Handheld devices

By Tamara Mitchell

Small electronic devices have become a part of many people’s lives throughout the world. Some people
have become almost completely dependent upon one of these devices for not only making and receiving
phone calls and checking the time, but for one of the countless other functions they can perform including
text messaging, emailing, taking photographs, reading books, listening to music, watching movies,
searching the internet, getting directions while driving, finding discounts on local meals, emailing, and
posting to Facebook. The fact that handheld devices are so ubiquitous, and they are actually a near-
necessity in some situations, means that people are spending a lot more time interacting with them.

While handheld devices are almost miraculous in their capabilities, it’s important to understand that
interacting with these devices present real challenges from the standpoint of ergonomics. The user tends
to hover close to the device to see it and users are required to do some fairly tedious and detailed manual
manipulations to hold it and to interact with it.

The Physical Challenges

With technology changing so rapidly, research on this topic becomes quickly obsolete as input
methods and devices change. The general rules of ergonomics apply regardless of the device.
The risk for Repetitive Strain Injury (RSI) exists where there is:
• Repetitive motion
• Done in an awkward posture
• Using some force
• Without allowing sufficient rest

Text messaging and hand strain. Text messaging is a very useful means of communicating when
a message is brief, when the message is not urgent and it can be read when the recipient decides
to read it. Text messages and conversations can be accomplished in environments where an
audible conversation is not appropriate. Texting is one of the activities performed on a mobile
device that may be potentially physically harmful if the thumbs are used extensively,
repetitively, forcefully, and for a long period of time. 91% of mobile device users text, email, or
instant messaging.1

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While several hand positions are used during text messaging,
over half of users have been found to prefer the use of the
thumbs, at least with small devices in the size range of 3.5
inches.1,2 Holding the phone with both hands and texting
using both thumbs results in significantly faster and more
accurate than when texting using one hand and one thumb.2
Using a one-handed grip while texting with the thumb
constrains hand movement, requires a more awkward posture
of the hand, and requires stabilizing the phone with the hand
while tapping resulting in greater hand tension.2 Users tend to
use the right index finger in combination with other fingers
with a larger touch screen (9.5 inches) perhaps because the
keys are larger, the device is generally held in the lap, and
this encourages people to type more as they would on a
conventional keyboard.1 Using a two-handed grip resulted in
wrist and thumb joint positions that were significantly less stressful to the hand than using a one-
handed grip, specifically more extended wrist and thumb postures.2 Phone movement was less
with the two-handed grip than with the one-handed grip also.2

Keystroke force has been shown to be greater for devices with physical keypads rather than those
with touch screen keyboards because the physical keys require more force for activation.1,3
Thumb muscles, finger flexor muscles, and wrist extensor muscles were all shown to have
significantly greater activity when using a physical keypad rather than a touch screen.1 This
muscle activity was not found to be related to whether the person used one or two thumbs to
text.1 When the user was texting on a physical keypad, holding the device in one hand while
texting with the same hand, there was significantly greater muscle activity in the wrist extensor
muscles.1 On the surface, it would seem that the use of touch screen keyboards would be the
preferred method since they clearly require less force, however typing speed was 60% lower and
accuracy was over 10% less on the virtual keyboards.3 In another study, typing speed was 4
times slower on a tablet computer in comparison to a laptop or netbook computer.4 In addition,
self-reported comfort of the hands, wrists, arms, and shoulders as well as overall preference for
keyboard style were vastly lower for virtual keyboards than for physical keyboards.3 Perhaps as
people use touch screen keyboards more this will change, but preference may have something to
do with the tactile feedback users receive when interacting with physical keypads or keyboards.

Research has shown that extensive use of the thumbs while texting on cell phones results in
DeQuervain’s tenosynovitis, tenosynovitis of the Extensor Pollicis Brevis and/or the Extensor
Pollicis Longus which is a swelling and inflammation of the tendon sheath and thickening of the
synovial fluid in the sheath.5 Other symptoms of reported have been pain in the forearm with
burning, numbness, and tingling around the thumb area with stiffness of the wrist and hand.6

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Upper body strain.
The most common physical injuries associated with the use of handheld devices aside from
damage to the hands during texting, is myofascial pain syndrome of the neck and upper back as
well as thoracic outlet syndrome.6 Research showed that the injuries were significantly more
likely to occur in the dominant hand and upper extremity.6

People spend an average of 2 to 4 hours a day with their heads tilted down reading or texting on
mobile devices.7 High school students may spend even more time using mobile devices in this
poor posture.7 As the head leans farther forward, the load on the neck, upper back, and spine
increases dramatically adding wear and tear, and degeneration in these areas even possibly
leading to the need for future surgery.7 It is critical that people interact with their mobile devices
with a neutral spine and become aware when their posture is hunched over to avoid muscle
tension and injury.7

