Conservative interventions for treating work-related complaints of the arm, neck or shoulder in adults

  • Review
  • Intervention

Authors


Abstract

Background

Work-related upper limb disorder (WRULD), repetitive strain injury (RSI), occupational overuse syndrome (OOS) and work-related complaints of the arm, neck or shoulder (CANS) are the most frequently used umbrella terms for disorders that develop as a result of repetitive movements, awkward postures and impact of external forces such as those associated with operating vibrating tools. Work-related CANS, which is the term we use in this review, severely hampers the working population.

Objectives

To assess the effects of conservative interventions for work-related complaints of the arm, neck or shoulder (CANS) in adults on pain, function and work-related outcomes.

Search methods

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 31 May 2013), MEDLINE (1950 to 31 May 2013), EMBASE (1988 to 31 May 2013), CINAHL (1982 to 31 May 2013), AMED (1985 to 31 May 2013), PsycINFO (1806 to 31 May 2013), the Physiotherapy Evidence Database (PEDro; inception to 31 May 2013) and the Occupational Therapy Systematic Evaluation of Evidence Database (OTseeker; inception to 31 May 2013). We did not apply any language restrictions.

Selection criteria

We included randomised controlled trials (RCTs) and quasi-randomised controlled trials evaluating conservative interventions for work-related complaints of the arm, neck or shoulder in adults. We excluded trials undertaken to test injections and surgery. We included studies that evaluated effects on pain, functional status or work ability.

Data collection and analysis

Two review authors independently selected trials for inclusion, extracted data and assessed risk of bias of the included studies. When studies were sufficiently similar, we performed statistical pooling of reported results.

Main results

We included 44 studies (62 publications) with 6,580 participants that evaluated 25 different interventions. We categorised these interventions according to their working mechanisms into exercises, ergonomics, behavioural and other interventions.

Overall, we judged 35 studies as having a high risk of bias mainly because of an unknown randomisation procedure, lack of a concealed allocation procedure, unblinded trial participants or lack of an intention-to-treat analysis.

We found very low-quality evidence showing that exercises did not improve pain in comparison with no treatment (five studies, standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -1.08 to 0.03), or minor intervention controls (three studies, SMD -0.25, 95% CI -0.87 to 0.37) or when provided as additional treatment (two studies, inconsistent results) at short-term follow-up or at long-term follow-up. Results were similar for recovery, disability and sick leave. Specific exercises led to increased pain at short-term follow-up when compared with general exercises (four studies, SMD 0.45, 95% CI 0.14 to 0.75)

We found very low-quality evidence indicating that ergonomic interventions did not lead to a decrease in pain when compared with no intervention at short-term follow-up (three studies, SMD -0.07, 95% CI -0.36 to 0.22) but did decrease pain at long-term follow-up (four studies, SMD -0.76, 95% CI -1.35 to -0.16). There was no effect on disability but sick leave decreased in two studies (risk ratio (RR) 0.48, 95% CI 0.32 to 0.76). None of the ergonomic interventions was more beneficial for any outcome measures when compared with another treatment or with no treatment or with placebo.

Behavioural interventions had inconsistent effects on pain and disability, with some subgroups showing benefit and others showing no significant improvement when compared with no treatment, minor intervention controls or other behavioural interventions.

In the eight studies that evaluated various other interventions, there was no evidence of a clear beneficial effect of any of the interventions provided.

Authors' conclusions

We found very low-quality evidence indicating that pain, recovery, disability and sick leave are similar after exercises when compared with no treatment, with minor intervention controls or with exercises provided as additional treatment to people with work-related complaints of the arm, neck or shoulder. Low-quality evidence also showed that ergonomic interventions did not decrease pain at short-term follow-up but did decrease pain at long-term follow-up. There was no evidence of an effect on other outcomes. For behavioural and other interventions, there was no evidence of a consistent effect on any of the outcomes.

Studies are needed that include more participants, that are clear about the diagnosis of work-relatedness and that report findings according to current guidelines.

Résumé scientifique

Interventions conservatrices pour le traitement des plaintes relatives à des douleurs chez l'adulte d’origine professionnelle au niveau du bras, du cou ou de l’épaule

Contexte

Les troubles des membres supérieurs d’origine professionnelle (WRULD), le syndrome de la surutilisation professionnelle (OOS) et les plaintes relatives à des douleurs d’origine professionnelle au niveau du bras, du cou ou de l’épaule (CANS) sont les termes les plus fréquemment utilisés pour les troubles qui se développent en raison de mouvements répétitifs, de postures contraignantes et des impacts liés aux contraintes extérieures, tels que ceux associés à l’utilisation des outils d’opération. Les CANS d’origine professionnelle, qui est le terme utilisé dans cette revue, nuisent gravement à la population active.

Objectifs

Evaluer les effets des interventions conservatrices pour les plaintes relatives à des douleurs d’origine professionnelle au niveau du bras, du cou ou de l’épaule (CANS) chez l'adulte sur la douleur, la fonction et les résultats liés au travail.

Stratégie de recherche documentaire

Nous avons effectué des recherches dans le registre Cochrane des essais contrôlés (La Bibliothèque Cochrane , 31 mai 2013), MEDLINE (de 1950 au 31 mai 2013), EMBASE (de 1988 au 31 mai 2013), CINAHL (de 1982 au 31 mai 2013), AMED (de 1985 au 31 mai 2013), PsycINFO (de 1806 au 31 mai 2013), les bases de données de Physiotherapy Evidence (PEDro; de leur origine jusqu' au 31 mai 2013) et Occupational Therapy Systematic Evaluation of Evidence (OTseeker; de leur origine jusqu' au 31 mai 2013). Nous n'avons appliqué aucune restriction concernant la langue.

Critères de sélection

Nous avons inclus des essais contrôlés randomisés (ECR) et des essais contrôlés quasi-randomisés évaluant des interventions conservatrices pour des plaintes chez l’adulte relatives à des douleurs d’origine professionnelle au niveau du bras, du cou ou de l’épaule. Nous avons exclu les essais réalisés pour tester les injections et la chirurgie. Nous avons inclus des études qui ont évalué les effets sur la douleur, l'état fonctionnel ou les aptitudes au travail.

Recueil et analyse des données

Deux auteurs de la revue ont indépendamment sélectionné les essais à inclure, extrait les données et évalué le risque de biais des études incluses. Lorsque les études étaient suffisamment similaires, nous avons effectué le regroupement statistique des résultats rapportés.

Résultats principaux

Nous avons inclus 44 études (62 publications) avec 6 580 participants qui évaluaient 25 interventions différentes. Nous avons classé ces interventions en fonction de leurs mécanismes de travail au niveau des exercices, de l’ergonomie, des comportements et des autres interventions.

Dans l'ensemble, nous avons estimé que 35 études présentaient un risque de biais élevé principalement en raison d'une procédure de randomisation inconnue, d’un manque de procédure d'assignation secrète, d’essai sans assignation en aveugle ou du manque d' analyse en intention de traiter.

Nous avons trouvé des preuves de très faible qualité indiquant que les exercices n'amélioraient pas la douleur comparés à l'absence de traitement (cinq études, différence moyenne standardisée (DMS) de 0,52, intervalle de confiance (IC) à 95% de 1,08 à 0,03), ou comparés à des interventions mineures dans les groupes témoins (trois études, DMS de 0,25, IC à 95% de 0,87 à 0,37) ou comparés à des traitements supplémentaires (deux études, des résultats contradictoires) lors du suivi à court terme ou lors du suivi à long terme. Les résultats étaient similaires pour les congés de récupération, d'incapacité et de maladie. Les exercices spécifiques conduisaient à une augmentation de la douleur lors du suivi à court terme par rapport à des exercices généraux (quatre études, DMS de 0,45, IC à 95% de 0,14 à 0,75)

Nous avons trouvé des preuves de très faible qualité indiquant que les interventions ergonomiques n'engendraient pas une réduction de la douleur par rapport à l'absence d'intervention lors du suivi à court terme (trois études, DMS de 0,07, IC à 95% de 0,36 à 0,22), mais ne réduisaient pas la douleur lors du suivi à long terme (quatre études, DMS de 0,76, IC à 95% de 1,35 à 0,16). Il n'y avait aucun effet sur l'incapacité, mais les congés maladies ont diminué dans deux études (risque relatif (RR) 0,48, IC à 95% de 0,32 à 0,76). Les interventions ergonomiques n’étaient pas plus bénéfiques au niveau des mesures de résultats par rapport à un autre traitement ou à l'absence de traitement ou à un placebo.

Les interventions comportementales avaient des effets contradictoires sur la douleur et l'invalidité, avec certains sous-groupes rapportant des bénéfices et les autres ne montrant aucune amélioration significative par rapport à l'absence de traitement, à des interventions mineures ou à d'autres interventions comportementales.

Dans les huit études qui évaluaient d’autres interventions, il n'y avait aucune preuve d'un effet bénéfique clair de l'une des interventions fournies.

Conclusions des auteurs

Nous avons trouvé des preuves de très faible qualité indiquant que la douleur, la récupération, l'incapacité et les congés de maladie sont similaires après des exercices par rapport à l'absence de traitement, à une intervention mineure ou à des exercices fournis en traitement supplémentaire chez les personnes souffrant de douleurs d’origine professionnelle au niveau du bras, du cou ou de l’épaule. Des preuves de faible qualité ont également montré que les interventions ergonomiques ne diminuaient pas la douleur lors du suivi à court terme, mais la réduisaient lors du suivi à long terme. Il n'y avait aucune preuve d'effet sur d'autres critères de jugement. Pour les interventions comportementales et autres, il n'y avait aucune preuve d'un effet constant sur aucun des critères de jugement.

Des études, incluant davantage de participants, avec un diagnostic d’origine professionnelle plus précis et qui soient conformes à la notification des directives, sont nécessaires.

Resumo

Intervenções conservadoras para tratar sintomas no braço, pescoço ou ombro relacionados ao trabalho em adultos

Introdução

As doenças ou lesões dos membros superiores relacionadas ao trabalho, lesões por uso repetitivo, síndrome de excesso de uso ocupacional e queixas do braço, pescoço ou ombro relacionadas ao trabalho são os termos gerais mais usados para descrever problemas que surgem como resultado de movimentos repetitivos, posturas incorretas e impacto de forças externas, como aquelas associadas com a operação de ferramentas vibratórias. As queixas de sintomas no braço, pescoço ou ombro relacionados ao trabalho (CANS em inglês, termo utilizado nesta revisão) têm um impacto importante sobre a população dos trabalhadores.

Objetivos

Avaliar os efeitos de intervenções conservadoras para o tratamento de adultos com sintomas no braço, pescoço e ombro relacionados ao trabalho (CANS) sobre a dor, função e desfechos relacionados ao trabalho.

Métodos de busca

Nós fizemos buscas nas seguintes bases de dados: Cochrane Central Register of Controlled Trials (The Cochrane Library,31 de Maio de 2013), MEDLINE (de 1950 a 31 de maio de 2013), EMBASE (de 1988 a 31 de maio de 2013), CINAHL (de 1982 a 31 de maio de 2013), AMED (de 1985 a 31 de maio de 2013), PsychINFO (de 1806 a 31 de maio de 2013), Physiotherapy Evidence Database (PEDro; desde o início até 31 de maio de 2013) e a Occupational Therapy Systematic Evaluatioon of Evidence Database (OTseeker; desde o início até 31 de maio de 2013). Nós não usamos nenhuma restrição de idioma.

