Interventions for the prevention and management of neck/upper extremity musculoskeletal conditions:...

REVIEW

Interventions for the prevention and management of neck/upper extremity musculoskeletal conditions: a systematicreviewM G Boocock, P J McNair, P J Larmer, B Armstrong, J Collier, M Simmonds, N Garrett. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Occup Environ Med 2007;64:291–303. doi: 10.1136/oem.2005.025593

Considered from medical, social or economic perspectives, thecost of musculoskeletal injuries experienced in the workplace issubstantial, and there is a need to identify the most efficaciousinterventions for their effective prevention, management andrehabilitation. Previous reviews have highlighted the limitednumber of studies that focus on upper extremity interventionprogrammes. The aim of this study was to evaluate the findingsof primary, secondary and/or tertiary intervention studies forneck/upper extremity conditions undertaken between 1999and 2004 and to compare these results with those of previousreviews. Relevant studies were retrieved through the use of asystematic approach to literature searching and evaluated usinga standardised tool. Evidence was then classified according to a‘‘pattern of evidence’’ approach. Studies were categorised intosubgroups depending on the type of intervention: mechanicalexposure interventions; production systems/organisationalculture interventions and modifier interventions. 31 interventionstudies met the inclusion criteria. The findings providedevidence to support the use of some mechanical and modifierinterventions as approaches for preventing and managingneck/upper extremity musculoskeletal conditions andfibromyalgia. Evidence to support the benefits of productionsystems/organisational culture interventions was found to belacking. This review identified no single-dimensional or multi-dimensional strategy for intervention that was consideredeffective across occupational settings. There is limitedinformation to support the establishment of evidence-basedguidelines applicable to a number of industrial sectors.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

See end of article forauthors’ affiliations. . . . . . . . . . . . . . . . . . . . . . . .

Correspondence to:Dr M G Boocock, PhysicalRehabilitation ResearchCentre, Auckland Universityof Technology, Private Bag92006, Auckland 1020,New Zealand;[email protected]

Accepted 17 August 2006Published Online First14 September 2006. . . . . . . . . . . . . . . . . . . . . . . .

One of the major problems facing industrialcountries is work-related musculoskeletaldisorders.1 Recent literature suggests that

the incidence of such injuries may continue to riseowing to increased exposure to workplace riskfactors,2 more segmented and repetitive work,increased mechanisation and shifts in workingpractices towards the service and informationsector.3

There are direct health costs associated with therehabilitation of workers with musculoskeletalinjuries, and also significant economic costs areimposed on the industry as a result of compensa-tion, lost productivity and retraining.4 The magni-tude of the problem in financial terms has been

estimated in the US to be as much as US$54 billionper year.1

Workers affected by work-related musculo-skeletal disorders are often afflicted by long-termpain, loss of function and disability. For theeffective prevention and management of suchdisorders, national organisations (eg, NationalInstitute for Occupational Safety and Health,USA; Health and Safety Executive, UK;Occupational Safety and Health, New Zealand)have often implemented a variety of single-dimensional and multi-dimensional programmesinvolving medical, physical and psychosocial inter-ventions. As intervention approaches within anindustrial setting are often complex and evolving,they require evidenced-based models to be effective.1

Any evaluation of the potential benefits ofinterventions is difficult. However, the work ofWestgaard and Winkel5 provides a model for theclassification of interventions, thereby allowing areview of the literature to be undertaken in astructured manner. Westgaard and Winkel5 cate-gorised intervention strategies into three maingroups: mechanical exposure, production systems/organisational culture and modifier interventions.Mechanical exposure interventions typically focuson changing the design of tools, such as thecomputer mouse or keyboard. Production systemsinterventions, however, generally implementchanges to the material production and/or theorganisational culture of a company. The lattermay involve team building and increased workerparticipation in the problem-solving of workplaceproduction (ie, participatory ergonomics). Finally,interventions that incorporate specific training ofworkers to manage exposure levels to physical andpsychosocial stressors are termed modifierinterventions. These may involve an exerciseprogramme and/or ergonomic education.

Previous reviews have highlighted a dearth ofliterature examining the effectiveness of interven-tion approaches for the prevention and manage-ment of neck/upper extremity musculoskeletalconditions.6–9 Furthermore, many of the experi-mental studies included in these reviews havebeen of low quality and few have includedrandomised controlled trials (RCT). Thus, theopportunity to establish effective evidence-basedmanagement programmes for work-related

Abbreviations: GATE, generic appraisal tool forepidemiology; RCT, randomised controlled trials; VDU,visual display unit

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musculoskeletal disorders has been restricted. Therefore, thereis a need to update our current knowledge using a systematicapproach. The aim of this study was to fulfil this need byconducting a systematic review and evaluation of the findingsof primary/secondary and/or tertiary intervention studies forneck/upper extremity musculoskeletal conditions undertakenbetween 1999 and 2004.

METHODSSearch strategyAn initial search of the literature integrated a variety of sourcesincluding textbooks and conference proceedings, national andinternational health and safety organisation websites, and ageneral internet search. From this initial search, an extensivekeyword list was developed to incorporate nationally andinternationally recognised work-related musculoskeletal termsand definitions (eg, musculoskeletal disorder, repetitive straininjuries and occupational overuse syndrome), inclusive ofdiagnostic conditions (eg, thoracic outlet syndrome and cubitaltunnel syndrome). Keywords specific to intervention studieswere generated, which used a combination of generic labels (eg,musculoskeletal control and ergonomic intervention) andspecific intervention approaches (eg, workstation design, jobrotation and physical training).

Four researchers (BA, MGB, JC and MS), guided by a libraryand information manager, carried out the literature search. Thekeyword list and all combinations of keywords were useduniformly by all four researchers to ensure a standardisedapproach to the search procedure. An initial check of thekeyword list was made against each of the subject headingsfrom 15 electronic databases (CINAHL (including CochraneReviews); EBSCO Megafile Premier (including Medline, HealthSource: Consumer Edition and Nursing/Academic Edition);Embase; Ergonomics Abstracts; Index NZ; AMED (Allied andComplementary Medicine); Annual reviews; Psych INFO(including PsycARTICLES); ProQuest 5000 (includingProQuest Health and Medical Complete); Expanded AcademicASAP; Sports Discus; Science Direct; Blackwell Synergy;Lippincott 100; OSH Reference Collection (includingOSHLINE with NIOSHTIC and NIOSHTIC2)). An examinationof review articles (unrestricted by date of publication), as wellas the personal libraries of the contributing authors, wasundertaken to identify further studies. Personal communica-tions with national and international representatives or expertswithin the field of musculoskeletal conditions were also made.Where appropriate, additional keywords were added andmodifications made to the keyword list.

The final search involved the previously mentioned 15electronic databases and an examination of the bibliographiesof recent review papers. To ensure that only high-quality paperswere included within the current literature review, strictinclusion/exclusion criteria were adopted. These criteria werebased on previous major reviews in this subject area(Bernard10).

Inclusion criteria

N Published within the past 5 years (Jan 1999–Oct 2004).

N Participation rate >70%.

N Health outcomes defined by symptoms and/or well-docu-mented questionnaires and/or physical examination.

N The body part in question was subjected to an independentexposure assessment—that is, direct observation or actualmeasurement of exposure.

N Musculoskeletal conditions of the neck, shoulder, elbow andhand/wrist (neck/upper extremities).

N Duration of subject follow-up >2 months.

N Sufficient documentation of intervention and interventionprocess.

N English language publications.

Exclusion criteria

N Back pain and lower extremity injuries.

N Laboratory-based studies.

N Clinical treatment of musculoskeletal disorders.

N Clinically based modifier interventions such as pharma-cological treatment, splinting, acupuncture and physiother-apy or chiropractic treatment.

