Abstract
Telehealth approaches to delivering ergonomics assessment hold great potential to improve service delivery in rural and remote settings. This case study describes a telehealth-based ergonomics service delivery process, and compares in-person and telehealth-based ergonomics approaches at an Alberta-based non-profit advocacy group. This project demonstrates that telehealth approaches to ergonomics do not lead to significantly different scoring outcomes for assessment of ergonomics issues, when compared to in-person assessments. This project also outlines the importance of live real-time video conferencing to improving communication, attaining key assessment information, and demonstrating ergonomic adjustments. However, some key considerations of bandwidth and hardware capabilities need to be taken into account. Key communication strategies are outlined to improve rapport, maintain employee confidentiality, and reduce client anxiety around telehealth ergonomics assessments. This project provides further support for telehealth approaches to office ergonomics, and outlines some key implementation strategies and barriers that should be considered.
Introduction
Musculoskeletal disorders remain a major source of personal, social and economic burden [1]. Research has noted that work exposures have an association with musculoskeletal issues [2, 3], but investment in ergonomics programs can lead to improvements in musculoskeletal and visual outcomes, reductions in lost-time claims, and improved productivity [4–8]. While there are benefits to establishing ergonomics programs, rural and remote workplaces often struggle to access ergonomics professionals due to significant logistical and financial costs.
Telehealth approaches to delivering ergonomics assessments hold great potential to improve service delivery/access in rural and remote settings. Telehealth has been used effectively in community health, oncology, training cancer support workers, pediatric assessment/education, audiology, mental health, cardiac rehabilitation, diabetes consultation, speech pathology, and many other areas of health care service delivery [9–18]. The application of this practice in ergonomics is less common [19–21], but similar approaches could be taken.
Overall, the proof of concept for use of telehealth approaches for ergonomics has been established [19, 20], but questions remain with respect to execution of the service delivery method. In a review of general telehealth approaches, it was noted that more implementation research projects are required to explore facilitators and barriers associated with the use of telehealth consults, technical support requirements, and a review of key communication strategies [22].
In this case study, we describe a pilot project approach to telehealth-based ergonomics servicedelivery. This project describes telehealth ergonomics with greater detail than what currently exists in available ergonomics literature. We describe the communication and the procedural approach to building rapport and performing the assessment. We compare the effectiveness of the telehealth ergonomics approach to in-person assessment using a validated office ergonomics assessment tool, and describe key lessons learned to facilitate telehealth ergonomics approaches.
Details of a telehealth approach to ergonomics
Participant group
An Alberta-based non-profit advocacy group volunteered to take part in this telehealth ergonomics project. This workplace was located within the city of Edmonton to allow a telehealth approach and in-person follow-up to be completed as a means of reviewing the telehealth process in a timely and effective manner. Nine employees required a professional ergonomic assessment as a result of: an inability to adjust equipment, a lack of fit/adjustability for existing equipment, and/or reports of musculoskeletal discomfort. Table 1 contains participantdemographics.
Participant Demographics
Participant Demographics
Each of the 9 employees agreed to receive a professional assessment. An email was sent to each of them explaining the procedures of the remote assessment, asking them to schedule an assessment with the trained ergonomics assessor. Included in the email was a link to a custom online questionnaire and consent form. The questionnaire collected information regarding demographics, workstation characteristics, discomfort experienced by the employee, and other information that is typically collected in an in-person ergonomic assessment. Employees were also sent a google document with instructions on how to take the specific photos (from the required angles, including side profiles, front facing views and over shoulder views) of their seated posture, chair, workstation layout, and monitor position. Finally, the document requested employees prepare for the assessment by ensuring they had access to a web camera and a measuring tape.
To evaluate each office workstation, and determine how various risk factors are impacted by adjustments and/or introduction of new equipment, we applied the Rapid Office Strain Assessment (ROSA) scoring system [23–25]. This tool is a picture-based assessment of chair, monitor/phone, and keyboard/mouse outcomes that impact on working posture. This evaluation tool was selected because it relies on visual inspections of postures and workstation layout to score potential risk factors. It does not require tactile perception or in-person measurement by the professional. It allows for a comparison of scores during both in-person assessment and with telehealth approaches.
Our telehealth approach to ergonomics
Pictures and questionnaire results were reviewed by the assessor prior to the telehealth assessment. The telehealth assessment was conducted over a 60-minute period using video conferencing software (GoToMeeting, Citrix). Both parties had a web camera or web camera-enabled device and microphone/speakers to communicate (Fig 1).
Sample picture of telehealth ergonomics assessment communications.
Review and discussion of discomfort and/or equipment issues for each employee was the first step in the web conference conversation. Questions about furniture adjustment, layout of the workstation and equipment were posed to the employee, as well as having the employee clarify depths and positions of various pieces of equipment. Using screen sharing and the photos provided by the employee, the assessor was able to illustrate where the identified ergonomic concerns were. When necessary, the web camera was moved to further explore available space under the desk, layout of furniture and devices, adjustment options on furniture, and other key information that was not immediately available from the pictures. All of these steps helped provide 3-dimensional contexts and understanding for the assessor. A ROSA score representing the pre-adjustment workstation set up was tabulated at this point.