Critério de seleção

Nós incluímos ensaios clínicos randomizados (ECRs) e quasi-randomizados que avaliaram intervenções conservadoras para queixas de braço, pescoço ou ombro relacionadas ao trabalho (CANS) em adultos. Nós excluímos os estudos que usaram tratamentos envolvendo injeções e cirurgias. Nós incluímos estudos que avaliaram os efeitos das intervenções sobre a dor, a função e a capacidade de trabalhar.

Coleta dos dados e análises

Dois autores da revisão selecionaram os estudos para inclusão, extraíram os dados e avaliaram o risco de viés dos estudos incluídos, de maneira independente. Quando os estudos eram suficientemente parecidos, nós combinamos seus resultados em metanálises.

Principais resultados

Nós incluímos 44 estudos (62 publicações) com 6.580 participantes que avaliaram 25 intervenções diferentes. Nós categorizamos essas intervenções, de acordo com o mecanismo de ação, como exercícios, ergonomia, técnicas comportamentais e outras intervenções.

Em geral, nós julgamos 35 estudos como tendo alto risco de viés principalmente por não especificarem claramente o método de randomização, pela falta de procedimentos para assegurar o sigilo de alocação, pela falta de cegamento dos participantes dos estudos ou pela falta de uma análise por intenção de tratar.

Nós encontramos evidência de qualidade muito baixa mostrando que os exercícios, nos seguimentos de curto ou longo prazo, não melhoraram a dor em comparação com nenhum tratamento [5 estudos, diferença média padronizada (DMP) -0,52, intervalo de confiança 95% (95% CI) -1,08 – 0,37) ou com controles com intervenção mínima (3 estudos, DMP -0,25, 95% CI -0,87 – 0,37) ou quando foi ofertado como tratamento adicional (2 estudos, resultados inconsistentes). Os resultados foram semelhantes em relação à recuperação, incapacidade e licença por doença. No seguimento a curto prazo, os exercícios específicos levaram a aumento da dor, quando comparados com exercícios gerais (4 estudos, DMP 0,45, 95% CI 0,14 – 0,75).

Nós encontramos evidência de muito baixa qualidade indicando que, no curto prazo, as intervenções ergonômicas não diminuíram a dor quando comparadas com nenhuma intervenção (3 estudos, DMP -0,07, 95% CI -0,36 – 0,22) mas diminuíram a dor no longo prazo (4 estudos, DMP -0,76, 95% CI -1,35 a -0,16). Essa intervenção não teve efeito sobre a incapacidade, mas diminuiu as licenças por doença em 2 estudos [risco relativo (RR) 0,48, 95% CI 0,32 – 0,76). Nenhuma das intervenções ergonômicas foi mais benéfica para qualquer outra medida de desfecho quando comparada com outro tratamento ou com nenhum tratamento ou com placebo.

As intervenções comportamentais produziram efeitos inconsistentes na dor e na incapacidade. Essas intervenções foram benéficas para alguns subgrupos e não provocaram melhora significativa em outros subgrupos, quando comparadas com nenhum tratamento, com controles que receberam intervençoes mínimas ou com outras intervenções comportamentais.

Os oito estudos que avaliaram várias outras intervenções não mostraram efeitos benéficos claros em nenhuma das intervenções oferecidas.

Conclusão dos autores

Nós encontramos pouca evidência, de qualidade muito baixa, indicando que a dor, recuperação, incapacidade e licença por doença são similares após os exercícios quando comparados com nenhum tratamento, com controles com intervenção mínima ou com exercícios oferecidos como tratamento adicional para pessoas com queixas de sintomas no braço, pescoço ou ombro relacionadas ao trabalho. Evidências de baixa qualidade também mostraram que intervenções ergonômicas não diminuíram dor no seguimento de curto prazo mas diminuíram a dor no longo prazo. Não houve evidência de efeito quanto aos outros desfechos. Não existe evidência de efeitos consistentes das intervenções comportamentais e outras intervenções sobre nenhum dos desfechos de interesse desta revisão.

São necessários mais estudos, com maior número de participantes, que especifiquem claramente como foi feito o diagnóstico de que a queixa teria relação com o trabalho e que relatem os desfechos de acordo com as diretrizes atuais.

Notas de tradução

Traduzido pelo Centro Cochrane do Brasil (Maíra Tristão Parra)

Plain language summary

Exercises, ergonomics and physical therapy for work-related complaints of arm, neck or shoulder

Background

Work-related complaints of the arm, neck or shoulder are also called repetitive strain injury or occupational overuse syndrome. They are a burden for individual workers, for their employers and for society at large because they impair functioning both in daily life and at work.

Studies included in the review

We included randomised controlled studies of all possible treatments such as exercises, ergonomic adjustments at the workplace, massage and manual therapy. These treatments aim to reduce pain and improve functioning, and they can be provided by general practitioners or physiotherapists. We excluded injections and surgical procedures that invade the body and require more special skills. We included studies only if the authors wrote that the people they studied had complaints that were work-related. We searched electronic databases up until May 2013.

Findings

We found 44 studies that included 6,580 persons. Twenty-one studies evaluated exercises, 13 evaluated ergonomic workplace adjustments and nine behavioural interventions. We combined the results of these studies per category. Eight other studies evaluated various other treatments.

We did not find a consistent effect of any treatment on pain, recovery, disability or sick leave. Ergonomic interventions reduced pain in the long term but not in the short term in several studies. We judged nine studies to be of high quality, but the results were very inconsistent. We found no reason for the variation in study results. Better studies are needed that are bigger, have a clearer diagnosis of work-relatedness and comply with reporting guidelines.

Résumé simplifié

Une thérapie physique, des exercices et de l’ergonomie pour les plaintes relatives à des douleurs d’origine professionnelle au niveau du bras, du cou ou de l’épaule

Contexte

Les plaintes relatives à des douleurs d’origine professionnelle au niveau du bras, du cou ou de l’épaule sont également connues sous le nom de microtraumatismes répétés ou de syndrome de la surutilisation professionnelle. Ceci est un fardeau pour les travailleurs individuels, pour leurs employeurs et pour la société à grande échelle, car cela impacte le fonctionnement social à la fois dans la vie quotidienne et au travail.

Études incluses dans la revue

Nous avons inclus les études contrôlées randomisées portant sur tous les traitements potentiels, tels que des exercices, des ajustements ergonomiques sur le lieu de travail, des massages et de la thérapie manuelle. Ces traitements visent à réduire la douleur et à améliorer le fonctionnement, ils peuvent également être fournis par des médecins généralistes ou des physiothérapeutes. Nous avons exclu les injections et les procédures chirurgicales ayant envahi le corps et exigeant davantage de compétences particulières. Nous avons inclus les études uniquement lorsque les auteurs indiquaient que les personnes étudiées se plaignaient de douleurs relatives au travail. Nous avons effectué des recherches dans les bases de données électroniques jusqu'en mai 2013.

Résultats

Nous avons trouvé 44 études portant sur 6 580 personnes. Vingt-et-une études évaluaient des exercices, 13 évaluaient des ajustements ergonomiques sur le lieu de travail et 9 évaluaient des interventions comportementales. Nous avons combiné les résultats de ces études par catégorie. Huit autres études évaluaient d’autres divers traitements.

Nous n'avons trouvé d’effet constant dans aucun traitement sur la douleur, la récupération, l'incapacité ou les congés de maladie. Dans plusieurs études, les interventions ergonomiques réduisaient la douleur à long terme, mais pas à court terme. Nous avons jugé que neuf études étaient de grande qualité, mais les résultats étaient très incohérents. Nous n'avons trouvé aucune cause de la variation dans les résultats des études. De meilleures études, avec une plus grande échelle, un diagnostic d’origine professionnelle plus précis et qui soient conformes à la notification des directives, sont nécessaires.

Notes de traduction

Traduit par: French Cochrane Centre 14th January, 2014
Traduction financée par: Financeurs pour le Canada : Instituts de Recherche en Santé du Canada, Ministère de la Santé et des Services Sociaux du Québec, Fonds de recherche du Québec-Santé et Institut National d'Excellence en Santé et en Services Sociaux; pour la France : Ministère en charge de la Santé

Laički sažetak

Tjelovježba, ergonomika i fizikalna terapija za liječenje problema s rukama, vratom ili ramenom koji su vezani za posao

Dosadašnje spoznaje

Tegobe koje se javljaju u rukama, vratu i ramenima, a koje su vezane za radno mjesto, još se nazivaju i ozljede prenaprezanja ili sindrom pretjerane uporabe. Te tegobe opterećuju radnike, njihove poslodavce te društvo u cijelosti zbog nemogućnosti funkcioniranja na poslu i u svakodnevnom životu.

Studije uključene u ovaj pregled

U ovaj Cochrane sustavni pregled su uključene randomizirane kontrolirane studije svih mogućih terapija kao što su vježbanje, ergonomska prilagodba radne sredine, masaža i manualna terapija. Cilj ovih terapija je bio smanjiti bol i poboljšati funkcioniranje. Terapije su mogli pružiti liječnici opće prakse i fizioterapeuti. Isključene su terapije injekcijama i invazivne kirurške procedure koje zahtijevaju specijalne vještine. Uključene su samo one studije u kojima su autori napisali da su tegobe vezane uz radno mjesto. Pretražene su elektroničke baze podataka kako bi se našle studije objavljene do svibnja 2013.

Rezultati

Autori su pronašli 44 studije, koje su uključile ukupno 6,580 osoba. 21 studija bavila se procjenom učinka vježbi, 13 procjenom učinka ergonomskih prilagodbi na radnom mjestu i devet bihevioralnih intervencija. Rezultati tih studija zbirno su analizirani po kategoriji. Osam drugih studija ocjenjivale su razne druge oblike terapije.

Nije pronađen postojan učinak ijednog oblika terapije na bol, razinu onesposobljenosti, duljinu oporavka i bolovanja. Ergonomske prilagodbe dugoročno ublažuju bol, ali ne i kratkoročno (rezultat nekoliko studija). 9 studija ocijenjeno je kao visokokvalitetne, ali su rezultati bili vrlo nedosljedni. Nije pronađen razlog varijabilnosti rezultata. Zaključeno je da su potrebna kvalitetnija istraživanja, čiji će rezultati biti napisani u skladu sa smjernicama za prikazivanje istraživačkih podataka, s jasnijom dijagnozom profesionalnih tegoba.

Bilješke prijevoda

Hrvatski Cochrane
Preveli: Ivan Šustić i Ivan Širić
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr 

Resumo para leigos

Exercícios, ergonomia e atividade física para queixas de sintomas no braço, pescoço ou ombro relacionadas ao trabalho

Introdução

Queixas de sintomas no braço, pescoço ou ombro relacionadas com o trabalho são também chamadas de lesões por uso repetitivo ou síndrome ocupacional por uso excessivo (CANS, em inglês). Elas são um fardo para os trabalhadores, para seus empregadores e para a sociedade em geral, porque têm impacto nas atividades da vida diária e no trabalho.

Estudos incluídos na revisão

Nós incluímos estudos randomizados controlados que testaram todos os tratamentos possíveis, como os exercícios, ajustes ergonômicos no ambiente de trabalho, massagem e terapia manual. Esses tratamentos objetivam reduzir a dor e melhorar a função, e podem ser oferecidos por clínicos gerais ou por fisioterapeutas. Nós excluímos desta revisão os estudos que testaram tratamentos envolvendo injeções e cirurgias porque são invasivos e necessitam de habilidades mais sofisticadas. Nós incluímos apenas estudos nos quais os autores escreveram que as pessoas participantes tinham queixas relacionadas ao trabalho. Nós fizemos buscas em diversas bases de dados eletrônicas por estudos publicados até maio de 2013.