Quality assessment and grading of studiesThe critical appraisal and grading of studies involved the use ofthe generic appraisal tool for epidemiology (GATE): appraisalmodules (effective practice, informatics and quality improve-ment).11 This tool focused specifically on issues of studyvalidity, quality of the study, the measure of occurrence, effectand precision of the study results and external validity.

After completion of the GATE checklists for interventionstudies, papers were graded according to the quality of thestudy using a modified version of the CochraneMusculoskeletal Injuries Group scoring system, in conjunctionwith the GATE tool, to provide an overall score for each study.12

The modified Cochrane Musculoskeletal Injuries Group scoringsystem comprised 13 separate questions graded between 0 and2, covering aspects of study design and outcome measures. Afinal overall score (quality rating), out of a possible 26, wasawarded to each intervention paper. Once each study had beenassigned a rating score, it was graded according to a three-pointrating scale: low, medium or high. The cut-off points for eachlevel of grading were based on the overall distribution of scoresacross the intervention studies: ,10 = ‘‘low’’-quality study;>10,19 = ‘‘medium’’-quality study; >19 = ‘‘high’’-qualitystudy.

Six reviewers (BA, MGB, JC, PJL, PJM and MS) were trainedin the review and scoring protocols. Two reviewers scored eachpaper independently, and if any discrepancy was foundbetween their scores a third person reviewed the paper toreach a consensus.

Evidence classificationA ‘‘pattern of evidence’’ approach for classifying the level ofevidence attached to intervention studies was adopted.1 Theterminology and criteria used to define these levels of evidencewere adapted from previous review papers6 7 10 13–15 and mod-ified according to the quality assessment procedure adopted bythis review (table 1). The overall level of evidence (ie, strong,moderate, some or insufficient) was then based on the numberof studies, study design and the quality rating ascribed to thatstudy.

Classification of intervention studiesUsing a format similar to Westgaard and Winkel,5 studies inthis review were categorised into subgroups depending on thetype of intervention: mechanical exposure interventions,production systems/organisational culture interventions andmodifier interventions. Interventions were also classified asprimary, secondary and/or tertiary according to the definitionsof the National Research Council1—that is, primary interven-tions before members of the population at risk having acquireda condition of concern; secondary interventions afteroccurrence of the condition within the population of concernand tertiary intervention strategies designed for individualswith chronically disabling conditions.

292 Boocock, McNair, Larmer, et al

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RESULTSIn excess of 5000 articles were identified from the initial search,of which 451 were suitable for abstract review; after a review ofthe abstracts, 102 intervention studies were considered. Intotal, 31 intervention studies were considered to have met theinclusion criteria and were suitable for full review (fig 1). Tenwere classified as mechanical exposure interventions, two asproduction systems/organisational culture interventions and 19as modifier interventions. On the basis of the type ofmechanical intervention involved and the group of workersreported upon, it was possible to further classify mechanicalinterventions into three subgroups: (1) work environment/workstation adjustments and visual display unit (VDU)

workers, (2) workstation equipment and VDU workers and(3) ergonomic equipment and manufacturing workers.Although no subgroups of production systems/organisationalculture interventions could be identified, it was possible togroup studies in the area of modifier interventions under sixbroad categories: (1) exercise and neck/upper extremityconditions; (2) exercise and fibromyalgia; (3) multiple modifier(including exercise) and neck/upper extremity conditions; (4)multiple modifier (including exercise) and fibromyalgia; (5)multiple modifier (excluding exercise) and neck/upper extre-mity conditions and (6) multiple modifier (excluding exercise)and fibromyalgia. Table 2 gives the tabulated informationpertaining to each paper.

Table 1 Level of evidence for evaluating the importance of intervention studies in the management of neck/upper extremitymusculoskeletal conditions

Level of evidence Definition

Strong When provided by generally consistent findings in multiple RCTs of high quality (QR>19)Moderate When provided by generally consistent findings in one RCT of high quality (QR>19) and in one or more RCTs of moderate or low quality, or by

generally consistent findings in multiple RCTs of moderate quality (QR,19>10).Some When limited evidence, with only one RCT (any quality rating). Some findings of a positive relationship between exposure to the intervention and

WRMD in one cohort or case–referent study, or consistent findings in multiple cross-sectional studies, of which at least one study was of mediumquality (QR>10,14)

Insufficient All other cases (ie, consistent findings in multiple low-quality (QR,10) cross-sectional studies, or inconsistent findings in multiple studies) orfindings of only one cross-sectional study, irrespective of the quality of the study

QR, quality rating; RCTs, randomised controlled trials; WRMD, work-related musculoskeletal disorders.

Figure 1 Overview of the literature search and review strategy.

Prevention and management of musculoskeletal conditions 293

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Mechanical exposure interventionsTen studies were classified as mechanical exposure interven-tions, and thereafter subdivided into three main groups asdescribed previously. Within the subgroup of work environ-ment/workstation adjustments (eg, modified lighting, newwork place, office layout and software application) in VDUworkers with neck/upper extremity conditions, four studies16–19

presented positive outcomes. Three were of medium qual-ity,16 17 19 and included an RCT,19 whereas one study18 was of lowquality. On the basis of the levels of evidence identified in table1, it was concluded that there was some evidence for positivehealth effects after work environment/workstation adjustmentsin VDU workers with neck/upper extremity conditions.

Three studies20–22 that involved changes to workstationequipment (ie, keyboards and mouse design) in VDU workerswith neck/upper extremity conditions reported positive out-comes resulting from these types of interventions. Rempel etal’s21 and Tittiranonda et al’s22 studies were RCTs of high andmedium quality, respectively, while Arras et al’s20 study was oflow quality. Hence, there was moderate evidence to support thistype of intervention.

Three studies23–25 that involved the introduction of ergonomicequipment (eg, adjustable chairs and vibration-proof tools) forworkers with neck/upper extremity conditions used in themanufacturing industry found positive health outcomes.However, all were rated as low quality. Thus, it was concludedthat there was insufficient evidence for positive health effectsresulting from this type of intervention.

Production systems/organisational cultureTwo studies26 27 did not find improvements in health outcomesassociated with organisational and work-task design changes inoffice workers and manufacturing assembly workers; bothstudies were of low quality. Thus, there was insufficientevidence to support production systems/organisational inter-vention strategies.

Modifier interventionsNineteen studies were classified under modifier interventions,and subsequently subclassified as described previously. Positivehealth outcomes were observed in three medium-qualitystudies28–30 that examined the effects of exercise (eg, strengthtraining, coordination and flexibility) in workers with neck/upper extremity conditions (excluding fibromyalgia). Thesestudies included an RCT.28 Thus, it was concluded that therewas some evidence that exercise has positive effects in workerswith neck/upper extremity conditions.

Of the four studies31–34 that investigated the effects of exercise(ie, aerobic, flexibility and biofeedback for relaxation) inpatients diagnosed with fibromyalgia, one study32 was ratedas high quality and three31 33 34 as medium quality. Schachter etal32 and van Santen34 found no significant differences acrosscontrol and experimental groups. Meiworm et al31 and Valim etal33 noted positive findings after the intervention, although acontrol group was lacking in the latter study. Overall, it wasconcluded that there was some evidence in support of the use ofexercise as an intervention for managing patients diagnosedwith fibromyalgia.

One RCT of medium quality38 and three of low quality35–37

provided some evidence that multiple modifier interventionsincluding exercise (ie, rest-breaks, Getsom programme, educa-tion and strengthening) can have positive effects in workerswith neck/upper extremity conditions (excluding fibromyalgia).Furthermore, four medium-quality studies40–43 that included anRCT,41 and one low-quality study39, provided some evidence thatmultiple modifier interventions including exercise (ie, land andpool exercises, relaxation, education and cognitive behaviouraltherapy) can have positive effects in workers with fibromyalgia.

