecision in the estimates could then
lead to the exclusion of the factor from the multivariate analysis, despite a sizable effect
estimate. One example is the exclusion of 'hand position in ulnar deviation' in the
multivariate analysis (only two VDT users).

4.2. Occurrences of musculoskeletal problems

High prevalences of problems in the neck region were detected, in both the questionnaires
Downloaded by [National Taiwan University] at 23:22 08 January 2015

and the diagnoses. Lower back pain symptoms were also common. Prevalences of
discomforts and diagnoses in elbow, wrist and hands were lower (see table I). These
prevalences are in general agreement with those of other studies of office workers
(Arons son et al. 1992, Hunting et al. 1981, Jeyaratnam et al. 1989, Kemmlert and Kilborn
1988, Linton and Kamvendo 1989, Nishiyama et al. 1984, Sauter et al. 1991).

4.3. Influence of individual factors

In the univariate analysis, most endpoints--especially those based on diagnoses-were
associated with gender. In the final models, however, this was often attributable to the
factor 'woman with children at home'. A strong influence of gender remained only in
the case of shoulder diagnoses (see table 2). Higher prevalences of musculoskeletal
problems for women compared with men have frequently been detected (Aronsson et
al, 1992, Kemmlert and Kilbom 1988). An influence of the 'double shift'-at work and
at home-on women's musculoskeletal problems has often been discussed. In analyses
of sick leaves or related health issues, a major factor for women-but not for men-was
the presence of small children at home (Bjorklund 1991, Coray et al. 1989, Leigh 1991).
Other studies have failed to identify this as a factor, though (Cox et al. 1984, Jeyaratnam
et al. 1989).
Stress-related reactions--especially stomach reactions-were associated in our
study with virtually all effect measures. Associations between stress related problems
and muscular discomforts have often been noted (e.g., Aronsson et al. 1992, Ayoama
et al. 1979, Coray et al. 1989, Hultman 1987, Linton and Kamvendo 1989, Smith et
al. 1981), but their etiologies are far from clear. In our study, situations were found
where stomach reactions potentiated the muscle problem impact of both organizational
and ergonomic factors.
The association of negative affectivity with any neck/shoulder discomfort but not
with intense ones, is consistent with one hypothetical mechanism through which
negative affectivity may affect reported discomfort-the 'symptom perception
hypothesis' (Watson and Pennebaker 1989)-since such a mechanism would be
expected to be more important for weakly perceived symptoms. While negative
affectivity was associated with neck/shoulder discomfort, it was not, however, a
confounder of other factors in any neck/shoulder discomfort model.

4.4. Influence of organizational factors

In this study, a perceived limited opportunity to take (primarily) unscheduled breaks
was associated with several effects. Permanently working in a sitting posture, or for a
 Musculoskeletal disorders among visual display terminal workers 773

few individuals, always in a standing posture was associated with increased odds for
neck/shoulder discomfort and cervical disorders. This was independent of whether the
work was classified as routine or not. Consistent results, in many cases depending on
both limited rest breaks and static work posture, have previously been obtained
(Aronsson et al. 1989, Aronsson et al. 1992, Hagberg and Sundelin 1986, Kemmlert
and Kilborn 1988, Sauter and Swanson 1992, Sundelin and Hagberg 1989, Weerstad
et al. 1991). It should be pointed out, that although use of lower arm support might be
one way of reducing armIhand disorders (as indicated in figure 3), it should not be
considered as a substitute for rest breaks.
Interactions were found between peer contacts, stress reactions and certain
musculoskeletal problems. In the case ofTNS, for example, an association with stomach
reactions was only found for individuals having extreme peer contacts--either limited
or extensive (see figure 4). The small number of individuals in relevant groups could
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be seen as a deterrent when making these conclusions. These findings were, however,
consistent also in TNS models only utilizing these three variables-and where the
numbers were higher (where, e.g., the group size for the 'extensive, often' group was
16, cf. figure 4). Social support is generally considered to be associated with a lower
occurrence of musculoskeletal problems (Karasek and Theorell 1990, Kemmlert et al.
1990, Linton and Kamvendo 1989). Our observations are consistent with this, in that
limited peer contacts were associated-for certain individuals-with increased
occurrences of muscular problems. The explanation of the second association in our
study, that between a high level of peer contacts and muscular problem frequencies is
less clear. One possibility is that certain individuals may react unfavourably to
time-consuming peer contacts, another is that these excessive peer contacts may be
secondary to certain problematic individual or work conditions; both stress reactions
and muscular problems could then be due to these.