Resultados

Nós encontramos 44 estudos que incluíram 6.580 pessoas: 21 estudos avaliaram exercícios, 13 avaliaram ajustes ergonômicos no ambiente de trabalho e 9 testaram intervenções comportamentais. Nós combinamos os resultados desses estudos em diversas categorias. Oito outros estudos avaliaram vários outros tratamentos.

Nós não encontramos efeitos consistentes de nenhum tratamento para dor, recuperação, incapacidade ou licença por doença. As intervenções ergonômicas reduziram a dor a longo prazo mas não em curto prazo em diversos estudos. Nós julgamos nove estudos como sendo de alta qualidade, mas seus resultados eram muito inconsistentes. Nós não encontramos razão alguma para a variabilidade nos resultados dos estudos. É preciso fazer mais estudos, com um número maior de participantes que tenham um diagnóstico mais claro de que as queixas sejam relacionadas com o trabalho e que sigam as diretrizes ao relatar seus achados.

Notas de tradução

Traduzido pelo Centro Cochrane do Brasil (Maíra Tristão Parra)

Background

Description of the condition

Work-related upper limb disorder (WRULD), repetitive strain injury (RSI), cumulative trauma disorder (CTD), occupational overuse syndrome (OOS) and work-related complaints of the arm, neck or shoulder (CANS) are the most frequently used umbrella terms for disorders that develop as a result of repetitive movements, awkward postures and impact of external forces such as those associated with operating vibrating tools (Boocock 2009). Work-related complaints can be divided into specific conditions with relatively clear diagnostic criteria and pathology, such as carpal tunnel syndrome, and non-specific conditions, such as tension neck syndrome. These non-specific conditions are primarily defined by the locations of complaints, and their pathophysiology is less clearly defined or is relatively unknown (Staal 2007).

In the USA, cumulative trauma disorders account for between 56% and 65% of all occupational injuries (Melhorn 1998; Pilligan 2000). Overall, the estimated prevalence of work-related CANS is around 30% (Melhorn 1998), and several studies report a rapidly increasing incidence (Yassi 1997). Work-related CANS severely hampers the working population in Western countries. Approximately one-third of compensation costs in Australia and the USA are due to work-related CANS (Shanahan 2006; Staal 2007). As a result, these complaints are responsible for a considerable number of lost working days. The Labour Force Survey shows that an estimated 3.8 million working days (full-day equivalent) were lost in 2008-2009 in the UK because of musculoskeletal disorders mainly affecting the upper limbs or neck, caused or made worse by work. On average, each affected person took an estimated 17.5 days off in that 12-month period. This equates to an annual loss of 0.16 days per worker (HSE 2010).

The aetiology of CANS is considered to be multi-factorial. In most people, no specific diagnosis can be made (Armstrong 1993). In addition, no pathological, neurological or radiological characteristics can be found to support the diagnosis of 'non-specific' CANS (Staal 2007). Several personal and physical risk factors are found to be associated with CANS (Feleus 2007; Karels 2007; Roquelaure 2009), and increasing attention is being paid to its prevention and treatment (IJmker 2007; Shanahan 2006; Tulder 2007).

Description of the intervention

We defined conservative interventions as all interventions that are different from surgical interventions or injections. Types of conservative interventions that are prescribed or performed in the treatment of CANS include physiotherapy (exercises, mobilisation, electrotherapy and ultrasound), spinal manipulation, behavioural therapy and ergonomic measures or occupational therapy (e.g. working practices, splints). These interventions have in common that they are usually provided by general practitioners or physiotherapists, whereas the invasive interventions of surgery and injections require special skills and treatment facilities. Treatment may consist of a single intervention or of multiple interventions that may be provided by a member of a single discipline or members of several disciplines, as in multi-disciplinary treatment, whereby a team involving members of different disciplines such as physiotherapists, occupational therapists and psychologists provides treatment. Ergonomic measures used in the treatment of CANS include specially designed office furniture, computer keyboards and computer mice.

How the intervention might work

Conservative interventions, such as physiotherapy and ergonomic adjustments, play a major role in the treatment of CANS (Staal 2007; Tulder 2007). The working mechanism at tissue level of most interventions is unclear. Below we describe hypothesised mechanisms. The principal aims of these treatments are to decrease pain levels and improve function through methods such as muscle relaxation and re-education techniques, soft tissue mobilisation, cognitive interactions and workplace adjustments. Several exposures at the workplace are implied in the occupational origin of CANS, such as the use of too much force, too frequent (repetitive) movements and awkward positions. The aim of ergonomic and workplace adjustments is to influence these exposures by evaluating different sitting positions and making keyboard or mouse adjustments to prevent repetitive movements and awkward sitting postures. Physiotherapy interventions aim to (1) educate people about better sitting postures, (2) lower muscle intensity when working and (3) provide strengthening exercises to improve muscle condition and massage to relax muscles that are painful.

Why it is important to do this review

As shown above, work-related CANS is a common disorder that has considerable impact on many individuals and society as a whole and frequently results in work loss. There is thus an imperative to find the best ways of treating people with CANS, especially so that they can return to work. Two previous Cochrane reviews on this topic found insufficient evidence to permit firm conclusions on the effectiveness of frequently applied treatment strategies (Karjalainen 2000; Verhagen 2006). However, several new studies have been published during the past few years. Therefore, there is a need to determine whether new evidence has an impact on previous results and to identify the most effective treatment strategy. Do conservative interventions have a significant impact on short-term and long-term outcomes? This new review, which replaces the two above-mentioned reviews (Karjalainen 2000; Verhagen 2006), provides an update of the evidence on this topic.

Objectives

To assess the effects of conservative interventions for work-related complaints of the arm, neck or shoulder (CANS) in adults on pain, function and work-related outcomes.

Methods

Criteria for considering studies for this review

Types of studies

We considered for inclusion in this review all randomised controlled trials (RCTs) and quasi-randomised controlled trials (using a method of allocating people to a treatment that is not strictly random, e.g. by date of birth or alternation). We also considered for inclusion cluster-RCTs, wherein the unit of randomisation is a group of individuals, and cross-over RCTs, in which participants, upon completion of one course of treatment, are switched to another.

Types of participants

We included studies that enrolled adults (18 years and older) suffering from work-related complaints of the arm, neck or shoulder (CANS). We excluded studies in which participants had acute trauma, neoplasms or inflammatory or neurological diseases. We considered complaints to be work-related when this was stated in the text, or when people were selected from a specific working population, such as an office, a factory or a laboratory.

Types of interventions

We considered all interventions that are not surgery or injections to be conservative interventions. We included all trials studying conservative interventions for the treatment of upper extremity work-related disorders in adults. Conservative interventions include exercises, relaxation, biopsychosocial rehabilitation programmes, physical applications such as ultrasound, biofeedback (a method of treatment that uses monitors to provide feedback to patients on physiological information of which they are normally unaware), myofeedback (a form of biofeedback that specifically focuses on muscular activity) and workplace adjustments. These interventions can be applied within or outside the workplace, in specialised training centres or in fitness centres. Treatment providers can vary but may involve clinical professionals such as physiotherapists, occupational therapists and psychologists or fitness instructors.

We included single conservative interventions or combinations of conservative interventions versus no intervention (e.g. waiting list control) or a placebo control, or a different conservative intervention. The studied intervention could be the only treatment or an add-on treatment. We excluded trials that tested injections and surgery.

We have set up separate comparisons for different categories of conservative interventions. We have grouped these primarily according to their working mechanisms as follows.

  • Exercises.

  • Ergonomic workplace adjustments.

  • Behavioural interventions.

  • Other interventions.

Types of outcome measures

We included studies that used the following primary outcome measures.

Primary outcomes
  • Functional status (e.g. Health Assessment Questionnaire (Fries 1982), Disabilities of the Arm, Shoulder and Hand Measurement Tool (DASH) (Hudak 1996)).

  • Pain (e.g. visual analogue scale (VAS) (Sriwatanakul 1983), West Haven-Yale Multidimensional Pain Inventory (WHYMPI) (Kerns 1985), ordinal scale (Von Korff 2000)).

  • Ability to work (e.g. sickness absence (days off work), return to work, productivity loss at work, change of occupation).

Secondary outcomes
  • Global perceived effect (e.g. overall improvement) (Beurskens 1996).

  • Quality of life (e.g. Short Form 36 (SF-36; Ware 1992), EQ-5D (a generic measure of health status; Williams 1990), Sickness Impact Profile (de Bruin 1994)).

  • Healthcare consumption (e.g. physician consultations, physiotherapy, ergonomic adjustments, intake of analgesics).

  • Recurrence of injury, disorder or complaint.

Search methods for identification of studies

Electronic searches

For this updated version of our review, we searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, 31 May 2013), MEDLINE (1950 to 31 May 2013), EMBASE (1988 to 31 May 2013), CINAHL (1982 to 31 May 2013), AMED (1985 to 31 May 2013), PsycINFO (1806 to 31 May 2013), PEDro (the Physiotherapy Evidence Database; inception to 31 May 2013) and OTseeker (the Occupational Therapy Systematic Evaluation of Evidence Database; inception to 31 May 2013). We did not apply any language restrictions.

In MEDLINE, we combined the subject-specific strategy with the sensitivity- and precision-maximising version of the Cochrane Highly Sensitive Search Strategy (Lefebvre 2009) for identifying randomised trials in MEDLINE and modified for use in other databases. Search strategies for the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE are shown in Appendix 1.

Searching other resources

We also searched reference lists of included articles and contacted experts in the field.

Data collection and analysis

Selection of studies

Three review authors (SMS, BWK and SMAB-Z) independently selected trials by inspecting titles, keywords and abstracts to determine whether studies met the inclusion criteria regarding design, participants and interventions. Full publications of studies of any possible relevance were retrieved for final assessment. Next, the review authors independently performed a final selection of the trials to be included in the review using a standardised form. Disagreements were resolved by consensus and, if necessary, by fourth party adjudication (APV).

Data extraction and management

Two review authors (SMAB-Z and APV) independently extracted data on trial methods, participants, settings, interventions, care providers, types of outcome measures, duration of follow-up, loss to follow-up and results using a standardised data extraction form from Verhagen 2006. Disagreements were resolved by consensus and, if necessary, by third party adjudication (HCWdV).

Assessment of risk of bias in included studies

Two review authors (BWK and SMS) independently assessed the risk of bias using a modified version of the assessment tool developed by The Cochrane Collaboration (Furlan 2009; Higgins 2011) (Table 1). This tool incorporates the Delphi list (Verhagen 1998), as used in previous versions of this review, and involves assessment of randomisation (sequence generation and allocation concealment), blinding (of participants, care providers and outcome assessors), completeness of outcome data, selection of outcomes reported and four other sources of bias. Disagreement was resolved by consensus or, if disagreement persisted, a third review author (APV) made the final decision.

Table 1. Criteria for assessing risk of bias in randomised clinical trials
  1. Risk of bias was assessed using the 12 criteria above (Furlan 2009). The criteria for a judgement of 'Yes' are outlined in Appendix 2.

