How to cite:

Utomo Wicaksono, I Made Muliarta, Luh Made Indah Sri Handari

Adiputra. (2021). Reducing CTS Complaints and the Fatigue of Rock

Breaker through Ergonomics Approach by Exercising Nerve-Tendon

Mobilization and Short Break. Journal Eduvest. 1(10): 1141-1151

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Eduvest – Journal of Universal Studies

Volume 1 Number 10, October 2021

p- ISSN 2775-3735 e-ISSN 2775-3727

REDUCING CTS COMPLAINTS AND THE FATIGUE OF ROCK BREAKER

THROUGH ERGONOMICS APPROACH BY EXERCISING NERVE-

TENDON MOBILIZATION AND SHORT BREAK

Utomo Wicaksono, I Made Muliarta, Luh Made Indah Sri Handari Adiputra

Udayana University

E-mail: [email protected], [email protected],

handari_adiputra@unud.ac.id

ARTICLE INFO ABSTRACT

Received:

September, 26

2021

Revised:

October, 16

2021

Approved:

October, 18

2021

The ergonomics problem related to the casual laborers which

here focus on rock breakers as their job, covers some aspects

such as their muscle usage, working hours, postures, tools and

environments. The ergonomics problem created health

problems where the workers are having Carpal Tunnel

Syndrome (CTS) and fatigue. This study intends to prove that

exercising nerve-tendon mobilization and short break through

ergonomics approach will be able to reduce the volume CTS

complaints and the fatigue of the rock breakers. This study

involves 7 samples from the controlling group and 7 samples

from the intervention group. The CTS complaints are measured

by using Symptom Severity Scale (SSS) from Boston Carpal

Tunnel Questionnaire (BCTQ) and the fatigue was surveyed

through 30 questionnaires from Item of Rating Scale of

Industrial Fatigue Research Committee (IFRC). The Data were

analyzed by applying Statistical Package for the Social Science

(SPSS) software. The goals of this study is to give nerve-tendon

mobilization exercise and short break through ergonomics

approach related to the problem of muscle usage, working

hours, postures, tools and environments would lessen the CTS

complaints about 12,71% while the fatigue level in the amount

of 5,69% that has been experienced by the rock breakers.

KEYWORDS

Carpal Tunnel Syndrome, Ergonomics, Fatigue, Nerve-Tendon

Mobilization, Short Break

This work is licensed under a Creative Commons

Attribution-ShareAlike 4.0 International

Utomo Wicaksono, I Made Muliarta, Luh Made Indah Sri Handari Adiputra

Reducing CTS Complaints and the Fatigue of Rock Breaker through Ergonomics

Approach by Exercising Nerve-Tendon Mobilization and Short Break 1142

INTRODUCTION

West Bangkal Awang Village which located in Karang Intan District, Banjar

Regency, South Kalimantan Province is a village close to the hills known as Bukit

Tahura. This village has many residents who sell crushed stones. The production of the

crushed stones includes processes such as rock collection, rock breaking and moving the

rock itself to the main storage. Breaking the rocks is the main process to produce crushed

stones so it would be ready to be sold to the customers. However, this process has high

risks for the workers. That is because the process is done manually and solely relying on

physical strength. The tools used consist of a sledgehammer. It has been modified by a

rattan handle in order to reduce the vibration caused by the impact between the

sledgehammer and the rock. The diameter and length of the handle are adjusted

subjectively to suit the user’s necessity. The weight of the sledgehammer varies between

8kg – 10kg. Another tool used in the process is a crowbar with a weight that varies

between 4kg – 6kg.