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 Illustration derived from Reference 7

Contrary to what one might expect, mobile

devices with larger screens are associated with
greater slumping postures because the device is
heavier and people tend to use them in their
laps.1 This results in greater upper trapezius
muscle activity as the upper back flexes more
and these muscles must work harder to support
the weight of the head.1 In one study, none of
the participants chose to place a 3.5 inch device
(cell phone) in their laps.1 In another study,
typing on a tablet computer vs. a laptop or
netbook resulted in significantly greater non-
neutral wrist, elbow, and neck postures, though
there was significantly less wrist deviation when using the tablet computer probably because
people tended to type with one finger rather than typing with both hands on a standard or small
scale keyboard.4 Sitting on a sofa rather than sitting at a computer workstation resulted in more
stressful postures for the wrists, elbows, and neck.4

Psychophysiological effects of text-messaging.

Research has shown that there are increases in respiration rate, heart rate, skin conductance, and
tension in the trapezius and thumb muscles during text messaging.8 83% of the subjects in one
study reported hand and neck pain during texting and they held their breath and experienced
arousal when receiving text messages.8 Most subjects were unaware of their physiological
changes. At the onset of receiving a text message, subjects held their breath and then continued
to breathe shallowly and rapidly. When sending text messages, breathing was shallow and rapid,

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heart rate, skin conductance, and muscle tension in the thumb and trapezius were increased.8
After texting, physiology returned to normal. The task of focusing on a small digital screen,
composing a text message, tightening of the neck and shoulders, and stabilization of the trunk
muscles to perform fine motor movements all indicate a predisposition to long-term physical
problems.8

Mental Challenges
The benefits and risks in using internet technology and cell phones probably lies in achieving a
balance in taking advantage of the opportunities it offers while placing limits and being aware of
the possible risks.9

Psychosocial Benefits Psychosocial Risks

• Sense of freedom • Feelings of dependence on the equipment
• Unlimited potential • Possible addiction and reliance
• Efficiency • Need to constantly acquire new
• Accessibility competence
• Simplification of many tasks • Reluctance regarding time spent on
• Connectedness to others equipment
• Social control • Invasiveness, disruption, and distraction
• Security – being able to always reach • Disturbance by phones and conversations
someone in public places
• Global “connectedness” • Lack of control
• Too much information
• Difficult to find what is needed
• Relationships intangible, possible social
isolation, and anonymity
• Being left out if don’t participate

Quite a lot of research has been done to understand the impact of smartphone, cell phone, and
electronic media on adolescent children, especially with regard to usage after going to bed. The
impact of text messaging, using Facebook or chat, calling, or playing games has been of interest
with regard to its impact on keeping kids awake after lights out, the effects of resulting sleep
deprivation, and increased symptoms of depression are all of interest, especially since the
occurrence of adolescent depression has increased dramatically since 1960.10 Development of
depressive symptoms during adolescence results in a high rate of recurrence in adulthood, so
determining controllable factors that may reduce adolescent depression is of great interest.10 The
following things have been found:
• Adolescents owning a smartphone tend to use the device more than adolescents owning a
conventional mobile phone and they tend to go to sleep later than their peers. Research
showed that the type of device did not significantly affect overall sleep duration, sleep
difficulties, or symptoms of depression.10
• Use of electronic media in bed before sleep is related to higher levels of depressive
symptoms. 10
• Use of electronic media in bed before sleep is related to shorter sleep duration and more
sleep difficulties. 10

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 • Sleep difficulties, though not sleep duration, appears to be strongly involved in the
mediating relationship between electronic media usage and symptoms of depression. So
use of electronic media appears to be related to sleep disturbance which may lead to
daytime dysfunction such as depression. 10
These results indicate that adolescents (and probably adults) could benefit from adhering to the
habit of leaving the cell phone or smart phone in another room and shutting it off when going to
bed so that lights out and bedtime are unplugged and disturbance from the device is eliminated.