An RCT of medium quality,44 which examined multiplemodifier interventions excluding exercise (ie, cognitive beha-vioural training and education), showed positive effects forworkers with neck/upper extremity conditions (excludingfibromyalgia). By contrast, one low-quality study45 examiningeducation found no significant effects. Therefore, there wassome evidence to support the use of this strategy. With respectto multiple modifier interventions excluding exercise (ie, socialsupport and education) for workers with fibromyalgia, therewas insufficient evidence from an RCT in a medium-qualitystudy46 to support this strategy.

DISCUSSIONThis review embodied the principles of a systematic review.Although some authors have suggested that an important facetof a systematic review might be to include a meta-analysis,47

this was not considered appropriate for this review due to theheterogeneity of study designs, the general poor quality ofstudies and the diversity of exposure and outcome measuresreported.

This review attempted to classify interventions according towhether they were primary, secondary or tertiary. Most studieswere considered to involve secondary and/or tertiary interven-tions, although the type of intervention was often difficult todetermine or not clearly stated, particularly for tertiaryinterventions (ie, studies often failed to define chronicallydisabling conditions). In most cases, tertiary interventions fellwithin the group of modifier interventions and, typically,involved subjects with fibromyalgia. Although some studiesincluded both subjects with pain (ie, secondary intervention)and those without pain (ie, primary intervention), thosewithout pain were rarely discussed independently within theresults sections of the respective studies. These difficulties,combined with the heterogeneity of outcome measures,prevented direct comparisons between interventions or theevaluation of the efficacy of certain intervention types.Furthermore, where studies failed to make a clear distinctionbetween subjects with and without pain, or to stratify theiranalysis according to the different participant groups, it isdifficult to fully appreciate whether an intervention wasbenefiting one group of subjects more than another—forexample, findings may well have been driven more by theprevention of new disorders than existing cases. The design offuture studies should clearly define the purpose and populationgroups targeted, clearly documenting those participants whobenefited most from the intervention.

To group intervention types and facilitate comparisons withprevious reviews, the classification system proposed byWestgaard and Winkel5 was adopted. This classified interven-tions according to whether they were mechanical, productionsystems/organisation culture or modifier interventions. In someinstances, further sub-grouping of interventions was possible,thereby enabling interventions to be more closely aligned tospecific industries, population groups and/or musculoskeletalconditions.

Mechanical interventionsTable 3 provides an overall summary of the effectiveness ofmechanical interventions based on the findings of the currentreview and makes comparisons with those of previous reviews.The finding that there was some evidence for work environ-ment/workstation adjustment for improved health outcomes inVDU workers with neck/upper extremity conditions wasconsistent with two previous reviews5 48 and similar to that ofVerhagen et al.9 With respect to the latter review, it should benoted that different levels for indicating evidence were adoptedand, on examination, their level denoted as ‘‘limited’’ can beconsidered similar to our level ‘‘some’’.


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gSu

bjec

tsD

iagn

osis

/con

ditio

n

Titti

rano

nda

etal

(1999)2

2

Rand

omis

edco

ntro

lled

tria

lYes

(pla

cebo

inte

rven

tion;

subj

ects

mat

ched

)4

grou

ps,

20

keyb

oard

oper

ator

sin

each

Car

palT

unne

lSyn

drom

e(C

TS)

and/

orte

ndon

itis

4co

mpu

ter

keyb

oard

s:st

anda

rd(p

lace

bo),

App

leA

djus

tabl

eK

eybo

ard

(kb1

),C

omfo

rtK

eybo

ard

Syst

em(k

b2)

and

Mic

roso

ftN

atur

alK

eybo

ard

(kb3

)Se

cond

ary/

tert

iary

(?)

Phys

ical

exam

inat

ion

Han

d/ar

mdi

scom

fort

and

pain

ques

tionn

aire

VA

Sof

stiff

ness

,nu

mbn

ess

orpa

inJo

bC

onte

ntIn

stru

men

t(J

CI)

Wor

kIn

terp

erso

nal

Rela

tions

hips

Inve

ntor

y(W

IRI)

Sign

ifica

ntre

duct

ion

inov

eral

lpai

nse

veri

tyin

kb3

at6

mon

ths

Sign

ifica

ntin

crea

sein

func

tiona

lsta

tus

afte

r6

mon

ths

inkb

3gr

oup

com

pare

dto

plac

ebo.

No

sign

ifica

ntde

crea

sein

prev

alen

ceof

clin

ical

mea

sure

saf

ter

6m

onth

s

18

Med

ium

Ergon

omic

equi

pm

ent

&m

anu

fact

urin

gw

orke

rs

Her

bert

etal

(2001)2

3

Coh

ortst

udy

No

N=

56

fem

ale

His

pani

can

dIn

dian

spoo

ling

wor

kers

atse

quin

man

ufac

turi

ngco

mpa

nyU

pper

extr

emity

Mus

culo

skel

etal

Dis

orde

rs(M

SDs)

Ergo

nom

iced

ucat

ion

and

intr

oduc

tion

ofad

just

able

chai

r(in

clud

ing

trai

ning

inco

rrec

tch

air

use)

Prim

ary/

seco

ndar

y

Sym

ptom

spo

rtio

nof

the

1993

NIO

SHqu

estio

nnai

rePr

e-/P

ostvi

deo-

anal

ysis

ofup

per

extr

emity

post

ures

usin

gth

eM

odifi

edEx

posu

reA

sses

smen

tM

etho

d

Redu

ced

pain

scor

esaf

ter

intr

oduc

tion

ofad

just

able

chai

rsat

mos

tan

atom

icsi

tes

Redu

ced

prev

alen

ceof

pain

inth

eri

ght

shou

lder

,le

ftel

bow

,an

dle

ftfo

rear

maf

ter

intr

oduc

tion

ofad

just

able

chai

r.Im

prov

edup

per

limb

post

ure

follo

win

gch

air

inte

rven

tion

8 Low

Aib

aet

al(1

999)2

4

Pros

pect

ive

long

itudi

nalc

ohor

tN

o383

man

ufac

turi

ngw

orke

rsus

ing

impa

ctw

renc

hes

Vib

ratio

nW

hite

Fing

er(V

WF)