Working with the sledgehammer makes the workers perform repetitive

movements that create a force whenever the sledgehammer strikes against the rock. When

a sledgehammer collides with a rock, it produces vibrations that propagate to the workers’

arms. Furthermore, the workers will also perform awkward postures, which tend to bend

their wrists for a long time. According to Ibrahim (2012) this condition is the most

significant factor in the incidence of CTS. The combination of repetitive movements of

force, exposure, and vibration from awkward wrist postures increases pressure within the

carpal tunnel tissue. Increased pressure causes tissue compression which will trigger

repeated small injuries, in a long term it can cause inflammation of the tendon which

further increases compression and causes poor circulation to the tissue and afterwards,

causing tissue ischemia resulting in musculoskeletal. If the compression condition is

ignored until a chronic stage, it will cause adhesions between the nerves and tendons in

the carpal tunnel which causes gradual tissue damage and will reduce the functional

ability of the workers (Duncan & Kakinoki, 2017; Ibrahim et al., 2012; Salawati &

Syahrul, 2014; Wardana, Wijayanti, & Ekawati, 2018).

As the presence of musculoskeletal and the high demand of work, it is no wonder

that psychological and physical fatigue of the worker would be affected (Adiputra, 2003;

Hedge, 2017; Kroemer & Grandjean, 2009). Fatigue experienced by rock breakers also

occurs as the result of improper work time management applied by workers (Bridger,

2003; Hedge, 2017; Kroemer & Grandjean, 2009). The working time set by the employer

begins at 08.00 a.m – 03.00 p.m of Indonesia Central Standard Time (UTC+08:00) for six

working days, as they are Monday to Saturday. Practically speaking, the working hours

and the rest hours that are provided to the workers depend on the ability of the worker

individually. The current habits create a stigma in which most workers choose to force

themselves to work continuously preferring to accumulate their rest time in the middle of

the day and because of that many workers are not able to continue working due to wrist

pain and fatigue throughout their body. Overworking can cause the body tends to spend

more energy than it actually targeted. In the process of producing energy, it is necessary

to break down glycogen which also produces lactic acid, so the more energy produced,

the more lactic acid is created and it will causes vasoconstriction of blood vessels,

resulting in obstruction of blood flow and the disposal of the body metabolic wastes. The

accumulation of lactic acid that occurs causes fatigue throughout the body in workers

(Hedge, 2017; Kroemer & Grandjean, 2009; Maharja, 2015). Musculoskeletal disorders

and fatigue are the factors that can reduce worker productivity (Damantalm et al., 2018;

Eduvest – Journal of Universal Studies

Volume 1 Number 10, October 2021

1143 http://eduvest.greenvest.co.id

Rusni, Tirtayasa, & Muliarta, 2017). This is supported by the testimony from the workers

who after having the related health complaints only able to work effectively until lunch

time meanwhile some of them went home and stopped their work. Which retards the

production and the income that should have been able to be earned by the workers for

about 3 – 4 days.

In order to fix the mentioned problems, it is necessary to have a comprehensive

study that totally focuses on the ergonomics approach. A total focus on ergonomics

approach will help encourage all parties to take part in identifying the root cause of the

problems, therefore will be able to apply a proper solution with appropriate technology. It

is meant to solve the problem by using the SHIP approach (Systemic, Holistic,

Interdisciplinary, Participatory) so that a beneficial mechanism would be created and the

aimed products quality can be obtained according to the demands of the current era

(Manuaba, 2003, 2005). The ergonomics approach is based on eight aspects, known as

muscle usage, work posture, nutrition, interactions between human and machine and also

situation and condition of time, environment, information and socio-cultural (Oesman &

Adiatmika, 2008). The ergonomics approach tries to conduct simple ergonomics

improvements based on the existing resource in small industries. In this case, every

improvement method applied is intended to be simple yet logical so it can be accepted

and applied easily. As the results, the ergonomics problems that will be solved are the

aspect of muscle use and work posture by adjusting the jobs to the worker by providing

nerve-tendon mobilization exercises after they perform the repetitive movements with

strength and make a awkward postures on their wrist; as well as to prevent the health

problems where the workers should use their provided rest time instead of constantly

working and accumulating their rest hours later.