Item Judgement
1. Was the method of randomisation adequate?Yes/No/Unsure
2. Was the treatment allocation concealed?Yes/No/Unsure

Was knowledge of the allocated interventions adequately prevented during the study?

3. Was the participant blinded to the intervention?

4. Was the care provider blinded to the intervention?

5. Was the outcome assessor blinded to the intervention?

Yes/No/Unsure

Yes/No/Unsure

Yes/No/Unsure

Were incomplete outcome data adequately addressed?

6. Was the dropout rate described and acceptable?

7. Were all randomly assigned participants analysed in the group to which they were allocated?

 

Yes/No/Unsure

Yes/No/Unsure 

8. Are reports of the study free of suggestion of selective outcome reporting?Yes/No/Unsure 

Other sources of potential bias:

9.  Were the groups similar at baseline regarding the most important prognostic indicators?

10. Were co-interventions avoided or similar?

11. Was compliance acceptable in all groups?

12. Was the timing of the outcome assessment similar in all groups?

 

Yes/No/Unsure

Yes/No/Unsure

Yes/No/Unsure

Yes/No/Unsure

We derived the interobserver reliability of the risk of bias assessment by Kappa statistics. We considered Kappa values > 0.7 as showing good agreement, between 0.5 and 0.7 moderate agreement and < 0.5 poor agreement.

Measures of treatment effect

We presented the various outcome measures separately. For dichotomous data, we expressed results, if possible, as risk ratios (RRs) with corresponding 95% confidence intervals (95% CIs). For continuous data, we calculated mean differences or, when outcome measures were dissimilar, standardised mean differences (SMDs) with 95% confidence intervals (Lau 1997).

Unit of analysis issues

Most treatment was targeted to individuals. However, in some trials, treatment allocation was randomised by groups or clusters rather than individuals.

For cluster-randomised trials that did not adjust for the cluster effect, we calculated the design effect based on the number of clusters and the number of participants and an assumed intraclass correlation (ICC) of 0.1 (Campbell 2001), as indicated in the Cochrane Handbook for Systematic Reviews of Interventions; Higgins 2011). We then used this design effect to adjust the number of participants included in the analysis.

When sufficient studies were available, we conducted a sensitivity analysis.

For cross-over trials, we did not know what a suitable wash-out period would be for the interventions of interest. Therefore, to avoid the carry-over of the treatment from the first period, we restricted the analysis to the first period of the trial only. This was possible for two studies (Sjögren 2005; Ylinen 2007). One other study (Takala 1994) did not provide enough data for this analysis and we included this study as if it were a parallel group trial. We accept that this may have resulted in the underestimation of the treatment effect. The fourth cross-over trial (Ferguson 1976) did not provide enough data to be included in the analysis.

Dealing with missing data

For dichotomous data, we performed an intention-to-treat analysis whereby all missing people were considered to have a bad outcome. However, for continuous data, when dropouts were identified, we used the actual number of participants contributing data at the relevant outcome assessment. Furthermore, we refrained from imputing values for standard deviations unless missing standard deviations could be derived from confidence intervals, standard errors or presented P values in the same study.

Assessment of heterogeneity

Clinicians on the review team assessed clinical heterogeneity on the basis of information on the study population (chronic vs. acute, specific vs non-specific), interventions (exercises, massage, ergonomic interventions, etc.), control interventions (no treatment vs. active treatment), outcomes (pain, function, recovery and sick leave) and timing of follow-up (short term: less than three months; long term: six months or longer). We assessed statistical heterogeneity between pooled trials using a combination of visual inspection of the graphs and consideration of the I2 statistic (Higgins 2011), as implemented in the forest plots in RevMan 5. We quantified the degree of heterogeneity using the I2 measure where an I2 value less than 40% indicates heterogeneity that is unimportant, 30% to 60% indicates a moderate degree of heterogeneity, values between 50% and 90% substantial heterogeneity and 75% to 100% considerable heterogeneity.

Assessment of reporting biases

We assessed publication bias by using a funnel plot.

Data synthesis

We used Review Manager (RevMan 2011) to analyse the data. We pooled studies that we judged to be similar with regard to participants, interventions, comparisons and outcomes.

We used the GRADE method as implemented in software GRADEpro (GRADEpro 2008) to evaluate the overall quality of evidence and the strength of recommendations (GRADE 2004).

The quality of the evidence for a specific outcome was based upon five domains and was downgraded by one level for each of the following factors if encountered.

  • Limitations in design (> 25% of participants came from studies with high risk of bias).

  • Inconsistency of results (significant statistical heterogeneity (I2 > 40%) or inconsistent findings among studies (≤ 75% of participants report findings in the same direction)).

  • Indirectness (i.e. generalisability of findings).

  • Imprecision (total number of participants < 300 for each outcome).

  • Other (e.g. publication bias, flawed design).

Two review authors (SMS, BWK) independently judged the quality of evidence for each outcome using these five factors. We considered single randomised studies (n < 300) to be inconsistent and imprecise and to provide "low quality evidence", which could be further downgraded to "very low quality evidence" if there were also limitations in design (i.e. high risk of bias), indirectness or other considerations. We rated the quality of the evidence as high, moderate, low or very low with the following implications.

  • High quality: Further research is very unlikely to change our confidence in the estimate of effect. Data are sufficient with narrow confidence intervals. No reporting biases are known or suspected; all domains were fulfilled.

  • Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate; one of the domains was not fulfilled.

  • Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change it; two of the domains were not fulfilled.

  • Very low quality: Great uncertainty surrounds the estimate; three of the domains were not fulfilled.

Subgroup analysis and investigation of heterogeneity

We performed subgroup analyses to evaluate the effects of specific work-related CANS (e.g. a specific cause and diagnosis are established) versus non-specific work-related CANS, setting of treatment (work vs. outside work location), care provider (general practitioner, physiotherapist or occupational therapist), location of the complaint (neck/shoulder vs. arm) or duration of the complaint (chronic vs. (sub)acute).

Sensitivity analysis

We performed sensitivity analyses by pooling only results from studies that we considered to have a low risk of bias.

Results

Description of studies

Results of the search

We randomly allocated two out of four of the review authors (SMAB-Z, SMS, BWK and APV) to perform the systematic search process independently. This resulted in 4,945 references after duplicates were removed. Based on title and abstract, we selected 275 references for full-text retrieval. Of these, we finally selected 44 studies (62 publications) for inclusion in this review (Figure 1).

Figure 1.

Study flow diagram.

Included studies

Study design

Of the 44 included studies, 35 studies randomly assigned participants individually to intervention or control groups. Two studies performed group randomisation (Heuvel 2003; Waling 2000), and three studies used cluster-randomisation (Andersen 2008a; Andersen 2008b; Esmaeilzadeh 2012). Three studies used a cross-over design (Ferguson 1976; Takala 1994; Ylinen 2007), and one study used a cross-over design with cluster-randomisation (Sjögren 2005). We adjusted the study outcome data for an assumed cluster effect for Heuvel 2003 and Andersen 2008b. We did not do so for Sjögren 2005 because this study used both a cluster-randomised and a cross-over design. For this study, we assumed that the too conservative estimate for the cross-over design would balance the too narrow confidence intervals resulting from the cluster design. Equally, we did not adjust the data for Waling 2000 or Esmaeilzadeh 2012 because groups were clustered only on the basis of the most convenient timing for participants. We assumed that the cluster effect would be negligible here. Andersen 2008a did not provide data for meta-analysis; therefore, we could not adjust study outcomes here. We excluded Ferguson 1976 from the analysis because these investigators did not present data from the first phase of the cross-over trial.

Study size

One study (Abasolo 2005) was extremely large; researchers included 13 077 participants, of which 1,605 suffered from work-related neck pain. In all other studies, the number of participants in each treatment group varied from nine to 187 (mean 108.4). In 19 of the other 43 studies, the smallest intervention group had fewer than 25 participants.

Setting

Of the 44 studies, 18 originated from the Scandinavian countries (eight from Finland alone); eight from the rest of Europe (of which five are from The Netherlands); 14 from the USA, Canada and Australia; ; two from China and two from Turkey.

Participants

In total, we included in this review data from 6,580 participants. Thirty-three studies selected study populations such as industrial workers or hospital staff.

Thirty-six studies included people with non-specific neck and shoulder complaints or non-specific upper extremity disorders. Three studies included people with work-related carpal tunnel syndrome (Rempel 1999; Tittiranonda 1999; Werner 2005) and two rotator cuff tendinitis (Cheng 2007; Szcurko 2009), whereas shoulder impingement (Bang 2000), epicondylitis (Nourbakhsh 2008) and hand or wrist complaints (Stralka 1998) were included in one study each.

A total of 39 studies included people with chronic complaints varying in duration between three and 12 months. When people with 'prevalent complaints' were included, the mean duration of the complaints at baseline appeared to vary between three months and 11 years. Four studies involved people with recent (< six weeks) onset of complaints (Heuvel 2003; Ketola 2002; Moore 1996; Tittiranonda 1999).

Sixteen studies included only women, and one study included men only (Ferguson 1976); all other 27 studies included both men and women.

We evaluated the definition of 'work-relatedness' in all studies. Most studies (n = 36) stated that work-relatedness was due to including office or computer workers with musculoskeletal complaints or complaints caused by the work or by repetitive stress. Authors used statements such as "...reported a gradual onset of symptoms that were apparently work-related", "...reported pain or complaints during work tasks", "...performed data processing tasks for 8 hours a day" or "...pain due to repetitive use or prolonged static postures".

Outcomes

Thirty-nine studies used pain as an outcome measure, most often using a visual analogue scale (VAS) or a numerical rating scale (NRS). Eight studies used an index or composite score measure 'pain complaints', 12 studies used 'return to work' or 'sick leave' as an outcome measure and seven studies measured recovery, benefit or satisfaction. Other outcome measures included disability (by questionnaire) or strength (by dynamometer). We defined short-term outcomes as outcomes measured within three months after randomisation, and long-term outcomes as those measured more than three months after randomisation.

Interventions

The 44 included studies evaluated seven different types of interventions. Twenty-five studies employed only two study arms, 14 studies had three and five studies used altogether four study arms. No studies compared a conservative treatment option versus other treatments such as oral medication, injection or surgery. Twenty-nine studies included a control intervention such as placebo treatment (four studies: Goldman 2010; Nourbakhsh 2008 Stralka 1998; Tittiranonda 1999), no treatment controls (13 studies: Dellve 2011; Esmaeilzadeh 2012; Heuvel 2003; Kamwendo 1991; Ketola 2002; Lundblad 1999; Ma 2011; Marangoni 2010; Rempel 2007; Sandsjö 2010; Sjögren 2005; Takala 1994; Viljanen 2003), a waiting list control group (four studies: Bru 1994; Moore 1996; Spence 1989; Spence 1995), a counselling or discussion control group (three studies: Andersen 2008a; Andersen 2008b; Waling 2000) or usual care controls (four studies: Abasolo 2005; Bernaards 2006; Martimo 2010; Meijer 2006).

One study did not evaluate a specific treatment but rather assessed treatment delivered by rheumatologist versus general practitioner (Abasolo 2005). All other interventions can be grouped as follows. 

1. Exercises

Twenty-one studies evaluated a form of exercise therapy including specific forms of exercises such as proprioceptive neuromuscular facilitation (PNF) (Ferguson 1976), Feldenkrais therapy (Lundblad 1999) or Mensendieck training (van Eijsden 2008). All 21 studies included participants with non-specific neck and shoulder pain, except for one study, which included participants with rotator cuff tendinitis (Szcurko 2009).