Intr

oduc

tion

ofvi

brat

ion-

dam

ped

wre

nch

Prim

ary

Stoc

khol

mW

orks

hop

Scal

efo

rV

WF

Que

stio

nnai

res

onw

ork

hist

orie

s,m

edic

alhi

stor

ies

and

subj

ectiv

esy

mpt

oms,

incl

udin

gV

WF

Med

ical

doct

orco

nfir

med

VW

Fby

show

ing

the

subj

ecta

phot

ogra

phof

typi

calV

WF

cond

ition

s

Prev

alen

ceof

VW

Fel

imin

ated

3 Low

Jetz

eret

al(2

003)2

5

Coh

ortst

udy

No

165

man

ufac

ture

rs&

inst

alle

rsof

conc

rete

roof

ing

tiles

Han

d-A

rmV

ibra

tion

Synd

rom

e(H

AV

S)or

CTS

Intr

oduc

tion

ofne

wto

ols

with

decr

ease

dle

vels

ofH

and-

Arm

vibr

atio

nex

posu

rean

d/or

ISO

10

819

glov

esPr

imar

y

Que

stio

nnai

reon

med

ical

and

wor

khi

stor

yC

linic

alha

ndex

amin

atio

nby

occu

patio

nalh

ealth

nurs

esV

ascu

lar

test

sde

pend

ing

onre

spon

ses

tom

edic

alqu

estio

nnai

rean

dSt

ockh

olm

Wor

ksho

pSc

ale

Tren

dto

war

dde

crea

sing

prev

alen

ceof

HA

VS

Wor

kers

who

used

new

low

-vib

ratio

nto

ols

and

wor

eIS

O10

819

glov

essh

owed

mos

tim

prov

emen

tan

dle

ast

decr

emen

tin

sym

ptom

s

6 Low

Prod

uctio

nsy

stem

s/or

gani

satio

ncu

lture

inte

rven

tions

Prod

uctio

nsy

stem

s/or

gani

satio

ncu

lture

inte

rven

tion

Chr

istm

anss

onet

al(1

999)2

6

Pre-

/pos

t-ca

se-s

tudi

esN

o17

win

dow

and

door

asse

mbl

yw

orke

rsU

pper

extr

emity

pain

diso

rder

s

Org

anis

atio

nal

tera

tions

,co

ntro

lsy

stem

san

dw

ork

desi

gn(d

istr

ibut

ion

ofw

ork

task

s)Pr

imar

y

Stru

ctur

edin

terv

iew

sV

ideo

anal

yses

usin

gH

and-

Arm

-Mov

emen

t-A

naly

sis

(HA

MA

)Ps

ycho

-soc

ialq

uest

ionn

aire

sM

edic

alex

amin

atio

n

No

impr

ovem

ent

inpr

eval

ence

ofup

per

extr

emity

MSD

sdu

ring

stud

ype

riod

Som

eps

ycho

soci

alfa

ctor

sim

prov

ed(e

g‘‘i

nflu

ence

onan

dco

ntro

lof

wor

k’’),

som

ew

orse

ned

(eg

‘‘rel

atio

nshi

pw

ithfe

llow

wor

kers

’’)

4 Low

Fern

stro

m&

Abo

rg(1

999)2

7

Coh

ort

No

22

fem

ale

offic

ew

orke

rspe

rfor

min

gda

taen

try

task

sN

eck,

shou

lder

,ar

man

dha

ndpa

in

Org

anis

atio

nal

tera

tions

and

diffe

rent

wor

kta

sks

Prim

ary/

seco

ndar

y

Clin

ical

exam

inat

ion

byph

ysio

ther

apis

tD

iagn

oses

acco

rdin

gto

ado

cum

ente

dsc

reen

ing

met

hod

Subj

ects

vide

otap

edth

roug

hout

test

days

No

impr

ovem

ent

inne

ck,

shou

lder

and/

orar

mpa

inN

odi

ffere

nce

innu

mbe

ror

dura

tion

ofre

stpe

riod

sbe

twee

nye

ars

Incr

ease

dno

n-co

mpu

ter

wor

kfr

om50

min

in1991

to93

min

in1992

8 Low

Table

2C

ontin

ued


www.occenvmed.com


http://oem.bmj.com/


Inte

rven

tion

class

ifica

tion

Aut

hor

Des

ign

Inte

rven

tion

Mea

sure

sFi

ndin

gs

Qua

lity

ofev

iden

ceD

esig

nty

peTy

peQ

ualit

ysc

ore

Con

trol

grou

pPr

imar

y/se

cond

ary

/ter

tiary

Qua

lity

ratin

gSu

bjec

tsD

iagn

osis

/con

ditio

n

Mod

ifier

inte

rven

tions

Exer

cise

and

upper

extr

emity

cond

ition

sLu

dew

igan

dBo

rsta

d(2

003)

28

Rand

omis

edco

ntro

lled

tria

lYes

(with

outin

terv

entio

nan

dw

ithou

tco

nditi

ons)

92

mal

eco

nstr

uctio

nw

orke

rspe

rfor

min

gov

erhe

adw

ork

Shou

lder

Impi

ngem

ent

Synd

rom

e

Stre

tchi

ngan

dpr

ogre

ssiv

est

reng

thtr

aini

ngpr

ogra

mm

eSe

cond

ary/

tert

iary

(?)

Self-

repo

rted

Shou

lder

Ratin

gQ

uest

ionn

aire

(SRQ

)M

odifi

edSh

ould

erPa

inan

dD

isab

ility

Inde

x(S

PAD

I)Q

uest

ionn

aire

Impr

ovem

ent

inse

lf-re

port

edSh

ould

erRa

ting

Que

stio

nnai

re(S

RQ)

and

Shou

lder

Satis

fact

ion

Scor

es

16

Med

ium

Hag

berg

etal

(2000)2

9

Rand

omis

edtr

ial

No

69

wom

enin

dust

rial

wor

kers

Cer

vico

-bra

chia

lsy

ndro

me

ICD

-10

code

M53.1

Isom

etri

csh

ould

eren

dura

nce

vers

usst

reng

th16

wee

ktr

aini

ngpr

ogra

mm

eTe

rtia

ry

VA

Spa

insc

ores

Sick

leav

e&

NSA

IDus

eSt

anda

rise

dph

ysic

alex

amin

atio

nSt

reng

th,

rang

eof

mot

ion

and

endu

ranc

ete

sts

Redu

ced

pain

,no

diffe

renc

eby

trai

ning

type

No

redu

ctio

nin

sick

leav

eIm

prov

edar

mm

otio

npe

rfor

man

cete

stIn

crea

sed

shou

lder

stre

ngth

14

Med

ium

Wal

ing

etal

(2002)3

0

Pros

pect

ive

quas

i-ra

ndom

ised

tria

lN

o126

fem

ale

adm

inis

trat

ive

wor

kers

Trap

eziu

sM

yalg

ia

Gro

uptr

aini

ngpr

ogra

mm

es:

a)St

reng

thgr

oup

b)En

dura

nce

grou

pc)

Coo

rdin

atio

ngr

oup

d)St

ress

man

agem

ent

(non

-tra

inin

g)re

fere

nce

grou

pTe

rtia

ry

VA

Spa

insc

ores

Freq

uenc

yof

pain

Pres

sure

pain

thre

shol

dsD

egre

eof

wor

ryU

seof

anal

gesi

csSi

ckle

ave

Redu

ced

freq

uenc

yof

pain

and

VA

Sin

allg

roup

sov

ertim

eN

och

ange

inpr

essu

repa

inth

resh

olds

No

diffe

renc

esbe

twee

ntr

aini

nggr

oups

and

refe

renc

egr

oup

onan

yva

riab

le

12

Med

ium

Exer

cise

&Fi

bro

mya

lgia

Mei

wor

met

al(2

000)3

1

Expe

rim

enta

ltri

alYes

(with

outin

terv

entio

n)39,

mos

tlyfe

mal

esFi

brom

yalg

ia(F

M)

12

wee

kpr

ogre

ssiv

eae

robi

cen

dura

nce

exer

cise

prog

ram

me

incl

udin

gw

alki

ng,

jogg

ing,

cycl

ing

and/

orsw

imm

ing

Seco

ndar

y/te

rtia

ry

Body

diag

ram

ofpa

inV

AS

pain

scor

ePr

essu

repa

inth

resh

olds

Dec

reas

edpa

infu

lbod

yar

eaRe

duce

dm

ean

num

ber

ofte

nder

poin

tsM

ean

pain

thre

shol

dun

chan

ged

VA

Ssc

ore

unch

ange

dN

och

ange

sin

cont

rolg

roup

10

Med

ium

Scha

chte

ret

al(2

003)3

2

Rand

omis

edco

ntro

lled

tria

lYes

(with

outin

terv

entio

n)143

fem

ales

FM

Diff

erin

gex

erci

sedu

ratio

n:a)

Long

Bout

ofEx

erci

se(L

BE)

b)Sh

ortBo

utof

Exer

cise

(SBE

)c)

No

exer

cise

(NE)