The application of nerve-tendon mobilization exercises is an option since work-

related diseases experienced by workers can be lessened or prevented before it gets worse

and affects the workers. According to Atya & Mansour (2011) the reason nerve-tendon

mobilization exercises recommended because it provide opportunities for the tissues to

relax thereby reducing its tension, smoothing the circulation of nutrients to tissues,

improving venous blood flow, preventing or reducing tissue tension, edema, and also the

pressure so that the tissue adhesion in the carpal tunnel does not occur. If it successfully

applied, complaints about CTS because of tissue ischemia can be solved and finally the

workers can carry out their work comfortably without health problems. Several other

research claims that the main outcome obtained from applying nerve-tendon mobilization

exercises is an increase in vascular reactivity. It can also give an effect on increasing

axonal transport and nerve conduction, resulting in improvements of functional state and

perceived fatigue (Coppieters & Butler, 2008; Puspadewi, Adiatmika, & Sutarja, 2018).

In addition, short breaks can also be considered as a preventive effort since it can

help to minimize exposure to risk factors and change the bad habits of the workers who

force themselves to work continuously, accumulating breaks and consequently create a

system that is not ergonomically friendly. If the latter is not followed, it can actually

increase work demands that cause musculoskeletal disorders and build up fatigue of the

workers. Having short breaks regularly will further reduce or prevent repetitive strain

injuries that can trigger musculoskeletal disorders and other disorders such as fatigue

Eduvest – Journal of Universal Studies

Volume 1 Number 10, October 2021

Reducing CTS Complaints and the Fatigue of Rock Breaker through Ergonomics

Approach by Exercising Nerve-Tendon Mobilization and Short Break 1144

(Chakrabarty et al., 2016). Short breaks can also reduce the workload, provide an

opportunity for the body to recover through valodilation of blood vessels and help the

heart's function to be as good as its original condition (Sutapa, Sudiarsa, & Susila, 2017),

making its cells able to relax and reduce musculoskeletal disorders (Puspadewi et al.,

2018), and prevent the accumulation of fatigue (Dewi et al., 2018).

RESEARCH METHOD

This research is an experiment with a randomized pre-post test control group

design involving 14 research samples with technique of purposive sampling. The sample

in this study was divided into two groups, which are 7 workers in the control group who

worked without any intervention and 7 workers in the treatment group who worked with

the intervention. The interventions meant through an ergonomic approach include: nerve-

tendon mobilization exercises following the Alexander protocol (2017) with a dose of 1

session carried out every 2 hours after work, thus designing 3 sessions in a day, each

session consists 1 series of nerve mobilization exercises and 1 series of tendon

mobilization exercises, each series was repeated 5 times, it performed in working days for

2 weeks; and a 5 minute short break after undergoing 55 minutes of work activity for 2

weeks. CTS cases first proposed by Chang (2008) when the workers confirm to feel the

following: numbness or tingling in the median nerve area, tingling at night, wrist pain

radiating to the shoulder, occurence of Phalen's and Tinel sign. CTS complaints were

measured using the Symptom Severity Scale (SSS) from the Boston Carpal Tunnel

Questionnaire (BCTQ) and fatigue was measured using a 30 Item of Rating Scale

questionnaire from the Industrial Fatigue Research Committee (IFRC). Data analysis used

Independent-Samples T Test for data that gave normal results while Mann-Whitney Test

for data with abnormal results with a significance level of 5% (α = 0.05).

RESULT AND DISCUSSION

1. Respondent Characteristics

Table 1. Respondents Characteristics

Variable

Average

Range

Age (yrs)

100

45,50

2,10

42 – 48

Weight (kg)

100

2,72

54 – 63

Height (cm)

100

163,14

3,01

158 – 168

Working Period (yrs)

100

14,86

2,66

12 – 19

IMT (kg/m

)

100

22,17

0,97

20,58 – 23,83

CTS Hand

Right

100

Left

Eduvest – Journal of Universal Studies

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The respondent age involved in this study is considered a productive age. Research

from Nurjana (Nurjana, 2015) shows that productive age ranges from 15 to 49 years.

Furthermore, the age of workers is classified by the risk of the CTS incidence, according

to a study by Cazares-Manríquez (2020) those over the age of 40 years have 1.92 of risk

to experience CTS complaints compared to those under 40 years. Body mass index (BMI)

of rock breaker workers in Awang village, West Bangkal is considered ideal. Excessive

BMI will inflict CTS complaints and fatigue (Purnawijaya & Adiatmika, 2016).