Exercises were compared with a control group of no treatment or an intervention like counselling in 11 studies (Andersen 2008a; Andersen 2008b; Dellve 2011; Kamwendo 1991; Lundblad 1999; Ma 2011; Sjögren 2005; Takala 1994; Viljanen 2003; Waling 2000; Ylinen 2003), with other exercises in eight studies (Andersen 2008a; Andersen 2008b;Ferguson 1976; Hagberg 2000; Lundblad 1999; van Eijsden 2008; Waling 2000; Ylinen 2003), with behavioural therapy in three studies (Dellve 2011; Ma 2011; Viljanen 2003), with massage in two studies (Ferguson 1976; Levoska 1993) and with manual therapy (Ylinen 2007) and neuropathic care (Szcurko 2009) in one study each. Exercise was evaluated as an add-on treatment to ergonomic instructions in two studies (Bernaards 2006; Omer 2003) and in addition to breaks during computer work in one study (Heuvel 2003). One study (Vasseljen 1995) compared physical therapy provided individually with group physical therapy, with both including exercises given at the workplace. 

2. Ergonomics

Various ergonomic strategies were evaluated in 13 studies and can be regarded as two different strategies: work hardening strategies (Bernaards 2006; Cheng 2007; Ketola 2002; Lundblad 1999) and strategies related to workplace computer or keyboard use (Esmaeilzadeh 2012; Heuvel 2003; Kamwendo 1991; Marangoni 2010; Martimo 2010; Rempel 1999; Rempel 2007; Ripat 2006; Tittiranonda 1999). Three studies included participants with specific complaints such as rotator cuff tendinitis (Cheng 2007) or carpal tunnel syndrome (Rempel 1999; Tittiranonda 1999).

Eight studies compared ergonomic programmes versus a no treatment control group (Bernaards 2006; Esmaeilzadeh 2012; Heuvel 2003; Ketola 2002; Lundblad 1999; Marangoni 2010; Martimo 2010; Rempel 2007) and one versus placebo (Tittiranonda 1999). Five studies compared various ergonomic interventions versus each other (Ketola 2002; Marangoni 2010; Rempel 1999; Rempel 2007; Ripat 2006), and in two studies, ergonomic changes at the workplace were an add-on treatment to exercises (Cheng 2007; Kamwendo 1991). One study compared both intensive ergonomic guidance and education in ergonomics (Ketola 2002) and an ergonomic programme versus an exercise group (Lundblad 1999).

3. Behavioural treatment

Nine studies evaluated a form of behavioural strategy, all in participants with non-specific neck and shoulder pain (Bru 1994; Dellve 2011; Ma 2011; Moore 1996; Sandsjö 2010; Spence 1989; Spence 1995; Viljanen 2003; Voerman 2007). One other study evaluated a multi-disciplinary treatment, including physical exercises and relaxation treatment, compared with usual care (Meijer 2006).

Four studies compared relaxation therapy, cognitive strategies or bio/myofeedback versus a waiting list control (Bru 1994; Moore 1996; Spence 1989; Spence 1995), two studies used a no-treatment control group (Dellve 2011; Ma 2011) and another two studies compared with usual care (Sandsjö 2010; Viljanen 2003). One study evaluated a behavioural strategy as an add-on treatment to ergonomic counselling (Voerman 2007).

4. Massage

Three studies evaluated massage as a part of the treatment compared with exercises in two studies (Ferguson 1976; Levoska 1993) and with additional treatment to spinal manipulative therapy in one study (Leboeuf 1987).

5. Electrical therapy

Two studies evaluated a splint. One study compared an energised splint versus placebo in participants with hand and wrist problems (Stralka 1998), and another study evaluated the use of a splint as add-on treatment to video education in participants with carpal tunnel syndrome (Werner 2005). One study evaluated low-frequency electrical stimulation versus placebo in participants with epicondylitis (Nourbakhsh 2008). 

6. Manual therapy

Two studies evaluated a form of manual therapy (Bang 2000; Ylinen 2007). One study compared manual therapy versus exercises (Ylinen 2007), and another study evaluated manual therapy as an additional treatment to exercise in participants with shoulder impingement syndrome (Bang 2000). 

7. Medication

One study compared amitriptyline, that is, pain medication, versus placebo in participants with non-specific neck and shoulder pain (Goldman 2010).

Excluded studies

Most of the excluded studies did not differentiate between participants with a musculoskeletal disorder and those without. They included healthy workers, as well as workers with neck pain, without separate reporting of results. This means that both prevention and treatment were evaluated in the studies (Figure 1).

Risk of bias in included studies

Results of the risk of bias assessment are presented in the Characteristics of included studies table and in Figure 2.

Figure 2.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Initially, there was agreement between both review authors of 83.5% (Kappa = 0.64), meaning a moderate level of agreement. The third review author made the final decision for 16 items.

Overall the amount of non-information (i.e. items that scored unclear risk of bias) varied between 11.4% (dropout rate described) and 97.7% (selective outcome reporting). The items that scored high on risk of bias were intention-to-treat analysis (52.3%), dropout rate described and adequate (27.3%), non-blinded participants (34.1%) and caregivers (34.1%) and outcome assessment (34.1%). See Figure 3.

Figure 3.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Based on our criterion of low risk of bias, "an overall sum score 50 per cent or more of the maximum score", nine studies could be categorised as having low risk of bias (Meijer 2006; Nourbakhsh 2008; Rempel 1999; Stralka 1998; Szcurko 2009; Tittiranonda 1999; van Eijsden 2008; Viljanen 2003; Ylinen 2003). We consider these studies to have low risk of bias in our GRADE analysis, meaning that they do not downgrade the level of evidence because of the design.

Allocation

Twenty-two studies provided no information on the randomisation procedure (Figure 2). We judged four studies to have an inadequate randomisation procedure (item 1) (Ferguson 1976; Marangoni 2010; Sandsjö 2010; Werner 2005).

We judged 11 studies to have described an adequate procedure for concealing allocation (item 2) (Bernaards 2006; Esmaeilzadeh 2012; Goldman 2010; Hagberg 2000; Meijer 2006; Sjögren 2005; Szcurko 2009; Tittiranonda 1999; van Eijsden 2008; Viljanen 2003; Ylinen 2003) and judged five studies to have done it inadequately (Marangoni 2010; Martimo 2010; Nourbakhsh 2008; Ripat 2006; Stralka 1998). The remaining 28 studies did not describe how or whether they concealed their randomisation procedure.

Blinding

Eight studies described blinding of outcome assessment (Bang 2000; Ferguson 1976; Goldman 2010; Nourbakhsh 2008; Rempel 1999; Stralka 1998; Tittiranonda 1999; Viljanen 2003), in six studies participants were blinded (Goldman 2010; Nourbakhsh 2008; Rempel 1999; Stralka 1998; Tittiranonda 1999; Viljanen 2003) and in four studies the care provider was blinded (Goldman 2010; Rempel 1999; Stralka 1998; Tittiranonda 1999).

Incomplete outcome data

We judged 23 (52.3%) of the included studies to have a high risk of bias, as they clearly did not perform an intention-to-treat (ITT) analysis. Only 14 (32.5%) of the included studies performed an ITT analysis or presented complete data. The dropout rate was described and acceptable, that is, was less than 20%, in 26 (59.1%) of the studies.

Selective reporting

We could retrieve a study protocol for only one study (van Eijsden 2008). Hence this was the only study that we scored as having a low risk of bias due to selective outcome presentation. We judged all remaining studies to have an unclear risk of bias due to selective reporting.

Other potential sources of bias

We assessed four other sources of bias: baseline imbalance, whether co-interventions were avoided or similar, whether compliance was acceptable and whether timing was comparable. We judged 29 studies (65.9%) to have a low risk of bias as the result of no baseline imbalance, although in nine studies, baseline similarity was unclear.

Only five studies reported that co-interventions were avoided or similar (Ma 2011; Nourbakhsh 2008; Sandsjö 2010; Viljanen 2003; Ylinen 2003), and two were considered to have a high risk of bias concerning co-interventions (Andersen 2008b; Szcurko 2009). Seventeen studies reported acceptable compliance rates. Thirty-seven studies reported comparable timing of outcome assessment. Only one study (Werner 2005) clearly reported that the 12-month outcome assessment varied between seven and 15 months.

Effects of interventions

In total, 29 studies presented dichotomous data or point estimates and measures of variability for their primary outcomes. According to our judgement, studies overall had low power and high risk of bias. Therefore the quality of evidence varied between low and very low.

Pain

Exercise versus no treatment controls

Ten studies presented short-term results on pain. Overall we found that exercise did not reduce pain when compared with no treatment or discussion controls, or when given as additional treatment (Analysis 1.1). Five studies (Dellve 2011; Ma 2011; Sjögren 2005; Takala 1994; Viljanen 2003) compared exercise versus no treatment and found no difference in pain (SMD -0.52, 95% CI -1.08 to 0.03). All studies concerned participants with chronic non-specific complaints.

In a sensitivity analysis, we omitted all studies that we judged to have a high risk of bias (Dellve 2011; Ma 2011; Sjögren 2005; Takala 1994) and still found no differences between groups. According to four studies (Andersen 2008a; Andersen 2008b; Szcurko 2009; Waling 2000), exercise did not reduce pain any more than participating in a discussion group.

In a subgroup analysis of participants with specific complaints, one study (Szcurko 2009), which was the only study judged to have a low risk of bias, showed that participation in a discussion control group reduced pain more than exercise (mean difference (MD) 0.74, 95% CI 0.30 to 1.18). We found no differences in pain in the subgroup of chronic non-specific complaints.

Two studies (Bernaards 2006; Omer 2003) compared exercise as an addition to work style education versus education alone and found conflicting results: One study (Omer 2003) reported significant benefit associated with additional exercises, and the other study (Bernaards 2006) found no differences.

Overall, this comparison suffered from major heterogeneity (I2 varied between 55% and 97%). This could be explained by clinical differences in the intervention or the population, although almost all participants had chronic non-specific complaints, or by the fact that most studies in this comparison were judged to have a high risk of bias.

We conclude that for pain, very low-quality evidence (downgraded by limitations of design, imprecision and inconsistency) that exercises lead to similar levels of pain as no treatment at both short-term and long-term follow-up.

We also assessed publication bias for this comparison. The funnel plot (Figure 4) shows that small studies with negative effects are missing in the right lower quadrant, which indicates possible publication bias.

Figure 4.

Funnel plot of comparison: 1 Exercise versus no treatment controls, outcome: 1.1 Pain intensity, short term.

Exercise versus active treatment controls

According to four studies (Andersen 2008b; van Eijsden 2008; Vasseljen 1995; Waling 2000), overall regular exercises reduce pain in the short term more than specific exercises (SMD 0.45, 95% CI 0.14 to 0.75) (Analysis 2.1). All four studies included participants with chronic non-specific complaints.

In a sensitivity analysis from which we omitted the studies we judged to have a high risk of bias (Andersen 2008b; Vasseljen 1995; Waling 2000), results showed that regular exercises reduce pain more than specific exercises. According to two studies (van Eijsden 2008; Ylinen 2003), both with a low risk of bias, regular exercise leads to less pain in the short term than specific exercises (MD 0.80, 95% CI 0.09 to 1.51) (van Eijsden 2008) but not in the long term (pooled SMD 0.10, 95% CI -0.18 to 0.38). One study (Ylinen 2007) compared exercises versus manual therapy and found no difference in short-term pain (MD 0.00, 95% CI -9.63 to 9.63).

