ErgoMOMics

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April 2002

By Sharon Maynard, OTR/L, CHT, and Lisa G. Blain, MS, OTR/L

Sharon Maynard, OTR/L, CHT, (right) helps a mother use the front carry-an ergonomically correct method of holding a baby. The mother should maintain neutral joint positions by keeping the arms close to her body in order to spread out the weight.

An educational program provides caregivers with ideal posture awareness, body mechanics, and joint posture techniques to ensure safety and comfort in performing child care tasks.

One of life's most widely performed jobs is caring for young children. In this scenario, the worker is the parent or caregiver, and the job site is the home or child care setting. The job is a physically demanding one, involving repetitive tasks such as lifting, feeding, and carrying. Similar to workers in a factory or office setting, proper body mechanics must be utilized during child care tasks in order to prevent repetitive strain injury.

As occupational therapists in an outpatient physical rehabilitation setting, we often treat clients with repetitive strain injuries, a blanket term that includes both musculoskeletal and neurovascular disorders of the neck, back, shoulders, arms, and hands.^1,2 When the job site is the home and the job is child care, there is little opportunity for rest from aggravating activities. These workers might continue the injurious activities until the pain or dysfunction progresses to a point where they are unable to perform such tasks as lifting a child into a car seat or changing a baby's diapers.

CASE STUDY
A 32-year-old woman was referred to our occupational therapy clinic for adaptive equipment and nondominance activity of daily living retraining. She was referred by a local physical therapy clinic after an unsuccessful course of treatment for her lateral epicondylitis and rotator cuff tendonitis.

This client was the mother of 20-month-old twins, one with cerebral palsy. After experiencing right dominant upper extremity pain, weakness, and intermittent numbness in her hand for more than 2 years, she finally sought physical therapy intervention when her symptoms exacerbated after assisting her husband with a home tiling project. At the time, she was unable to carry her children, and relied on her husband and father to complete the majority of child care tasks.

Prior to her pregnancy, the client was a full-time office manager and avid runner. She denied prior musculoskeletal injuries or medical disorders. She was placed on bed rest in her fifth month of pregnancy, delivering the twins by cesarean section in her eighth month. Following the twins' birth, the child with cerebral palsy remained hospitalized for 11 weeks. At 20 months, this child required total physical care due to inability to sit, crawl, or ambulate.

During her prolonged bed rest, the mother became deconditioned, exhibiting diminished muscle mass and aerobic capacity. After the birth of the twins, she was unable to return to work outside the home or resume her premorbid exercise program. Furthermore, hormonal changes associated with pregnancy heightened her body's susceptibility to musculoskeletal injury and increased circulation of the sex hormone, estrogen, and the ovarian hormone, relaxin, which are associated with increased laxity in connective tissues during pregnancy.³ Having engaged in the rigors of full-time care of her twins for almost 2 years, she came to our outpatient occupational therapy clinic with neurovascular and musculoskeletal impairment of her dominant right upper extremity, significantly impairing her ability to safely and comfortably care for her children.

We know that increasing an individual's awareness of posture and body mechanics can decrease occurrences and intensity of musculoskeletal pain.⁴ Do we sufficiently educate our clients on how to apply this awareness to a variety of daily activities, including child care?

Education Is The Key
It is imperative that caregivers implement proper posture, body mechanics, and joint protection techniques during child care activities in order to prevent debilitating injuries. With this mission in mind, we have combined our occupational therapy background of anatomy, joint protection, and activity analysis with first-hand child care and parenting experience to develop an educational program entitled ErgoMOMics. The curriculum applies common principles of ergonomics to the everyday tasks of child care. The goal of the educational program is to increase awareness of posture and body mechanics, and the importance of applying these techniques to daily activities such as child care, home management, leisure, and sleep.

This educational program is currently offered to a new mothers support group at Mercy Medical Center in Springfield, Mass. Initially, we survey the group participants as to the occurrence of pain or physical limitations during or following child care activity, and then focus our discussion of preventive strategies to address the mothers' particular identified problem areas. Emphasis is placed on awareness of injurious neck, spine, arm, and hand positions, as well as modifications to avoid repetitive stress injuries.

A common response to our symptom survey is neck or upper back strain that is not relieved by sleep or rest. As a group, we analyze how many child care and other daily activities find us with our head and neck held in flexion. After increasing awareness of this strained posture, we propose many solutions to avoid static neck flexion. One possible strategy to encourage neck and back extension during child care is to lie prone on the floor during playtime. Another easily implemented strategy is to look up and side to side every 5 minutes during prolonged activity such as breast-feeding, washing dishes, or reading.

Shoulder and arm fatigue is another symptom commonly reported by the group. The mothers often attribute this to carrying their babies, portable car seats, and diaper bags. Frequently, the awkward shape of the car seat handle and the car seat itself force the caregiver to carry the weight of the seat on an outstretched arm, far from the center of gravity, which leads to quick fatigue and strain on the back and upper extremity joints. Possible solutions are to carry the portable car seat with both arms at waist height at the front and center of the body, or to carry the child in one arm and the car seat in the other for a more even distribution of weight.⁵

The ErgoMOMics course also emphasizes the importance of restorative rest and sleep positions. Many new mothers are already accustomed to using pillows for increased sleeping comfort during pregnancy; continued use of pillows is encouraged in sitting as well as when lying down to support limbs and maintain optimal spinal alignment. Due to nighttime feedings and diaper changes, new mothers tend to have fewer hours of consecutive sleep. Thus, it is critical that the few hours they do get are restful and restorative, allowing the body to heal itself from the challenges and rigors of daytime activity. It is imperative that beds, mattresses, and pillows provide appropriate support and spinal alignment in order to promote healthful restorative sleep.^5,6
During the educational session, the mothers have their children with them, allowing for hands-on, immediate, and realistic practice of recommended techniques. We also utilize pictures of potentially injurious postures during activities such as breast-feeding, bottle-feeding, and placing and retrieving children in swings or Exersaucers. As a group, we analyze, demonstrate, or role play the most advantageous technique, emphasizing proper posture, body mechanics, and joint protection for each activity.

References
1. Keller K, Corbett J, Nichols D. Repetitive strain injury in computer keyboard users: pathomechanics and treatment principles in individual and group intervention. J Hand Ther. 1998;11:9-26.
2. Quilter D. The Repetitive Strain Injury Recovery Book. New York: Walker and Company; 1998.
3. Lowdermilk DL, Perry SE, Bobak IM. Maternity and Women's Health Care. 7th ed. St Louis: Mosby; 2000:348-349.
4. Lieber SJ, Rudy TE, Boston JR. Effects of body mechanics training on performance of repetitive lifting. Am J Occup Ther. 2000;54:166-175.
5. Pirie A, Herman H. How To Raise Children Without Breaking Your Back. West Somerville, Mass: IBIS Publications; 1995:33-51.
6. Novak J. Posture, Get It Straight! New York: The Berkley Publishing Group; 1999:111-116.

Sharon Maynard, OTR/L, CHT, and Lisa G. Blain, MS, OTR/L, are occupational therapists at the Weldon Center for Rehabilitation in Springfield, Mass. They can be reached via the Web at www.ergomomics.com.

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