(con

trol

)Te

rtia

ry

Body

pain

diag

ram

sA

IMS2

Que

stio

nnai

reA

ffect

Scal

eSc

ore

Fibr

omya

lgia

Impa

ctQ

uest

ionn

aire

(FIQ

)V

AS

pain

scor

eC

PSS

Redu

ced

dise

ase

seve

rity

and

impr

oved

self-

effic

acy

with

inSB

Egr

oup

and

com

pare

dto

NE

grou

pIm

prov

emen

tsin

phys

ical

func

tion,

dise

ase

seve

rity

,sy

mpt

oms,

self-

effic

acy

and

psyc

holo

gica

lwel

l-bei

ngin

LBE

grou

p

19

Hig

h

Val

imet

al(2

003)3

3

Rand

omis

edtr

ial

No

76

fem

ales

FM

Two

exer

cise

mod

aliti

es:

a)A

erob

icex

erci

se(A

E)w

alki

ngpr

ogra

mm

e,b)

Stre

tchi

ngex

erci

se(S

E)Te

rtia

ry

Sitan

dre

ach

(flex

ibili

ty)

test

Fibr

omya

lgia

Impa

ctQ

uest

ionn

aire

(FIQ

)Sh

ortFo

rm–3

6(S

F-36)

Que

stio

n-na

ire

Beck

Dep

ress

ion

Inve

ntor

y(B

DI)

Trac

e-St

ate

Anx

iety

Inve

ntor

yPa

insc

ore

from

tend

erpo

ints

VA

Spa

insc

ore

Impr

ovem

ents

inA

Egr

oup

com

pare

dto

SEgr

oup

ofto

talF

IQsc

ore

and

role

emot

iona

land

men

talh

ealth

dom

ains

ofFI

Q,

the

men

talc

ompo

nent

sum

mar

yof

SF-3

6,

BDI,

VA

Ssc

ore

and

num

ber

ofte

nder

poin

tsN

oim

prov

emen

tin

SEgr

oup

inm

enta

lhe

alth

orro

leem

otio

nald

omai

nsan

dth

eM

enta

lCom

pone

ntSu

mm

ary

ofth

eSF

-36

orBD

I

17

Med

ium

Table

2C

ontin

ued


www.occenvmed.com


http://oem.bmj.com/


Inte

rven

tion

class

ifica

tion

Aut

hor

Des

ign

Inte

rven

tion

Mea

sure

sFi

ndin

gs

Qua

lity

ofev

iden

ceD

esig

nty

peTy

peQ

ualit

ysc

ore

Con

trol

grou

pPr

imar

y/se

cond

ary

/ter

tiary

Qua

lity

ratin

gSu

bjec

tsD

iagn

osis

/con

ditio

n

van

Sant

enet

al(2

002)3

4

Pre-

/pos

t-te

sttr

ial

Yes

(with

outin

terv

entio

n)143

Fem

ales

FM

Two

inte

rven

tion

mod

aliti

es:

a)G

roup

supe

rvis

edfit

ness

prog

ram

me,

(aer

obic

exer

cise

and

isom

etri

cst

reng

then

ing)

b)Bi

ofee

dbac

ktr

aini

ngfo

rm

uscl

ere

laxa

tion

Tert

iary

VA

Spa

insc

ore

VA

Sfa

tigue

scal

eH

ealth

stat

us:

Art

hriti

sIm

pact

Mea

sure

men

tSc

ale,

Sick

ness

Impa

ctPr

ofile

(SIP

)Ps

ycho

logi

caldi

stre

ss:

Sym

ptom

Che

cklis

t-90-

Revi

sed

(SC

L-90)

Phys

ical

fitne

ss-

bicy

cle

ergo

met

er

No

sign

ifica

ntfin

ding

sex

cept

phys

ical

fitne

ssw

orse

ned

for

allg

roup

sov

erth

est

udy

peri

od.

Dec

reas

ew

asle

ssin

fitne

ssgr

oup

com

pare

dto

cont

rolg

roup

14

Med

ium

Mul

tiple

mod

ifier

inte

rven

tions

(incl

udin

gex

erci

se)

&up

per

extr

emity

cond

ition

s

deG

reef

etal

(2003)3

5

Rand

omis

edco

ntro

lled

tria

lYes

(with

outin

terv

entio

n)53

Sym

phon

yO

rche

stra

Mus

icia

nsPR

MD

s

Spec

ific

mob

ilisi

ng,

stre

ngth

enin

g,an

dco

nditi

onin

gpr

ogra

mm

e(th

eG

roni

ngen

Exer

cise

Ther

apy

for

Sym

phon

yO

rche

stra

Mus

icia

ns(G

ETSO

M)

prog

ram

me)

Seco

ndar

y/te

rtia

ry(?

)

Phys

ical

Com

pete

nce

Scal

e(P

CS)

Wor

ldH

ealth

Que

stio

nnai

refo

rM

usic

ians

(WH

QM

)

Mus

culo

skel

etal

diso

rder

sde

crea

sed

Perc

eive

dph

ysic

alco

mpe

tenc

ein

crea

sed

9 Low

Cha

net

al(2

000)3

6

Pre-

/pos

t-te

sttr

ial

No

12

Wor

k-re

late

dla

tera

lepi

cond

yliti

sof

elbo

w

Educ

atio

non

path

olog

yan

der

gono

mic

sre

late

dto

WRM

DS,

stre

tchi

ng&

stre

ngth

enin

gex

erci

ses

tobe

perf

orm

edat

hom

ean

dw

ork

hard

enin

gpr

otoc

ols

Seco

ndar

y/te

rtia

ry(?

)

VA

Spa

insc

ores

LLU

MC

(Lom

aLi

nda

Uni

vers

ityM

edic

alC

entr

e)A

ctiv

itySo

rtBa

ltim

ore

Ther

apeu

ticEq

uipm

ent

(BTE

)Pr

imus

mea

sure

sD

exte

rEv

alua

tion

Com

pute

rSy

stem

Satis

fact

ion

with

Perf

orm

ance

Scal

edQ

uest

ionn

aire

Redu

ctio

nsin

pre/

post

VA

Spa

insc

ores

mai

ntai

ned

at4

and

12

wee

kfo

llow

-up

Incr

ease

dBT

EPr

imus

mea

sure

sIn

crea

ses

inLL

UM

CA

ctiv

itySo

rtSc

ores

and

Satis

fact

ion

with

Perf

orm

ance

Scal

edQ

uest

ionn

aire

Scor

esm

aint

aine

dat

4th

and

12th

wee

ksof

follo

w-u

p

7 Low

Om

eret

al(2

003/2

004)3

7

Rand

omis

edco

ntro

lled

tria

lN

otr

ueco

ntro

lgro

up50

VD

Uw

orke

rsC

umul

ativ

eTr

aum

aD

isor

ders

(CTD

s)in

clud

ing

Myo

fasc

ialP

ain

Synd

rom

e(M

PS)

and

Car

palT

unne

lSyn

drom

e(C

TS)

Ergo

nom

ican

dhe

alth

educ

atio

n(‘co

ntro

l’gr

oup)

vers

usan

exer

cise

prog

ram

me

(flex

ibili

ty,

RoM

,re

laxa

tion,

stre

ngth

enin

gan

dpo

stur

alex

erci

ses

invo

lvin

gth

ene

cksh

ould

ers

and

wri

sts

perf

orm

ed3

days

per

wee

kat

lunc

htim

e)(tr

eatm

ent

grou

p)Se

cond

ary/

tert

iary

(?)