We conclude that for pain, low-quality evidence (downgraded by limitations of design and imprecision) suggests a benefit of regular exercises over specific exercises at short-term follow-up only. 

Ergonomic intervention versus no treatment controls

Five studies (Bernaards 2006; Cheng 2007; Ketola 2002; Martimo 2010; Tittiranonda 1999) compared ergonomic interventions versus placebo or no treatment or as an additional treatment for short-term pain (Analysis 3.1). One study (Tittiranonda 1999) evaluated various keyboards versus placebo in participants with carpal tunnel syndrome (CTS) and found a reduction in pain with the placebo keyboard (SMD 0.53, 95% CI 0.01 to 1.04). Three studies (Bernaards 2006; Ketola 2002; Martimo 2010) compared ergonomic interventions versus no treatment in participants with non-specific complaints and found no differences between the groups (SMD -0.07, 95% CI -0.36 to 0.22), although this analysis suffered from moderate heterogeneity (I2 = 49%). One study (Cheng 2007) compared ergonomic interventions on their own and when given in addition to exercises in participants with rotator cuff pain and found that the combination reduced pain more than ergonomic interventions on their own (SMD -0.60, 95% CI -1.01 to -0.18).

Subgroup analysis of the study by Ketola 2002 involving subacute participants only showed pain to decrease more with ergonomic interventions than with no treatment (SMD -0.52, 95% CI -0.99 to -0.05), while the two studies with chronic complaints (Bernaards 2006; Martimo 2010) reported no difference (SMD 0.10, 95% CI -0.09 to 0.29).

Four studies (Bernaards 2006; Esmaeilzadeh 2012; Ketola 2002; Lundblad 1999) compared ergonomic interventions versus no treatment in reducing pain over the long term and found a significant difference in favour of the ergonomic intervention (SMD -0.76, 95% CI -1.35 to -0.16). However, this analysis (Analysis 3.2) exhibited large heterogeneity (I2 = 84%).

We conclude that very low-quality evidence (downgraded by limitations of design, imprecision and inconsistency) indicates that ergonomic interventions lead to similar results as no treatment in reducing pain in the short term. For the long term, very low-quality evidence (downgraded by limitations of design, imprecision and inconsistency) shows a small benefit of ergonomic interventions when compared with no treatment.

In subgroups of subacute participants and in the subgroup of participants with specific complaints, we found a very low level of evidence (downgraded by limitations of design, imprecision and inconsistency) for ergonomic interventions reducing pain more than placebo, or when given as additional interventions to exercises.

Ergonomic intervention versus active treatment controls

One study (Rempel 1999) evaluated an experimental keyboard versus the standard one for reducing pain in the short term in participants with CTS. Another study (Tittiranonda 1999) evaluated three different keyboards versus placebo, also for reducing pain in the short term. One study (Ketola 2002) evaluated both short-term and long-term pain reduction with intensive versus standard ergonomic training in participants with recent non-specific complaints, and another study evaluated reduction in pain over the long term due to ergonomic interventions versus regular exercises in participants with chronic non-specific complaints (Lundblad 1999). Overall, we found no differences in pain between the groups in the short term (SMD 0.11, 95% CI -0.24 to 0.46) (Analysis 4.1) or over the long term (SMD -0.02, 95% CI -1.22 to 1.18) (Analysis 4.2).

We found very low-quality evidence overall (downgraded by limitations of design, imprecision and inconsistency) showing that various ergonomic interventions lead to similar pain levels in the short term and over the long term.

Behavioural intervention versus no treatment controls

Four studies (Dellve 2011; Ma 2011; Sandsjö 2010; Viljanen 2003) evaluated a behavioural intervention versus no treatment and found no difference in pain (SMD -0.67, 95% CI -1.49 to 0.16) (Analysis 5.1; Analysis 5.2). Three studies (Moore 1996; Spence 1989; Spence 1995) compared a behavioural intervention versus a waiting list control group, all including participants with chronic non-specific complaints, and found that the intervention reduced pain in the short term (SMD -0.74, 95% CI -1.32 to -0.15).

In a sensitivity analysis we omitted the studies we judged to have a high or unclear risk of bias and only one remained (Viljanen 2003). This study reported no difference in pain intensity in the short term (SMD 0.08, 95% CI -0.16 to 0.33) or over the long term (SMD -0.04, 95% CI -0.28 to 0.20).

Meta-analyses of behavioural interventions versus no treatment or a waiting list control suffered from moderate to large heterogeneity (I2 varied between 49% and 97%). We could not explain this by differences in participants, as all studies concerned participants with chronic non-specific complaints. The only explanation left is low methodological rigour as we deemed that all but one of the studies (Viljanen 2003) to have a high risk of bias.

We conclude that very low-quality evidence (downgraded by limitations of design, imprecision and inconsistency) indicates that behavioural intervention leads to similar pain levels at short term and over the long term as no treatment. 

Behavioural intervention versus active treatment controls

Two studies (Spence 1989; Spence 1995) evaluated various behavioural interventions versus regular treatment and found no differences between the groups in terms of pain (SMD -0.23, 95% CI -0.73 to 0.27) (Analysis 6.1; Analysis 6.4). We judged all three studies to have a high risk of bias, and all included participants with chronic non-specific complaints. Three studies (Dellve 2011; Ma 2011; Viljanen 2003) evaluated behavioural interventions versus exercises and found no differences in pain in the short term (SMD -0.02, 95% CI -0.24 to 0.19). Sensitivity analysis on the one study with low risk of bias (Viljanen 2003) also found no differences between groups in the short term (SMD 0.00, 95% CI -0.24 to 0.24) or over the long term (SMD 0.08, 95% CI -0.16 to 0.32).

We conclude that very low-quality evidence (downgraded by limitations of design, imprecision and inconsistency) indicates that various behavioural interventions lead to similar results in reducing pain in the short term and over the long term.

Disability

Exercise versus no treatment controls

Three studies (Ma 2011; Lundblad 1999; Viljanen 2003) evaluated exercise versus no treatment. When we pooled study results, we found no differences in disability between study groups at short-term (SMD -0.77, 95% CI -2.50 to 0.97) or long-term follow-up (SMD 0.14, 95% CI -0.08 to 0.34; Analysis 1.3; Analysis 1.4; Analysis 1.5).

Exercise was compared with discussion in two studies (Szcurko 2009; Ylinen 2003). Szcurko 2009 found that discussion relieved disability better than exercise in the short term (SMD 0.51, 95% CI 0.08 to 0.94), whereas exercise produced better results in the long term in the study by Ylinen 2003 (SMD -0.55, 95% CI -0.87 to -0.23; Analysis 1.3; Analysis 1.5). Heterogeneity varied between 0 and 93%, and we could explain this by risk of bias or subgroups.

One study (Bernaards 2006), which we judged to have a high risk of bias, compared exercises only with exercises in addition to work style education. This study found no differences in disability (risk ratio (RR) 1.00, 95% CI 0.82 to 1.21; Analysis 1.4).

We conclude that very low-quality evidence (downgraded by limitations of design, imprecision and inconsistency) indicates that exercises lead to similar levels of disability as no treatment both in the short term and over the long term.

Exercise versus active treatment controls

One study each compared the effects of different types of exercise (van Eijsden 2008) and exercise with manual therapy (Ylinen 2007) on disability in the short term. Neither study found a significant difference in disability in the short term: van Eijsden 2008—MD 2.00, 95% CI -2.18 to 6.18; Ylinen 2007—MD 1.00, 95% CI -2.20 to 4.20; Analysis 2.3.

Two studies compared the effects of different types of exercise (van Eijsden 2008; Ylinen 2003) on disability in the long term. No difference in disability was noted between exercises and other exercises in the long term in these two studies (SMD 0.11, 95% CI -0.17 to 0.38; Analysis 2.4).

We conclude that very low-quality evidence (downgraded by limitations of design, imprecision and inconsistency) shows that exercises lead to similar levels of disability as other exercises or manual therapy both in the short term and over the long term.

Ergonomic intervention versus no treatment controls

One study (Tittiranonda 1999) evaluated various keyboards versus placebo in participants with carpal tunnel syndrome (CTS) and found that participants using the placebo keyboard felt less disabled (MD 0.93, 95% CI 0.28 to 1.57; Analysis 3.3).

Three studies (Bernaards 2006; Esmaeilzadeh 2012; Lundblad 1999) evaluated ergonomic interventions in chronic non-specific participants versus no treatment and found no differences in disability at long-term follow-up (RR 0.98, 95% CI 0.85 to 1.14; SMD -0.33, 95% CI -0.71 to 0.06; Analysis 3.4; Analysis 3.5).

One study (Cheng 2007) found that ergonomic interventions and exercise decreased disability more than exercise alone in participants with rotator cuff pain (MD -9.00, 95% CI -15.02 to -2.98).

We conclude that very low-quality evidence (downgraded by limitations of design, imprecision and inconsistency) shows that ergonomic interventions lead to similar levels of disability as no treatment both in the short term and over the long term.

Behavioural intervention versus no treatment controls

Two studies (Ma 2011Viljanen 2003) compared behavioural interventions versus no treatment in reducing disability in the short term. Pooling their results led to such a large degree of heterogeneity (I2 = 96%) that meta-analysis was not meaningful (Analysis 5.3). Another two studies (Spence 1989; Spence 1995) evaluated five different behavioural interventions versus a waiting list control group. When pooled together, the behavioural interventions appeared to decrease disability in the short term (SMD -0.58, 95% CI -1.05 to -0.12; Analysis 5.3).

We conclude that very low-quality evidence (downgraded by limitations of design, imprecision and inconsistency) shows that in the short term behavioural interventions lead to similar levels of disability as no treatment. Furthermore, we conclude that very-low quality evidence (downgraded by limitations of design, imprecision and inconsistency) suggests that behavioural interventions decrease disability in the short term more than being in a waiting list control group.

Behavioural intervention versus active treatment controls

Three studies (Ma 2011; Dellve 2011; Viljanen 2003) compared behavioural interventions and exercises in reducing disability or, conversely, in improving work ability in the short term. There was no difference between the groups in disability (SMD -0.57, 95% CI -1.66 to 0.52; Analysis 6.2) or in work ability (SMD -0.15, 95% CI -0.84 to 0.54; Analysis 6.3). One study (Viljanen 2003) also measured long-term effects on disability and work ability and found no differences between behavioural interventions and exercises: disability—MD 0.00, 95% CI -3.65 to 3.65; Analysis 6.5; work ability—MD 0.20, 95% CI -0.09 to 0.49; Analysis 6.6.  

We conclude that very low-quality evidence (downgraded by limitations of design, imprecision and inconsistency) shows that in the short term behavioural interventions lead to similar levels of disability as exercises.

Recovery

Exercise versus no treatment controls

Three studies, all with participants with chronic non-specific complaints (Bernaards 2006; Heuvel 2003; Waling 2000), compared exercise with no treatment (Waling 2000) versus exercise additional to work style education (Bernaards 2006) and with computer breaks (Heuvel 2003) on short-term recovery. We pooled the results of three different exercise interventions compared with no treatment in Waling 2000 and found that exercise improves recovery (RR 0.53, 95% CI 0.37 to 0.78; Analysis 1.6). In contrast, exercises conducted as additional treatment did not seem to improve recovery more than regular exercise in the two studies by Bernaards 2006 and Heuvel 2003 (RR 1.25, 95% CI 0.18 to 1.93; Analysis 1.7). We judged all three studies to have a high risk of bias. Ferguson 1976 did not find a significant effect on recovery, but the study could not be included in the meta-analysis.