According to the Cazares-Manríquez (Cazares-Manríquez et al., 2020) study, a BMI that

exceeds its ideal has 2.90 of risk to develop CTS. The average working hours of the

workers in this study have a high risk of getting CTS. Lazuardi (2016) research states that

≥4 years of working period is one of the reasons for the occurrence of high complaints of

CTS, also Atiqoh (2014) states that a long working period can cause high levels of

boredom and fatigue for the workers. Another study states that workers who have a

working period of 4 years have 11.71 greater risk of experiencing musculoskeletal

disorders compared to workers with a working period who <4 years (Riningrum &

Widowati, 2016). The arms of workers affected by CTS all occurred on their right hand.

This event can happen seeing that every worker has a dominant arm on the right hand

(Rambe, 2004).

2. Working Environment Conditions

Table 2. Working Environment Conditions

Variable

Control

Treatment

p-Value

Average

Lighting (lx)

4341,33

0,88

4341,17

1,86

0,85*

Humidity (%)

68,7

0,21

68,72

0,15

0,64*

Temperatures (°C)

28,97

0,18

28,95

0,23

0,89*

Noises (dB)

68,85

0,15

68,82

0,12

0,68*

*Independent-Sample s T Test, **Mann-Whitney Test

As explained in the research by Putra and Madyono (2017), the intensity of lighting

in the work environment of the control groups already has an ideal level of lighting. Work

that is carried out routinely should have an intensity level of lighting at least 300lx.

Meanwhile, the humidity level in the control and treatment groups has met the worker

standard comfort. Rezalti and Susetyo (2020) state, the humidity that meets the standards

of the industrial work environment is 65% – 95%. The results of measuring the

temperature of the industrial work environment in both the control group and the

treatment group can be concluded that they have met its quality standard. The research of

Lady and Wiyanto (2019) discuss that the temperature condition of the industrial work

environment should be at 18°C – 30°C. Next, the noise level in the work environment of

both groups is considered to be quite good. According to Permenkes No. 70 concerning

Standards and Requirements for Health in the Industrial Work Environment (Menteri

Kesehatan Republik Indonesia, 2016), the noise level for 8 hours of work in a day is

supposed to be <85dB. Thereupon, statistical analysis of lighting conditions, humidity,

temperature, and noises in the work environment of both groups were not significantly

different (p-value > 0.05). Thus, all aspects of environmental conditions during the study

Utomo Wicaksono, I Made Muliarta, Luh Made Indah Sri Handari Adiputra

Reducing CTS Complaints and the Fatigue of Rock Breaker through Ergonomics

Approach by Exercising Nerve-Tendon Mobilization and Short Break 1146

can be controlled and did not give impact to the activity of the workers.

3. CTS Complaints

Table 3. CTS Complaints

Variable

Control

Treatment

p-Value

Average

Pre-CTS Complaints

26,71

0,76

0,37**

Post-CTS Complaints

32,57

0,53

28,43

0,98

0,00**

*Independent-Sample s T Test, **Mann-Whitney Test

There was no significant difference in the initial conditions (pre) of CTS

complaints between the control group and the treatment group (p-value > 0.05). This

shows that the initial conditions in both groups are similar. The statistical test for the final

condition (post) of CTS complaints in the control group and treatment group obtained a

p-value (0.00) <0.05, which means that CTS complaints in the treatment group prove it

has a significantly smaller value than the control group. Thus, complaints of CTS in the

treatment group decreased remarkably with a percentage decrease of 12.71%. Some

effects of CTS complaints that the workers encounter are pain level during the day from

severe to moderate, the frequency of pain during the day from 3 – 5 times to 1 – 2 times,

the tingling that is felt in moderate to mild, whilst at night it feels moderate to mild. These

events occurred because of the intervention of nerve-tendon mobilization exercises

through an ergonomic approach on the between working period. According to Ibrahim

(Ibrahim et al., 2012) high complaints of CTS that experienced by workers related to

occupational factors, such as long work postures to perform extreme wrist flexion or

extension, repetitive use of flexor muscles, and exposure to vibrations is said to cause

stress on the tissue and lesions in the carpal tunnel tissue which if left unchecked can lead

to inflammation and adhesions between the tissues and will develop into a serious

problem like CTS.