The screen-sharing function in the web conference software, as well as verbal description was then used to illustrate and coach employees on how to properly adapt their workstation, chair and visual set-up to minimize ergonomic risk factors. A second ROSA score based on these adjustments completed during the telehealth assessment was tabulated. The assessor visited the employees’ workstations in person the following week to conduct a 15- minute follow-up. A third ROSA score was tabulated to determine if the in-person assessment would lead to differences in scoring. A fourth ROSA score was tabulated to represent the potential score change once all recommendations were implemented. A report was generated summarizing ergonomic concerns and recommendations and was provided to theemployer.
Non-parametric statistical tests (Kruskal-Wallis Test) were used to compare ROSA scores from the 9 telehealth assessments with ROSA scores from 159 assessments in similarly sized work places, with similar work station layouts and adjustability to see if the scores attained during the telehealth approach match the distribution of scores attained from in-person reviews. In each of the score categories there were no significant differences for either the pre-adjustment scores or the changes that were anticipated after implementation of recommended equipment (Table 2). Also, a visual inspection of the ROSA scores taken after the telehealth adjustments and the in-person follow up reveal there were no differences for all 9 employees (Table 3). This indicates that the telehealth assessment did not miss any potential issues or required adjustments when compared to in person assessment.
Kruskal-Wallis Test p-values comparing ROSA scores the telehealth ergonomics assessment to a larger population of in-person assessment
Kruskal-Wallis Test p-values comparing ROSA scores the telehealth ergonomics assessment to a larger population of in-person assessment
ROSA scores across various phases for the project
Previous research has shown an association between decreases in ROSA scores and improved worker comfort [25]. Based on this, we assume that the lowering of ROSA scores from the initial assessment, to the telehealth ergonomics adjustments, and eventual equipment implementation represents positive outcomes for musculoskeletal comfort and reducing in injury risk.
These results confirm earlier work that stated telehealth approaches to ergonomics were effective at identifying particular office ergonomics issues and risk factors [20]. One main difference in our paper is that we did not note an increase in sensitivity when scoring potential issues using telehealth approaches [20]. This may be related to the fact that the ROSA scoring tool aggregates potential issues into a representative scoring table and would be less sensitive to small differences in issue counts between assessment types.
Use of video conferencing software
While previous research has noted the use of static digital photos to perform ergonomics assessment [20, 24], the reliance on only static digital photography for analysis can lead to unacceptable levels of error in identifying issues [24]. For this project, the assessor was better able to review and score potential issues with depth and distance and share common views of furniture, devices and postures during real-time conversation and prescribed measurements with the employee, reinforcing the importance of real time video conferencing.
Some important considerations for video conferencing software did emerge, however. First, it is important to note that many workplaces have high levels of network security that restrict access to some video conferencing services. Conversations with technical support specialists on-site with the participant company were key to rectifying these issues. Another key consideration is network connection speed and bandwidth. Quality of video and audio was affected by these parameters. Reviewing the recommended bandwidth requirements outlined by the video conferencing software and comparing it to the work site specification is strongly recommended prior to scheduling an assessment. It is also worth considering that DSL and fibre-optic internet solutions may be limited in very rural areas (<400 people per square kilometer) and other connection options may need to be explored [26]. Finally, if employees do not have audio transmission, microphone or web camera capabilities at their workstation this must beaddressed.
Communications and interaction with the client employee
This process relies on the client taking a very active role in the process. While written descriptions and guideline documents were provided to the employees, some additional instruction was also needed. It is recommended that an initial web conference communication be held with each employee to provide information and training with respect to taking the digital photos. It should also be reinforced with the client that they should have a measuring tape available for the assessment. When employees did not come prepared with this tool, it created delays.
Another key consideration for employee interaction involves protection of personal information. In many workplaces, open offices are common. Discussing discomfort or health-related issues that are aggravated by work over video conferencing in an open office workplace can lead to co-workers, supervisors and managers overhearing sensitive information about the client. Discussions of symptoms, discomfort and personal issues should be held over the phone or video conference in a private room.
Feedback from individuals who took part in the project included mention of initial uncertainty regarding participants comfort level, and the appropriateness/effectiveness of this service approach and technology. This is not an uncommon issue, and it has been reported in other fields which apply telehealth approaches [22]. Developing rapport with the client by providing a photo and biography of the assessor, and placing initial phone calls and video conferencing calls to introduce the assessor to the employee may help to reduce these uncertainties associated with the assessment.
Conclusions
This project provides further evidence of the effectiveness of telehealth approaches to ergonomics and provides guidelines for implementation. The process of attaining and assessing office-based issues, and demonstrating key measures and adjustment to the client are outlined. We also note some key technology considerations and communication barriers that should be planned for and considered in such projects. Perhaps an assessment package of “tools”, including a measuring tape, web camera, microphone headset and cellular network internet device could be shipped to clients at low cost to solve issues related to missing hardware and poor local internet connections.
Additional research to evaluate implementation of telehealth approaches are required. Specifically, studies of how telehealth approaches in ergonomics are perceived by client employees, and whether they believe the assessment and recommendations are delivered in as effective a manner as in person assessment could be useful.
Conflict of interest
None to report.