We conclude that very low-quality evidence (downgraded by limitations of design, imprecision and inconsistency) suggests that in the short term exercises improve recovery more than no treatment, but there is no additional benefit on recovery if exercises are administered together with computer breaks or work style education.

Exercise versus active treatment controls

Three studies (van Eijsden 2008; Vasseljen 1995; Waling 2000) compared the effects of different types of exercise on recovery in the short term. One study (Levoska 1993) compared the recovery-improving effects of exercise and massage, and another study (Ylinen 2007) compared exercise with manual therapy. There were no differences in effectiveness between different forms of exercise (RR 0.86, 95% CI 0.43 to 1.71; Analysis 2.5) or between exercises and massage (RR 0.78, 95% CI 0.55 to 1.11). Only manual therapy appeared to improve recovery more than exercises in one study (Ylinen 2007), which we judged to have a high risk of bias (RR 1.88, 95% CI 1.29 to 2.74; Analysis 2.5).

We conclude that very low-quality evidence (downgraded by limitations of design, imprecision and inconsistency) shows no differences between different forms of exercise or between exercise and massage in recovery in the short term. Manual therapy may be more effective than exercise based on only one study with a high risk of bias.

Ergonomic intervention versus no treatment controls

One study (Tittiranonda 1999) compared the effects of different keyboards on recovery in the short term in participants with carpal tunnel syndrome (CTS). Recovery was better with participants who used a placebo keyboard (RR 1.89, 95% CI 0.85 to 4.21; Analysis 3.7). Another study (Bernaards 2006) compared an ergonomic intervention with no treatment in participants with chronic non-specific complaints. Participants recovered better in the ergonomic intervention group when measured at short-term (RR 0.88, 95% CI 0.78 to 0.99; Analysis 3.7) and at long-term follow-up (RR 0.90, 95% CI 0.81 to 1.00; Analysis 3.8).

We conclude that very low-quality evidence (downgraded by limitations of design, imprecision and inconsistency) shows that both in the short term and over the long term ergonomic interventions improve recovery more than no treatment.

Sick leave

Exercise versus no treatment controls

Two studies (Lundblad 1999; Viljanen 2003) evaluated the effects of exercise versus no treatment on sick leave in the long term. We found no differences between groups (SMD -0.03, 95% CI -0.26 to 0.19; Analysis 1.8). We judged one of the two studies (Viljanen 2003) to have a low risk of bias.

We conclude that moderate-quality evidence (downgraded by imprecision) shows no difference between exercise and no treatment on sick leave over the long term. 

Ergonomic intervention versus no treatment controls

Two studies (Heuvel 2003; Martimo 2010) compared the effects of ergonomic interventions and no treatment on sick leave at short term and found no difference (RR 0.49, 95% CI 0.32 to 0.76; Analysis 3.9).

We conclude that low-quality evidence (downgraded by limitations of design and imprecision) shows that in the short term ergonomic interventions lead to similar effects on sick leave as no treatment.

Behavioural intervention versus no treatment controls

Three studies (Dellve 2011; Sandsjö 2010; Viljanen 2003) compared the effects of behavioural interventions and no treatment on sick leave at short term. When we pooled the results of Dellve 2011 and Viljanen 2003, we found no differences (SMD 0.02, 95% CI -0.21 to 0.24; Analysis 5.5), nor did Sandsjö 2010 (RR 1.05, 95% CI 0.79 to 1.41; Analysis 5.6).

We conclude that moderate-quality evidence (downgraded by imprecision) shows that in the short term behavioural interventions lead to similar effects on sick leave as no treatment.

Nine of the remaining included studies (Abasolo 2005; Andersen 2008a; Bru 1994; Hagberg 2000; Kamwendo 1991; Marangoni 2010; Rempel 2007; Ripat 2006; Stralka 1998) did not provide data and therefore are not included in the comparisons above.

Other interventions

Behavioural interventions

One other study (Meijer 2006) evaluated a multi-disciplinary treatment including physical exercises and relaxation treatment compared with usual care and found a statistically non-significant benefit in favour of the multi-disciplinary treatment (SMD -2.2, 95% CI -3.08 to 1.32) for pain at short term.

Massage

One study (Levoska 1993) compared the recovery-improving effects of exercise and massage and found no differences in effectiveness between exercise and massage (RR 0.78, 95% CI 0.55 to 1.11; Analysis 2.5). Another study (Leboeuf 1987) evaluated manual therapy compared with manual therapy plus massage and found the combination reducing symptom severity more than manual therapy alone (RD 0.4, 95% CI 0.11 to 0.69).

Electrical therapy

One study evaluated the use of a splint as add-on treatment to video education in participants with carpal tunnel syndrome (Werner 2005) and found no benefit of the additional splint for symptom severity score at short term (SMD -0,31, 95% CI -0.62 to 0). Another study evaluated low-frequency electrical stimulation versus placebo in participants with epicondylitis (Nourbakhsh 2008) and found significant short-term pain relief associated with the electrical stimulation (SMD -1.27, 95% CI -2,32 to -0.23). 

Manual therapy

One study (Bang 2000) compared exercise versus exercise and manual therapy in participants with an impingement syndrome (shoulder pain). Investigators found significant pain reduction and disability reduction (SMD 0.8, 95% CI 0.2 to 1.4 for pain; SMD 0.8, 95% CI 0.2 to 11.3 for disability) for exercise plus manual therapy at short term. Another study (Ylinen 2007) compared exercise versus manual therapy and found no difference (SMD 0, 95% CI -0.35 to 0.35) in pain at short-term follow-up.

Medication

One study compared amitriptyline, that is, pain medication, versus placebo in participants with non-specific neck and shoulder pain (Goldman 2010) and found no differences between the two groups in terms of pain at short-term follow-up (SMD 0.06, 95% CI -0.31 to 0.42).

Discussion

Summary of main results

In total, we included 44 studies and 6,580 participants in this review. The studies had an overall high risk of bias. We judged only nine studies to have a low risk of bias.

Overall we found no clear benefit of exercise over no treatment or discussion controls or as additional treatment for pain, disability or sick leave. In participants with chronic non-specific complaints, regular exercises relieve pain more in the short-term when compared with specific exercises. We found no differences in disability or recovery.

The placebo keyboard seems to be more effective than experimental keyboards in reducing pain and disability and improving recovery. Ergonomic interventions reduced pain at long term, but not at short term. Also, ergonomic interventions seem to reduce pain but not disability in subacute participants and in participants with rotator cuff syndrome, when compared with no treatment. None of the ergonomic interventions provided greater benefit compared with another, or compared with placebo, on any of the outcome measures.

Overall, behavioural interventions did not show benefit when compared with no treatment, waiting list controls or other behavioural interventions, except for short-term pain when compared with waiting list controls. 

Overall completeness and applicability of evidence

The aim of this review was to summarise existing evidence concerning the efficacy of frequently performed interventions in work-related neck, arm or shoulder musculoskeletal disorders (CANS). We applied a broad search strategy aimed at finding all trials that included people suffering from work-related CANS. No specific search strategy can be used to select participants with work-related complaints, mostly because defining which disorders are work-related appears to be rather difficult. Therefore, two independent review authors checked a large number of references.

Quality of the evidence

We considered only nine of the included studies to have low risk of bias. Most studies (n = 22) lacked information on the randomisation procedure and the analysis. Furthermore, blinding was difficult in these pragmatic studies.

Heterogeneity is another problem. We included several main groups of interventions, of which exercise was the largest. Each of these intervention groups consisted of a large variety of interventions and outcome measures. Although we were able to include 44 trials, it is disappointing that we could present so little evidence on the effects of interventions for CANS. In part, this is a result of the many different interventions available and the presentation of both short-term and long-term results, and it also reflects the overall high risk of bias. We found hardly any clinical heterogeneity in the study populations selected for inclusion in the original trials. Most studies included participants with chronic non-specific neck or shoulder complaints. CANS is mostly divided into specific and non-specific disorders, and the latter appear to constitute the larger group. This review contributes especially to the body of knowledge on non-specific work-related disorders.

Furthermore, 19 studies had small sample sizes (fewer than 25 participants in the smallest treatment arm). Although sample size does not contribute to the assessment of study risk of bias, it does show that most studies included in this review were underpowered to provide clear answers. 

Potential biases in the review process

One of the possible biases of this review is selection bias. The most important difficulties include lack of a definition of work-relatedness, the wide variety of interventions used to treat people with possible CANS and the overall poor methodological quality. There is no clear definition of the work-relatedness of complaints. In the included trials, we noticed that defining the study population in this regard appeared to be difficult and subjective. Therefore, we might have missed studies that could have been included in this review.

The inconsistency in study results can also be due to our categorisation of studies into broad intervention categories. Even though we did our best to make the comparisons as homogeneous as possible, considerable variation is evident in intervention intensity and compliance. For example, Takala 1994 provided low-intensity exercises and Szcurko 2009 high-intensity training. However, a few studies (Ma 2011; Omer 2003) were clear outliers with exceptionally beneficial results that we could not explain by intervention intensity or compliance. The same argument holds for the category of ergonomic studies, which included a variety of interventions. Here too, we could find no proper explanation for the variable results. Heterogeneity could also have been the result of combining studies on all parts of the upper limb, neck and shoulder, but this did not explain the most pronounced differences in results.

Agreements and disagreements with other studies or reviews

The relevance of this systematic review in contributing to the body of knowledge concerning the efficacy of interventions in non-specific work-related CANS lies mainly in the fact that it points out a clear lack of evidence regarding the effectiveness of the interventions most often prescribed.

Although this version of the review includes 21 additional trials in comparison with the previous version (Verhagen 2006), the main conclusion of not finding clear evidence for the effectiveness of any treatment still holds. Some results of this updated review are slightly different compared with findings of the previous review. Our conclusion is in line with that of a large systematic review on the benefit of exercise for people with neck pain (Smidt 2005).

Authors' conclusions

Implications for practice

This review concludes that low- to very low-quality evidence indicates that exercise does not provide a clear benefit over no treatment or discussion controls or as additional treatment for pain, disability or sick leave for people with work-related complaints of the arm, neck or shoulder. Specific exercises are less effective than regular ones. We also found low-quality evidence suggesting that ergonomic interventions in the workplace and behavioural interventions lead to similar results to those obtained with no or alternative interventions. 

Implications for research

In this review, we evaluated a working population with a complaint. This complaint is not necessarily work-related. We need an agreed upon definition of what can be considered a work-related disorder. When consensus is reached, a clear participant population can be selected for future studies.

Future research should examine clear and well-defined interventions and especially should compare the intervention versus a no treatment control group.

Larger and adequately powered trials are needed that will focus on appropriate allocation concealment; blinding, if possible, of participant and therapist, or keeping them naive; and adequate data presentation and analysis.

Acknowledgements

We thank Helen Handoll, Co-ordinating Editor of the Bone, Joint and Muscle Trauma Review Group, and Jos Verbeek, Co-ordinating Editor of the Cochrane Occupational Safety and Health Review Group, for their valuable comments and advice. We also thank Lesley Gillespie for her help with the search strategies, and Joanne Elliott, Lindsey Elstub and Amy Kavanagh for their help and comments about the protocol. We thank Jani Ruotsalainen, Managing Editor of the Cochrane Occupational Safety and Health Review Group, for his extensive comments on and editing of the review text. Finally, we thank Dolores Matthews for copy editing the text.