Nomophobia is the anxiety brought on a large number of people when faced with the inability to
communicate through a mobile device.11,12 It is being considered for inclusion in the Diagnostic
and Statistical Manual of Mental Disorders (DSM) which is the primary manual for assessing
psychiatric diseases.12 The disorder is characterized by behaviors that are actually becoming
fairly common: 12
• spending considerable time on one or more devices and always carrying a charger
• feeling anxious or nervous at the thought of losing, misplacing, or being unable to use the
device for some reason
• checking the device frequently to see if messages or calls have come in
• always keeping the device switched on and sleeping with the device near the bed
• limiting face-to-face interactions and prefer this type of communication
• incurring debts or high expenses from using the mobile device.
Of course, as with any mental disorder, it’s a matter of degree to which some or all of these
symptoms are exhibited. There is actually a very high percentage of people (70% women, 61%
men, and 77% youngsters and adolescents) who exhibit symptoms of nomophobia and it is
prevalent in many countries and cultures.12 Those who suffer from Panic Disorder and
agoraphobia are especially susceptible to nomophobia and exhibit intense physical and
psychological symptoms when they are apart from or unable to use a mobile device.11 Anxiety
and stress produce very unhealthy mental and physical responses in the body.13

Avoiding injury from handheld devices.

Prevention is certainly desirable, since rehabilitation is intensive and expensive. Every person
has a different physical tolerance to the stresses and strains of repetitive strain injury, so there
cannot be a hard and fast rule regarding how much usage is too much. In fact each device has a
unique user interface design and each user adopts a method of interaction and a habitual posture
that is unique to them. Take notice if you are beginning to feel any tension, stiffness, or soreness
in your hands, wrists, shoulders, or neck. One study included only people who sent at least 25
text messages or emails a day or people who browsed the internet or played games for more than
1 hour per day using a handheld device with following symptoms of pain.6 Those should
probably be viewed as an outside limit to anyone’s tolerance, though many people exceed this on
a regular basis.

Researchers continuously attempt to design key layouts that are more efficient from a usage or
logical letter sequencing standpoint or allow chording of multiple keys, however acceptance of
alternate key layouts to the traditional QWERTY layout meets with consumer resistance.14,15

Injury prevention strategies suggested are:2,6

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 • Select devices that are designed to permit typing or usage with all the fingers rather than
just the thumb or one finger.
• When typing or tapping, if thumbs are used, hold the device with both hands and use both
thumbs.
• Limit the total hours of usage.
• Take frequent short breaks between usage.
• Maintain correct posture.
• Use voice to text software when possible.
• To avoid psychological dependence, get in the habit of turning the device off when
communication is not necessary especially at night. Consider taking a day each week to
totally unplug from technology.

Illustration courtesy of Summerlandmassage.com

We provide further tips for using cell phones and tablets on our website:
http://www.working-well.org/Website/laptop_tips.html

We also provide recommendations for accessories which can help reduce upper body and hand
strain on our products web page: http://www.working-well.org/Website/plaptop.html#tablets

Rehabilitation
Rehabilitation has been shown to be very effective in treating hand and upper body injuries
resulting from handheld device overuse.6 Treatment is intensive, expensive, and time-
consuming. In the end, it concludes with the establishment of healthy usage habits which could
have been developed in the first place to prevent injury.

A 2-4 week program of rehabilitation of four phases based on pain level was used in one study to
successfully heal and retrain handheld device users.6
 Phase I
• Soft tissue mobilization including trigger point release, myofascial release, positional
release, and muscle energy techniques.
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 • Grade 1 and 2 mobilization of the upper extremity for pain
• Range of motion exercises for the elbow, wrist, and finger joints
• Ultrasound, low level laser therapy, contrast bath, and taping
 Phase II
• Gentle active and passive stretching of the muscles of the upper extremity, especially the
hand
• Hand exercises inside a water tub (Hydrotherapy)
• EMG biofeedback for retraining the muscle during usage of handheld devices and
ergonomic modification
 Phase III
• Strengthening of the upper extremity muscles especially the hand
• Postural awareness and retraining
 Phase IV
• Improving hand activity usage in everyday living
• Maintenance of regained function by involvement in leisure and sport activities
• Home program for maintenance
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This article and all of our articles are intended for your information and education. We are not experts
in the diagnosis and treatment of specific medical or mental problems. When dealing with a severe
problem, please consult your healthcare or mental health professional and research the alternatives
available for your particular diagnosis prior to embarking on a treatment plan. You are ultimately
responsible for your health and treatment!