Performing mobilization exercises can serve as an opportunity for the carpal tunnel

tissue to stretch so that it can reduce the tension, give an ease for the nutrients tissue

circulates, prevent or reduce edema from pressure so that there is no adhesion between

tissues in the carpal tunnel. Therefore, CTS complaints about tissue ischemia can be

solved, workers can finish their work comfortably and healthily (Atya & Mansour, 2011;

Muliarta, Adiputra, Dinata, Adiputra, & Tunas, 2020). This study is consistently follow

previous studies that have analyzed about nerve-tendon mobilization exercises proven to

be able to provide: a significant improvement in the severity of the complaints, functional

ability, perceived pain, and quality of life of CTS patients (Horng et al., 2011); a

significant effect on the improvement of CTS symptoms, which are the subside of silent

pain by 7.85% and motion pain by 11.80% (Zuhri, Miharjanto, & Trisnowiyanto, 2012);

it also recovers some symptoms like the reduction in pain, paresthesias, tingling,

nocturnal symptoms and trouble of sleeping (Marryam, Yasmeen, Malik, Malik, &

Amjad, 2018); and another significant improvement in complaints of tingling sensation,

pain, hypesthesia, impaired touch sensation, vanishing of positive Phalen sign, increased

grip strength, decreased symptom severity, and increased functional ability (Bartkowiak,

Eliks, Zgorzalewicz-Stachowiak, & Romanowski, 2019).

Eduvest – Journal of Universal Studies

Volume 1 Number 10, October 2021

1147 http://eduvest.greenvest.co.id

The lesser complaint of CTS also occurred because of the intervention in the form

of a short 5 minute break after undergoing 55 minutes of work activity. In the control

group who was not given the intervention, the workers were only able to work for a

shorter time, which is ±4 hours from 08.00 – 12.00 of Indonesia Central Standard Time

(UTC+08:00) meanwhile in the intervention group workers were able to work longer and

that is about ±7 hours from 08.00 – 15.00 of Indonesia Central Standard Time. The

reason the control group did a shorter working time is because the occurrence of CTS

complaints and fatigue felt by workers is faster, and as a consequence they should stop

working. Giving short breaks passively or actively will reduce repetitive workloads which

can prevent repetitive strain injuries in the tissues involved in performing risky work

(Chakrabarty et al., 2016; Luger, Maher, Rieger, & Steinhilber, 2017). The results of this

study are in line with research conducted by Wood (2017), the application of short breaks

significantly reduces neuromusculoskeletal complaints from its effects, which can restore

posture, soft tissue mobility, and reduce stress due to work processes. Nooryana (2020)

also found similar findings, that providing short breaks can significantly reduce

musculoskeletal disorders by 7.72% because by doing it the workers will get the

opportunity to recover their energy even after doing awkward postures and relaxing the

soft tissues involved in the work process.

4. Fatigue

Table 4. Fatigue

Variable

Control

Treatment

p-Value

Average

Pre-Fatigue

1,11

1,63

0,36*

Post-Fatigue

72,71

1,80

68,57

1,90

0,00**

*Independent-Sample s T Test, **Mann-Whitney Test

There was no significant difference in the initial conditions (pre) of fatigue

between the control group and the treatment group (p-value > 0.05). This shows that the

initial conditions in both groups are similar. The final condition (post) of fatigue in the

control group and treatment group based on statistical tests obtained p-value (0.00) <0.05,

which means that the fatigue in the treatment group shows that it is significantly smaller

than the control group. It reveals that fatigue in the treatment group experienced a

significant decrease with a percentage decrease of 5.69%. Of the three types of fatigue

associated with weakened activity, weakened motivation, physical fatigue, it was found

that the intervention of nerve-tendon mobilization exercise and short break through an

ergonomic approach had the most effect on the type of physical fatigue felt by workers

with a decreasing effect of 11.16%. By applying the intervention of mobilization

exercises to the tissues involved in the work process, it will provide opportunities for the

tissues to stretch so as to reduce tissue tension, vascular reactivity, facilitate venous

return, facilitate circulation of nutrients to the tissues, and result in increased blood flow

to the tissues (Atya & Mansour, 2011; Coppieters & Butler, 2008; Muliarta et al., 2020;