Pain

asse

ssm

ent

usin

gN

umer

icRa

ting

Scal

e(N

RS)

Pain

Dis

abili

tyIn

dex

(PD

I)Ti

redn

ess

Scal

e(T

S)Be

ckD

epre

ssio

nIn

vent

ory

BDI)

Scal

e

Impr

oved

NRS

,PD

Iand

BDIs

core

sfo

rtr

eatm

ent

grou

p9 Lo

w

van

den

Heu

vel

etal

(2003)3

8Ra

ndom

ised

cont

rolle

dtr

ial

Yes

(with

outin

terv

entio

n)268

VD

Uw

orke

rsW

ork-

rela

ted

uppe

rlim

bre

petit

ive

stra

inin

juri

esac

cord

ing

toth

eH

ealth

Cou

ncil

ofth

eN

ethe

rlan

ds

Mic

robr

eaks

prom

pted

byco

mpu

ter

softw

are

and

‘‘nat

ural

’’re

stbr

eaks

vers

usm

icro

brea

ksan

dna

tura

lres

tbr

eaks

com

bine

dw

ithth

epe

rfor

man

ceof

regu

lar

exer

cise

spe

rfor

med

atth

ew

orks

tatio

nal

sopr

ompt

edby

the

softw

are

Seco

ndar

y/te

rtia

ry(?

)

Perc

eive

dov

eral

lrec

over

yfr

omco

mpl

aint

sFr

eque

ncy

ofco

mpl

aint

sSe

veri

tyof

pain

VA

Ssc

ale

Self-

repo

rted

sick

leav

ePr

oduc

tivity

Self-

repo

rted

reco

very

high

erin

inte

rven

tion

grou

pN

odi

ffere

nces

betw

een

the

grou

psfo

rsi

ckle

ave

Impr

oved

prod

uctiv

ityin

Gro

up1

(bre

aks

and

noex

erci

ses)

com

pare

dto

cont

rolg

roup

Impr

oved

accu

racy

rate

inin

terv

entio

ngr

oups

com

pare

dto

cont

rolg

roup

13

Med

ium

Table

2C

ontin

ued


www.occenvmed.com


http://oem.bmj.com/


Inte

rven

tion

class

ifica

tion

Aut

hor

Des

ign

Inte

rven

tion

Mea

sure

sFi

ndin

gs

Qua

lity

ofev

iden

ceD

esig

nty

peTy

peQ

ualit

ysc

ore

Con

trol

grou

pPr

imar

y/se

cond

ary/

tert

iary

Qua

lity

ratin

gSu

bjec

tsD

iagn

osis

/con

ditio

n

Mul

tiple

mod

ifier

inte

rven

tions

(incl

udin

gex

erci

se)

&Fi

bro

mya

lgia

Baile

yet

al(1

999)3

9

Pros

pect

ive

pre-

/pos

t-co

hort

stud

yN

o106

FM

Fibr

o-Fi

tPr

ogra

mm

e:12-w

eek

out-pa

tient

exer

cise

and

mul

tidis

cipl

inar

ypr

ogra

mm

eTe

rtia

ry

Fibr

o-Fi

tse

lf-ef

ficac

yqu

estio

nnai

reC

anad

ian

Stan

dard

ised

Test

ofFi

tnes

s(C

STF)

Fibr

omya

lgia

Impa

ctQ

uest

ionn

aire

(FIQ

)C

anad

ian

Occ

upat

iona

lPe

rfor

man

ceM

easu

re(C

OPM

)Fa

mily

Cri

sis

Ori

ente

dPe

rson

alEv

alua

tion

Scal

es(F

-CO

PES)

Impr

ovem

ents

inal

lout

com

em

easu

res

Rela

tions

hip

betw

een

smok

ing

and

pain

.i.e

.sm

oker

sha

dle

ssim

prov

emen

tin

pain

Atte

ndan

cera

teof

FMsu

ppor

tgr

oup

rela

ted

togr

eate

rim

prov

emen

tin

pain

Patie

nts

who

refu

sed

pain

oran

ti-de

pres

sant

med

icat

ions

had

poor

erou

tcom

es

8 Low

Ced

rasc

hiet

al(2

004)4

0

Pre-

/pos

t-te

sttr

ial

Yes

(with

outin

terv

entio

n)61

FM

Gro

uptr

aini

ngpr

ogra

mm

e.C

onsi

sted

ofpo

olex

erci

se,

rela

xatio

n,lo

wim

pact

land

exer

cise

,ac

tiviti

esof

daily

livin

gan

ded

ucat

ion.

Tert

iary

Num

ber

ofte

nder

poin

tsan

dm

yalg

icsc

ore

Glo

balr

atin

gby

phys

icia

nQ

uest

ionn

aire

s

Impr

ovem

ent

inFi

brom

yalg

iaIm

pact

Que

stio

nnai

re(F

IQ)

and

Psyc

holo

gica

lG

ener

alW

ell-B

eing

(PG

WB)

Inde

xN

och

ange

inob

ject

ive

phys

icia

nm

easu

res

14

Med

ium

Gow

ans

etal

(1999)4

1

Rand

omis

edco

ntro

lled

tria

lYes

(del

ayed

inte

rven

tion;

subj

ects

asow

nco

ntro

ls)

41

FM

6-w

eek

exer

cise

and

educ

atio

npr

ogra

mm

e(tw

oex

erci

sean

dtw

om

ultid

isci

plin

ary

educ

atio

nals

essi

ons

per

wee

k)Te

rtia

ry

Fibr

omya

lgia

Impa

ctQ

uest

ionn

aire

(FIQ

)A

rthr

itis

Self-

Effic

acy

Scal

e(A

SES)

Kno

wle

dge

ofFM

man

agem

ent

Que

stio

nnai

re6

min

wal

kte

st

Impr

ovem

ent

in6

min

wal

kdi

stan

ce,

wel

l-bei

ng,

self-

effic

acy,

and

FMkn

owle

dge

Redu

ced

mor

ning

fatig

ueA

llga

ins

mai

ntai

ned

atfo

llow

-up

exce

ptm

orni

ngfa

tigue

and

subj

ects

’kn

owle

dge

ofFM

man

agem

ent

whi

chre

sum

edto

base

line

leve

ls

11

Med

ium

Man

nerk

orpi

etal

(2000)4

2

Pre-

/pos

t-te

sttr

ial

No

true

cont

rolg

roup

used

69

fem

ales

FM

Two

inte

rven

tion

mod

aliti

es:

a)G

roup

pool

exer

cise

prog

ram

me

b)Ed

ucat

ion

prog

ram

me

Tert

iary

Fibr

omya

lgia

Impa

ctQ

uest

ionn

aire

(FIQ

)Sh

ortFo

rm-3

6Q

uest

ionn

aire

(SF-

36)

Swed

ish

Mul

ti-di

men

sion

alPa

inIn

vent

ory

(MPI

-S)

Art

hriti

sSe

lf-Ef

ficac

ySc

ale

(ASE

S-S)

Art

hriti

sIm

pact

Mea

sure

men

tSc

ales

(AIM

S)Q

ualit

yof

Life

Que

stio

nnai

re(Q

OLS

)

Impr

oved

FIQ

scor

ean

dw

alk

dist

ance

com

pare

dw

ithed

ucat

ion

grou

pIm

prov

edFI

Qph

ysic

alfu

nctio

ning

and

anxi

ety

scor

esin

exer

cise

com

pare

dw

ithed

ucat

ion

grou

pIm

prov

edSf

-36

gene

ralh

ealth

scor

e,so

cial

func

tioni

ng,

pain

seve

rity

and

affe

ctiv

edi

stre

ssco

mpo

nent

sof

MPI

-Sin

exer

cise

grou

pIm

prov

edA

IMS

depr

essi

onan

dQ

OLS

inex

erci

seco

mpa

red

toed

ucat

ion

grou

p

14

Med

ium

Table

2C

ontin

ued


www.occenvmed.com


http://oem.bmj.com/


Inte

rven

tion

class

ifica

tion

Aut

hor

Des

ign

Inte

rven

tion

Mea

sure

sFi

ndin

gs

Qua

lity

ofev

iden

ceD

esig

nty

peTy

peQ

ualit

ysc

ore

Con

trol

grou

pPr

imar

y/se

cond

ary

/ter

tiary

Qua

lity

ratin

gSu

bjec

tsD

iagn

osis

/con

ditio

n

Redo

ndo

etal

(2004)4

3

Pros

pect

ive,

long

itudi

nal,

quas

i-ra

ndom

ised

,pa

ralle

ltri

alN

o40

fem

ales

FM

Two

inte

rven

tion

mod

aliti

es:

a)Ph

ysic

alEx

erci

se(P

E)an

dca

rdio

vasc

ular

fitne

sspr

ogra

mm

eb)