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References
1. Mobile input device type, texting style and screen size influence upper extremity and trapezius muscle
activity, and cervical posture while texting. By Kietrys, D.M., Gerg, M.J., Dropkin, J., and Gold, J.E.
Applied Ergonomics, Vol. 50, Sept. 2015, pgs. 98-104.
http://www.sciencedirect.com/science/article/pii/S0003687015000368
2. Two-handed grip on a mobile phone affords greater thumb motor performance, decreased fariability,
and a more extended thumb posture than a one-handed grip. By Trudeau, M.B., Asakawa, D.S.,
Jindrich, D.L., and Dennerlein, J.T. Applied Ergonomics, Vol. 52, Jan. 2016, pgs. 24-28.
http://www.sciencedirect.com/science/article/pii/S0003687015300272
3. Differences in typing forces, muscle activity, comfort, and typing performance among virtual,
notebook, and desktop keyboards. By Kim, J.H., Aulck, L., Bartha, M.C., Harper, C.A., and Johnson,
P.W. Applied Ergonomics, Vol. 45, 2014, pgs. 1406 – 1413. http://ac.els-
cdn.com/S000368701400043X/1-s2.0-S000368701400043X-main.pdf?_tid=cfae5794-6305-11e5-
b6a9-00000aacb35f&acdnat=1443131411_842946534df7433b2bc13390657ba7af
4. Effects of portable computer devices on posture, muscle activation levels and efficiency. By Werth,
A. and Babski-Reeves, K. Applied Ergonomics, Vol. 45(6), Nov. 2014, pgs. 1603-1609.
http://www.sciencedirect.com/science/article/pii/S0003687014000957
5. Extensor Pollicis Longus Injury in Addition to DeQuesrvain’s with text Messaging on Mobile Phones.
By Eapen, C., Kumar, B., Bhat, A.K., and Venugopal, A. Journal of Clinical and Diagnostic
Research, Nov. 2014, Vol. 8(11), pgs. LC01-LC04.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4290268/

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6. Musculoskeletal Disorders of the Upper Extremities Due to Extensive Usage of Hand Held Devices.
By Shara, D., Mohandoss, M., Ranganathan, R., and Jose, J. Annals of Occupational and
Enviornmental Medicine, 2014, Vol. 26(22). http://www.biomedcentral.com/content/pdf/s40557-014-
0022-3.pdf
7. Assessment of Stresses in Cervical Spine Caused by Posture and Position of the Head. By Hansraj,
K.K., Neuro and Spin Surgery, Surgical Technology International XXV, 2014. http://www.berliner-
zeitung.de/blob/view/29108108,30347052,data,spine-study.pdf.pdf
8. Psychophysiological Patterns During Cell Phone Text Messaging: A Preliminary Study. By Lin, I-
M., and Peper, E. Applied Psychophysiolocial Biofeedback, 2009, Issue 34, pgs. 53-57.
http://rd.springer.com/article/10.1007/s10484-009-9078-1
9. The use of information technology among young adults – experience, attitudes and health beliefs. By
Gustafsson, E., Dellve, L., Edlund, M., and Hagberg, M. Applied Ergonomics, Vol. 34 (6), Nov.
2003, Pgs. 565-570. http://www.sciencedirect.com/science/article/pii/S0003687003000826
10. Adolescents’ Electronic Media Use at Night, Sleep Disturbance, and Depressive Symptoms in the
Smartphone Age. By Lemola, S., Perkinson-Gloor, N., Brand, S., Dewald-Kaufmann, J.F., and Grob,
A. Journal of Youth and Adolescence, Feb. 2015, Vol. 4(2), pgs. 405-418.
http://rd.springer.com/article/10.1007/s10964-014-0176-x/fulltext.html
11. “Nomophobia”: Impact of Cell Phone Use Interfering with Symptoms and Emotions of Individuals
with Panic Disorder Compared with a Control Group. By King, A.L.S., Valenca, A.M., Silva, A.C.,
Sancassiani, F., Machado, S., and Nardi, A.E. Clinical Practice & Epidemiology in Mental Health,
Vol. 10, 2014, pgs. 28-35. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3962983/
12. A proposal for including nomophobia in the new DSM-V. By Bragazzi, N.L. and Puente, G.D.
Psychology Research and Behavior Management, Vol. 7, 2014, pgs. 155-160.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4036142/
13. Stress: Part I. The physiology of stress. By Tamara Mitchell, Working-Well.org.
http://www.working-well.org/articles/pdf/Stress1.pdf
14. New chording text entry methods combining physical and virtual buttons on a mobile phone. Wu, F-
G, Huang, Y-C, Wu, M-L. Applied Ergonomics, 2014, Vol 45, pgs. 825-832. http://ac.els-
cdn.com/S0003687013002214/1-s2.0-S0003687013002214-main.pdf?_tid=9e2d1c32-5e5a-11e5-
ba0f-00000aacb35d&acdnat=1442618079_f53c8b577c6b5bcae97c9f7879da6238
15. A systematic technique of smart phone keyboard layout design for optimal text-messaging. Chun, C.
Consumer Electronics (ICCE), 2015 IEEE International Conference on Jan. 9-12, 2015, pgs. 603-605.
http://ieeexplore.ieee.org/xpls/abs_all.jsp?arnumber=7066545

September 25, 2015