Puspadewi et al., 2018). Due to the success of this intervention in reducing

musculoskeletal disorders, the workers felt less tired. The results of this study are in the

same understanding with research by Lacaze (2010) that states exercise at work has a

significant effect on reducing musculoskeletal disorders, physical and mental fatigue

 
 
Utomo Wicaksono, I Made Muliarta, Luh Made Indah Sri Handari Adiputra 
 
Reducing CTS Complaints and the Fatigue of Rock Breaker through Ergonomics 
Approach by Exercising Nerve-Tendon Mobilization and Short Break  1148 
rather  than  just resting  passively. Another  study  that supports the results of this  study 
concluded that doing exercises on the body parts involved after performing work tasks 
had a significant effect on reducing fatigue at the end of work by 29.22% (Wahyu et al., 
2020). 
Not  only  providing  training  between  working  hours,  the  treatment  group  also 
practically got a short 5 minute break after undergoing 55 minutes of work activity. The 
intervention is purposely done in order to make the workers have their work done in an 
ergonomic way. The workers should avoid working nonstop of their full working hours 
because they should have a rest for the sake of their own health and also to ensure they 
can  they  optimilized  their  job.  Short  break  will  help  the  body  to  recover  through 
vasodilation  of  blood vessels so that  the heart's burden  is  reduced  and even  regain  its 
original condition (Sutapa et al., 2017), providing an opportunity for muscles to relax so 
the cells can recover muscles that can reduce musculoskeletal disorders (Damantalm et 
al., 2018; Puspadewi et al., 2018), and prevent the accumulation of fatigue (Dewi et al., 
2018;  Dhari,  Muliarta,  &  Adiputra,  2017).  Research  by  Sarker  (2021)  bears  similar 
results to this study, the impact of short breaks to the workers who perform monotonous 
work or tasks can crucially reduce the cause of fatigue by preventing muscle discomfort. 
Further research from (Damantalm et al., 2018) states that short breaks have a significant 
effect in reducing fatigue by 23.75% so that the urge to work remains high and utilizes 
time at work effectively. 
In this study, the score of CTS complaints and fatigue in the treatment group was 
shown to decrease more compared to the control group, but the intervention provided was 
not  able  to  reduce  the  degree  of  complaints  and  fatigue  felt  by  workers,  which  
fortunately is still at a moderate degree. This is because there are several factors that play 
a major role in the incidence of CTS and uncontrolled fatigue such as prolonged awkward 
work postures, repetitive movements, and exposure to vibration (Ibrahim et al., 2012). In 
addition, researchers find it difficult to control working time since it is diverse to each 
person. There are differences in the working time, the control group has a shorter working 
time whereas the treatment group has a longer working time. This is the answer why the 
intervention provided was only able to reduce the value of CTS complaints and fatigue 
but yet to reduce the degree of perceived complaints subjectively (Sani & Widajati, 2021; 
Wahyu et al., 2020). 
 
CONCLUSION 
 
The  nerve-tendon  mobilization  exercises  and  short  break  using  an  ergonomic 
approach was able to reduce the  level of CTS complaints by  12.71% and the level of 
fatigue  by  5.69%.  It is  expected  the  future  research  would be able  to  conduct  similar 
study by focuses on work-related factors that have an impact on the occurrence of carpal 
tunnel syndrome (CTS), for instance are work duration, working period, work posture, 
working  tools,  repetitive  movements  like  grab  on  something,  and  the  exposure  to 
vibration during the process of working. 
 
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