Cog

nitiv

e-be

havi

oura

lth

erap

y(C

BT)

Tert

iary

Fibr

omya

lgia

Que

stio

nnai

re(F

IQ)

Shor

tFo

rm-3

6(S

F-36)

Beck

Anx

iety

Inve

ntor

yC

hron

icPa

inSe

lf-Ef

ficac

ySc

ale

(CPS

S)C

hron

icPa

inC

opin

gIn

vent

ory

Rang

eof

Mot

ion

and

Pain

scal

e

PEG

roup

:Im

prov

emen

tsin

mos

tite

ms

and

tota

lsco

reof

FIQ

Impr

ovem

ent

inth

ebo

dily

pain

dom

ain

ofSF

-36

Aton

eye

arfo

llow

-up

none

ofcl

inic

alva

riab

les

wer

esi

gnifi

cant

lybe

tter

than

the

initi

alas

sess

men

tC

BTG

roup

:Im

prov

edite

ms

ofFI

Q(s

tiffn

ess,

tota

lsco

re)

at8

wee

ksA

t6

mon

than

don

eye

arch

ange

sno

tm

aint

aine

d,ex

cept

impr

oved

gene

ral

heal

thdo

mai

nsof

SF-3

6ED

UC

grou

p:sy

mpt

oms

and

pain

impr

oved

0–6

wee

ks;

retu

rned

toba

selin

e6–3

2w

eeks

16

Med

ium

Mul

tiple

mod

ifier

inte

rven

tions

(exc

ludin

gex

erci

se)

&up

per

extr

emity

cond

ition

s

Fauc

ettet

al(2

002)4

4

Rand

omis

edco

ntro

lled

tria

lYes

(with

outin

terv

entio

n)139

engi

neer

san

dm

icro

scop

icas

sem

bly

wor

kers

ofel

ectr

onic

man

ufac

turi

ngco

rpor

atio

nU

pper

limb

Wor

k-Re

late

dM

uscu

losk

elet

alD

isor

ders

(WRM

SDs)

Mus

cle

Lear

ning

Ther

apy

(MLT

)or

educ

atio

nalg

roup

(ED

UC

)co

nsis

ting

ofO

HN

-del

iver

eded

ucat

ion

and

Cog

nitiv

eBe

havi

oura

lTra

inin

g(C

BT)

that

addr

esse

dsy

mpt

oman

dst

ress

man

agem

ent

and

prob

lem

solv

ing

Prim

ary

Sym

ptom

Dia

ryD

ata

VA

Spa

inm

easu

res

Surf

ace

Elec

trom

yogr

aphy

(EM

G)

MLT

grou

p:0–6

wee

ksno

chan

gein

sym

ptom

san

dpa

in;

6–3

2w

eeks

wor

sene

dC

ontr

olgr

oup:

0–6

–32

wee

kssy

mpt

oms

and

pain

stea

dily

wor

sene

dD

iffer

ence

sat

6w

eeks

sign

ifica

nt,

butno

tov

eral

ltim

epe

riod

s

10

Med

ium

Bohr

(2000)4

5Ra

ndom

ised

cont

rolle

dtr

ial

No,

com

pari

son

oftw

oin

terv

entio

ngr

oups

102

VD

Uw

orke

rsN

eck,

shou

lder

and

uppe

rlim

bpa

in

Trad

ition

aler

gono

mic

educ

atio

nve

rsus

part

icip

ator

yer

gono

mic

educ

atio

nPr

imar

y

Pape

ran

dpe

ncil

surv

eys

Obs

erva

tiona

lche

cklis

tsSt

anda

rdis

edN

ordi

cm

uscu

losk

elet

alqu

estio

nnai

reW

ork

AG

PAR

scor

e

No

diffe

renc

ebe

twee

ntw

ogr

oups

for

obse

rvat

ion

data

scor

esfo

rth

ew

ork

area

conf

igur

atio

n,w

orke

rpo

stur

es,

orov

eral

lsco

res

No

diffe

renc

ebe

twee

ntw

ogr

oups

for

uppe

rbo

dypa

in/d

isco

mfo

rtor

APG

AR

scor

es

9 Low

Mul

tiple

mod

ifier

inte

rven

tions

(exc

ludin

gex

erci

se)

&Fi

bro

mya

lgia

Oliv

eret

al(2

001)4

6

Rand

omis

edco

ntro

lled

tria

lYes

(with

outin

terv

entio

n)600

patie

nts

FM

Soci

alsu

ppor

tve

rsus

soci

alsu

ppor

tco

mbi

ned

with

heal

than

dse

lf-he

lped

ucat

ion

Tert

iary

Hea

lthC

are

Cos

tsK

now

ledg

eof

FM‘G

uttm

an-li

ke’

Gro

upC

ohes

iven

ess

Scal

eA

dapt

edA

rthr

itis

Self-

Effic

acy

Scal

e

Redu

ced

help

less

ness

for

part

icip

ants

inal

lgro

ups

butm

ore

mar

kedl

yin

soci

alsu

ppor

tan

ded

ucat

ion

grou

p

12

Med

ium

Table

2C

ontin

ued


www.occenvmed.com


http://oem.bmj.com/


In this study, there was moderate evidence that workstationequipment (mouse and keyboard design) can lead to positivehealth benefits in VDU workers with neck/upper extremitymusculoskeletal conditions. However, there was insufficientevidence for equipment interventions among manufacturingworkers with neck/upper extremity musculoskeletal conditions.Previous reviews have not delineated according to types ofoccupation. With respect to the findings for VDU workers,Williams et al8 reported a trend towards positive benefits forseveral workplace interventions associated with modificationsto keyboard designs, while our findings showed strongersupport for this intervention strategy. This difference mayreflect the more objective approach to grading evidence used inthis review. In contrast to our conclusions related to VDUworkers were those of Verhagen et al,9 who found limitedevidence for the efficacy of some keyboards in people withcarpal tunnel syndrome. However, it should be noted thatVerhagen et al9 reported that the RCT study by Tittiranonda etal22 provided no evidence to support modifications to keyboarddesign, a finding in contrast with our appraisal of the paper andalso that of Williams et al.8

Production systems interventionsThe finding of insufficient evidence for the benefits ofproduction systems/organisation culture interventions wasconsistent with one previous review.5 Westgaard and Winkel5

identified seven Swedish production systems interventionstudies and concluded that ‘‘this group of papers providedlittle evidence to suggest that improved health can be achievedthrough redesign of the production systems’’.

The two production systems/organisation culture interven-tions26 27 identified in this review were of low quality, showedno improvements in outcome measures and involved non-RCT.Although RCTs are considered the most powerful study design,ensuring randomisation and control within the workplace,particularly with respect to changes in production systems orthe organisational culture within a company, is not alwayspossible or ethical.1 49 This raises the question as to whetherthese types of interventions should be subjected to the samerigour as those used to evaluate the efficacy of mechanical ormodifier interventions, and whether different criteria on whichto base evidence classification should be adopted.