4.5. Influence of ergonomic factors

The association between keyboard vertical position and neck/shoulder problems was
positive, while that between keyboard position and arm/hand problems was negative.
This is consistent with findings from some experimental studies (Cushman 1984, Life
and Pheasant 1984, Weber et al. 1984), but contrary field study findings have been
reported (HUnting et al. 1981, Sauter et al. 1991). However, both placement of
documents and preferred work postures appear to be involved in the complex
relationships between keyboard vertical position and discomforts (Arndt 1983,
Grandjean et al. 1983, HUnting et al. 1981, Life and Pheasant 1984)-making
generalization difficult. Thus, the focus of remedial measures should perhaps be
adjustability in keyboards position and angle, according to the needs and preference of
the user (Arndt 1983, Grandjean et al. 1983, Hedge etal. 1992, Miller and Suther 1983).
Judging from our data, such adjustability should also allow keyboards to be placed
somewhat below elbow height.
Non-use of lower arm support and hand held in non-neutral position both appeared
to be associated with arm/hand problems. The considerable uncertainty of the estimates
for hand held in non-neutral position was due to the small number of individuals to
whom such conditions applied. A few other studies have also indicated the importance
of these factors (Gobba et al. 1988, HUnting et al. 1981, Laubli 1987, Sauter et al. 1991,
Weber et al. 1984).
Individuals who worked with a VDT at eye level reported more frequently intense
 774 U. Bergqvist et al.

neck/shoulder discomforts than those with a VDT placed lower. This is consistent with
some earlier studies (Hunting et al. 1981, Stammerjohn et al. 1981) and the 'preferred
viewing angles' obtained by Grandjean et al. (1983). In another study (Sauter et at.
1991), 'gaze angle to display', failed to qualify as a predictor of trunk discomfort,
however.

5. Conclusion
Several factors relating to the individual were found to be important in relation to
musculoskeletal problems, especially age, children at home for women, and
stomach-related stress reactions. Limited rest break opportunity appeared to be a major
factor for several muscular problems. Limited or extensive peer contacts were also
associated with musculoskeletal problems--especially for individuals who also
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reported stomach-related stress reactions. Neck and shoulder problems were associated
with posture factors such as 'only sitting or only standing'. highly placed keyboards,
and possibly also with highly placed VDTs. Arm/hand problems were associated with
hand and keyboard position and non-use of lower arm support.
The findings provide examples of important factors for musculoskeletal problems
of VDT operators, and should be relevant for intervention activities. Since the study
group may be a favourably selected group for, e.g., certain ergonomic conditions, it may
not be appropriate to generalize from the lack of associations between other factors and
muscle problems, however.

Acknowledgement
We wish to thank Dr Birgitta Floderus for valuable contributions made during
discussions. We also wish to express our appreciation for the co-operation of the
employees and companies where the study was conducted. We are also grateful for the
considerable amount of VDT work performed by Asa Hultgren and Anna Wibom who
coded the questionnaire responses. The study was supported by grants from the Swedish
Work Environment Fund.

Note
A multivariate analysis attempts to take several factors simultaneously into
consideration, often by using various regression models.
A linear regression model would assume that the risk is a linear combination of
contributions from several factors:
risk = ao + a, X Xl + a2 X X2 + al2 X Xl X X2 + ...,
where Xi are various factors and Xi X Xj are combinations of factors ('interactions').
The coefficient ai describes the impact of the factor Xi on the effect-the analysis
-is accordingly aimed at determining the a;' s. One problem with a linear approach
is that precautions against non-valid risk estimates (risk as a probability may only
°
take on values between and I) are not built into the model, another that odds ratios
are not directly obtainable from the results.
The logistic regression model assumes instead that risk is a logistic function of
the factors Xi:
risk = (I + exp( - (ao + a, X Xl + a2 X X2 + al2 X Xl X X2 + ...)))- I ,
with the same general meaning attached to ai and Xi' This function is limited to the
0, I interval. From the ai coefficients, the odds ratio of that specific factor or factor
 Musculoskeletal disorders among visual display terminal workers 775

combination can be computed. In such a model, the inclusion of a factor Xi is intended

to remove the possible confounding by that factor on the odds ratios of the other
factors. The inclusion of a combination of factors Xi X Xj is intended to model an
interaction (effect modification) between them. The coefficient au will describe the
'strength' of such an interaction on the effect.
For further reading, see Kleinbaum et al. (1982) and Rothman (1986).

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