Modifier interventionsTable 4 provides an overall summary of the efficacy of modifierinterventions based on the findings of the current review andalso makes comparisons with the findings of previous reviews.Westgaard and Winkel5 concluded that modifier interventionsinvolving the worker (eg, physical training) often achievepositive benefits. The current study concurred with theseconclusions in that it found there was some evidence thatexercise alone had positive effects in workers with neck/upperextremity musculoskeletal conditions. This finding was similarto Verhagen et al,9 but in contrast to Williams et al8 who foundinsufficient evidence for the effectiveness of exercise pro-grammes when managing neck/upper extremity musculoske-letal conditions. With respect to Williams et al,8 only one paperwith a low sample size and without a control group formed thebasis of their conclusion. However, in this study, evidence wasbased on the findings from three medium-quality studies, one

Table 3 A comparison between the current and previous reviews for the level of evidence in support of mechanical interventions forneck/upper extremity musculoskeletal conditions

Intervention condition/industry group

Evidence

Strong Moderate Some Insufficient

Mechanical exposure interventionsWork environment/work station adjustments and VDU workers with neck/upperextremity musculoskeletal conditions

* � � �

Work station equipment and VDU workers with neck/upper extremitymusculoskeletal conditions

* � �

Work station equipment and manufacturing workers with neck/upper extremitymusculoskeletal conditions

*

VDU, visual display unit.*Current review.�Previous reviews (NB: includes multiple findings from different reviews. As descriptions for ratings of evidence may have varied between review papers, these havebeen aligned with the current rating system based on the wording used).

Table 4 A comparison between the current and previous reviews for the level of evidence in support of modifier interventions forneck/upper extremity conditions

Intervention condition/industry group

Evidence

Strong Moderate Some Insufficient

Modifier interventionsExercise and neck/upper extremity musculoskeletal conditions (excludingfibromyalgia)

* � � �

Exercise and fibromyalgia *Multiple modifier interventions (including exercise) and neck/upper extremitymusculoskeletal conditions (excluding fibromyalgia)

* � �

Multiple modifier interventions (including exercise) and fibromyalgia * �Multiple modifier interventions (excluding exercise) and neck/upper extremitymusculoskeletal conditions (excluding fibromyalgia)

* � �

Multiple modifier interventions (excluding exercise) and fibromyalgia * �

*Current review.�Previous reviews (NB: includes multiple findings from different reviews. As descriptions for ratings of evidence may have varied between review papers, these havebeen aligned with the current rating system based on the wording used).


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of which was an RCT. With regard to fibromyalgia, someevidence for exercise interventions was found, although itshould be noted that contrasting findings led to this conclusion.No other reviews have focused upon the effects of exercise andfibromyalgia.

The current review found some evidence for multiplemodifier interventions, inclusive and exclusive of exercise, inpatients with neck/upper limb conditions. Such programmesincluded a combination of various types of low-intensity groupexercise training, education, relaxation techniques and/orcognitive behavioural therapy. A review by Karjalainen et al7

focused upon multidisciplinary biopsychosocial rehabilitationstudies and found insufficient evidence to support theseprogrammes in the rehabilitation of adult patients with upperlimb repetitive strain injuries. However, only two studies werereported upon in this review and these were published in 1994–5. Similarly, Verhagen et al9 concluded that there was a clearlack of evidence for multidisciplinary treatment. However, thisconclusion was based on a single study, whereas the currentreview identified 12 studies examining multiple modifiers.Some evidence was found to support the use of multi-disciplinary rehabilitation inclusive of exercise for fibromyalgia.Multiple modifier interventions exclusive of exercise were noteffective in improving musculoskeletal health in patients withfibromyalgia, although there was an indication that somepsychological factors, such as feelings of helplessness, may beimproved. Similarly, Karjalainen et al14 considered the effects ofmultidisciplinary rehabilitation exclusive of exercise for fibro-myalgia, reviewing seven studies of which four were of lowquality, and concluded that there was insufficient evidence tosupport these programmes.

Limitations of the reviewAlthough this review included those studies that used well-documented questionnaires for pain symptom outcomes, thevalidity and reliability of these measures could not always bedetermined. Unpublished studies, conference proceedings,reports and PhD theses were not reviewed. Reviewers werenot blinded to authors or affiliations of published articles and,finally, the review was restricted to studies written in English.

CONCLUSIONThis review identified no one single strategy for interventionthat was considered effective for all types of industrial settings.The findings provided evidence to support the use of somemechanical and modifier interventions as approaches for theprevention and management of neck/upper extremity muscu-loskeletal conditions and fibromyalgia. With respect to thelatter, there was a distinct lack of well-designed modifierintervention studies where the intervention was specificallytailored for the work environment and the tasks performed bythe workers. Evidence to support the benefits of productionsystems/organisational culture interventions was lacking. Thesefindings may be a reflection of the difficulty of undertakingstudies within the workplace that include interventions focusedupon health benefits compared with increased productivity andperformance.

Overall, there seemed to be no clearly defined researchstrategy targeted at the identification of effective interventionsspecific to high-risk industrial workers or individual neck/upperextremity musculoskeletal conditions. At present, there are onlyisolated studies, often of low quality, that provide limitedinformation for the establishment of new evidence-basedguidelines applicable across a number of industrial sectors.Future consideration should be given to a national/internationalresearch strategy plan targeted at specific groups (industries) orneck/upper extremity musculoskeletal conditions. In this respect,a series of well-designed, related projects will improve our

understanding of the complexity of issues related to injury andoccupational health management. Until then, we will continue tobe faced with isolated research projects, the findings of which donot provide sufficient evidence for changing existing injuryprevention and management practices.

ACKNOWLEDGEMENTSThe financial support of the Accident Compensation Corporation ofNew Zealand in funding this research project is greatly appreciated. Weacknowledge the valuable assistance and guidance of AUT’sInformation and Education Services, in particular Andrew South.

Authors’ affiliations. . . . . . . . . . . . . . . . . . . . . . .

M G Boocock, P J McNair, P J Larmer, B Armstrong, J Collier,M Simmonds, N Garrett, Physical Rehabilitation Research Centre,Auckland University of Technology, Auckland, New Zealand

Competing interests: None declared.

REFERENCES1 Panel on Musculoskeletal Disorders and the Workplace, Commission on

Behavioral and Social Sciences and Education, National Research Council andInstitute of Medicine. Musculoskeletal disorders and the workplace: low back andupper extremities. Washington, DC: National Academy Press, 2001:17–37.

2 Buckle P, Devereux J. Work-related neck and upper limb musculoskeletaldisorders. Bilbao, Spain: European Agency for Safety and Health at Work,1999:7–10.

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Main messages

N An international systematic review of contemporaryliterature (within the past 5 years) found 31 ergonomicinterventions for the prevention and management ofneck/upper extremity musculoskeletal conditions

N Findings support the use of some mechanical andmodifier interventions for managing upper extremityconditions and fibromyalgia

N Although evidence is lacking to support the benefits ofproduction systems/organisational culture interventions,new quality criteria to replace that of blinding andrandomisation may be necessary if the efficacy of theseinterventions is to be properly understood

N Future consideration should be given to a national/international research strategy plan targeted at specifichigh-risk industry groups and/or neck/upper extremityconditions.

Policy implications

N Until such evidence is available, interventions for theprevention and management of neck/upper extremitymusculoskeletal conditions should continue to use multi-factorial approaches

N The use of production systems/organisational culturechanges should not be viewed as a single specificintervention that will bring about improved outcomes inthose workers with neck/upper extremity musculoskeletalconditions.


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Answers (true (T), false (F)) to the questions on How to undertake a systematicreview in an occupational setting by Nicholson, on pages 361–6

1. a) T; b) T; c) F; d) F; e) T.2. a) F; b) F; c) T; d) T; e) F.3. a) F; b) T; c) T; d) T; e) T.4. a) T; b) F; c) T; d) T; e) F.5. a) T; b) F; c) T; d) T; e) T.


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doi: 10.1136/oem.2005.025593September 14, 2006

2007 64: 291-303 originally published onlineOccup Environ Med M G Boocock, P J McNair, P J Larmer, et al. reviewmusculoskeletal conditions: a systematicmanagement of neck/upper extremity Interventions for the prevention and

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