Data and analyses

Download statistical data

Comparison 1. Exercise versus no treatment controls
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Pain intensity, short term10 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
1.1 Versus no intervention5431Std. Mean Difference (IV, Random, 95% CI)-0.52 [-1.08, 0.03]
1.2 Versus discussion/counselling3235Std. Mean Difference (IV, Random, 95% CI)-0.25 [-0.87, 0.37]
1.3 Exercises plus additional treatment versus additional only2309Std. Mean Difference (IV, Random, 95% CI)-1.02 [-2.99, 0.95]
2 Pain intensity, long term4 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
2.1 Versus no treatment2308Std. Mean Difference (IV, Random, 95% CI)-0.31 [-0.96, 0.33]
2.2 Versus discussion/counselling2305Std. Mean Difference (IV, Random, 95% CI)-0.07 [-0.68, 0.54]
3 Disability, short term3 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
3.1 Versus no treatment2295Std. Mean Difference (IV, Random, 95% CI)-0.77 [-2.50, 0.97]
3.2 Versus discussion/counselling185Std. Mean Difference (IV, Random, 95% CI)0.51 [0.08, 0.94]
4 Disability, short term1 Risk Ratio (M-H, Random, 95% CI)Totals not selected
4.1 Exercises plus additional treatment versus additional only1 Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
5 Disability, long term3 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
5.1 Versus no treatment2308Std. Mean Difference (IV, Random, 95% CI)0.14 [-0.08, 0.37]
5.2 Versus discussion/counselling1179Std. Mean Difference (IV, Random, 95% CI)-0.55 [-0.87, -0.23]
6 Improvement, short term1 Risk Ratio (M-H, Random, 95% CI)Subtotals only
6.1 Versus discussion/counselling1126Risk Ratio (M-H, Random, 95% CI)0.53 [0.37, 0.78]
7 Improvement, short term2 Risk Ratio (M-H, Random, 95% CI)Subtotals only
7.1 Exercises plus additional treatment versus additional only2396Risk Ratio (M-H, Random, 95% CI)1.25 [0.81, 1.93]
8 Sick leave, long term2 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
8.1 Versus no treatment2308Std. Mean Difference (IV, Random, 95% CI)-0.03 [-0.26, 0.19]
Analysis 1.1.

Comparison 1 Exercise versus no treatment controls, Outcome 1 Pain intensity, short term.

Analysis 1.2.

Comparison 1 Exercise versus no treatment controls, Outcome 2 Pain intensity, long term.

Analysis 1.3.

Comparison 1 Exercise versus no treatment controls, Outcome 3 Disability, short term.

Analysis 1.4.

Comparison 1 Exercise versus no treatment controls, Outcome 4 Disability, short term.

Analysis 1.5.

Comparison 1 Exercise versus no treatment controls, Outcome 5 Disability, long term.

Analysis 1.6.

Comparison 1 Exercise versus no treatment controls, Outcome 6 Improvement, short term.

Analysis 1.7.

Comparison 1 Exercise versus no treatment controls, Outcome 7 Improvement, short term.

Analysis 1.8.

Comparison 1 Exercise versus no treatment controls, Outcome 8 Sick leave, long term.

Comparison 2. Exercise versus active treatment controls
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Pain intensity, short term5 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
1.1 Specific exercise versus regular exercises4208Std. Mean Difference (IV, Random, 95% CI)0.45 [0.14, 0.75]
1.2 Exercise versus manual therapy1123Std. Mean Difference (IV, Random, 95% CI)0.0 [-0.35, 0.35]
2 Pain intensity, long term2 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
2.1 Specific versus regular exercise2201Std. Mean Difference (IV, Random, 95% CI)0.10 [-0.18, 0.38]
3 Disability, short term2 Mean Difference (IV, Random, 95% CI)Totals not selected
3.1 Specific versus regular exercise1 Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
3.2 Versus manual therapy1 Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
4 Disability, long term2201Std. Mean Difference (IV, Random, 95% CI)0.11 [-0.17, 0.38]
4.1 Specific versus regular exercise2201Std. Mean Difference (IV, Random, 95% CI)0.11 [-0.17, 0.38]
5 Improvement, short term5 Risk Ratio (M-H, Random, 95% CI)Subtotals only
5.1 Specific versus regular exercise3205Risk Ratio (M-H, Random, 95% CI)0.86 [0.43, 1.71]
5.2 Versus massage147Risk Ratio (M-H, Random, 95% CI)0.78 [0.55, 1.11]
5.3 Versus manual therapy1125Risk Ratio (M-H, Random, 95% CI)1.88 [1.29, 2.74]
Analysis 2.1.

Comparison 2 Exercise versus active treatment controls, Outcome 1 Pain intensity, short term.

Analysis 2.2.

Comparison 2 Exercise versus active treatment controls, Outcome 2 Pain intensity, long term.

Analysis 2.3.

Comparison 2 Exercise versus active treatment controls, Outcome 3 Disability, short term.

Analysis 2.4.

Comparison 2 Exercise versus active treatment controls, Outcome 4 Disability, long term.

Analysis 2.5.

Comparison 2 Exercise versus active treatment controls, Outcome 5 Improvement, short term.

Comparison 3. Ergonomic intervention versus no treatment controls
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Pain intensity, short term5 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
1.1 Versus placebo180Std. Mean Difference (IV, Random, 95% CI)0.53 [0.01, 1.04]
1.2 Versus no treatment3506Std. Mean Difference (IV, Random, 95% CI)-0.07 [-0.36, 0.22]
1.3 Ergonomic intervention plus additional treatment versus additional only194Std. Mean Difference (IV, Random, 95% CI)-0.60 [-1.01, -0.18]
2 Pain intensity, long term4 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
2.1 Versus no treatment4402Std. Mean Difference (IV, Random, 95% CI)-0.76 [-1.35, -0.16]
3 Disability, short term2 Mean Difference (IV, Random, 95% CI)Subtotals only
3.1 Versus placebo180Mean Difference (IV, Random, 95% CI)0.93 [0.28, 1.57]
3.2 Ergonomic intervention plus additional treatment versus additional only194Mean Difference (IV, Random, 95% CI)-9.0 [-15.02, -2.98]
4 Disability, short term1 Risk Ratio (M-H, Random, 95% CI)Totals not selected
4.1 Versus no treatment1 Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
5 Disability, long term2107Std. Mean Difference (IV, Random, 95% CI)-0.33 [-0.71, 0.06]
5.1 Versus no treatment2107Std. Mean Difference (IV, Random, 95% CI)-0.33 [-0.71, 0.06]
6 Disability, long term1 Risk Ratio (M-H, Random, 95% CI)Totals not selected
6.1 Versus no treatment1 Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
7 Improvement, short term2 Risk Ratio (M-H, Random, 95% CI)Subtotals only
7.1 Versus placebo180Risk Ratio (M-H, Random, 95% CI)1.89 [0.85, 4.21]
7.2 Versus no treatment1310Risk Ratio (M-H, Random, 95% CI)0.88 [0.78, 0.99]
8 Improvement, long term1 Risk Ratio (M-H, Random, 95% CI)Totals not selected
8.1 Versus no treatment1 Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
9 Sick leave, short term2 Risk Ratio (M-H, Random, 95% CI)Subtotals only
9.1 Versus no treatment2330Risk Ratio (M-H, Random, 95% CI)0.49 [0.32, 0.76]
Analysis 3.1.

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 1 Pain intensity, short term.

Analysis 3.2.

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 2 Pain intensity, long term.

Analysis 3.3.

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 3 Disability, short term.

Analysis 3.4.

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 4 Disability, short term.

Analysis 3.5.

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 5 Disability, long term.

Analysis 3.6.

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 6 Disability, long term.

Analysis 3.7.

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 7 Improvement, short term.

Analysis 3.8.

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 8 Improvement, long term.

Analysis 3.9.

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 9 Sick leave, short term.

Comparison 4. Ergonomic intervention versus active treatment controls
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Pain intensity, short term3 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
1.1 Versus ergonomic intervention3134Std. Mean Difference (IV, Random, 95% CI)0.11 [-0.24, 0.46]
2 Pain intensity, long term2 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
2.1 Versus ergonomic interventions289Std. Mean Difference (IV, Random, 95% CI)-0.02 [-1.22, 1.18]
Analysis 4.1.

Comparison 4 Ergonomic intervention versus active treatment controls, Outcome 1 Pain intensity, short term.

Analysis 4.2.

Comparison 4 Ergonomic intervention versus active treatment controls, Outcome 2 Pain intensity, long term.

Comparison 5. Behavioural intervention versus no treatment controls
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Pain intensity, short term7 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
1.1 Versus no treatment4374Std. Mean Difference (IV, Random, 95% CI)-0.67 [-1.49, 0.16]
1.2 Versus waiting list controls3121Std. Mean Difference (IV, Random, 95% CI)-0.74 [-1.32, -0.15]
2 Pain, short term2 Risk Ratio (M-H, Random, 95% CI)Totals not selected
2.1 Versus no treatment1 Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
2.2 Behavioural intervention plus additional treatment versus additional only1 Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
3 Disability, short term4 Std. Mean Difference (IV, Random, 95% CI)Totals not selected
3.1 Versus no treatment2 Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
3.2 Versus waiting list controls2 Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
4 Disability, short term2 Risk Ratio (M-H, Random, 95% CI)Totals not selected
4.1 Versus no treatment1 Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
4.2 Behavioural intervention plus additional treatment versus additional only1 Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
5 Sick leave, short term2 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
5.1 Versus no treatment2298Std. Mean Difference (IV, Random, 95% CI)0.02 [-0.21, 0.24]
6 Sick leave, short term1 Risk Ratio (M-H, Random, 95% CI)Totals not selected
6.1 Versus no treatment1 Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]
7 Pain, long term1 Std. Mean Difference (IV, Random, 95% CI)Totals not selected
7.1 Versus no treatment1 Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
8 Disability, long term1 Mean Difference (IV, Random, 95% CI)Totals not selected
8.1 Versus no treatment1 Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
Analysis 5.1.

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 1 Pain intensity, short term.

Analysis 5.2.

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 2 Pain, short term.

Analysis 5.3.

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 3 Disability, short term.

Analysis 5.4.

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 4 Disability, short term.

Analysis 5.5.

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 5 Sick leave, short term.

Analysis 5.6.

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 6 Sick leave, short term.

Analysis 5.7.

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 7 Pain, long term.

Analysis 5.8.

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 8 Disability, long term.

Comparison 6. Behavioural intervention versus active treatment controls
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Pain intensity, short term5396Std. Mean Difference (IV, Random, 95% CI)-0.06 [-0.25, 0.14]
1.1 Versus behavioural interventions263Std. Mean Difference (IV, Random, 95% CI)-0.23 [-0.73, 0.27]
1.2 Versus exercises3333Std. Mean Difference (IV, Random, 95% CI)-0.02 [-0.24, 0.19]
2 Disability, short term2 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
2.1 Versus exercises2293Std. Mean Difference (IV, Random, 95% CI)-0.57 [-1.66, 0.52]
3 Work ability, short term2 Std. Mean Difference (IV, Random, 95% CI)Subtotals only
3.1 Versus exercises2303Std. Mean Difference (IV, Random, 95% CI)-0.15 [-0.84, 0.54]
4 Pain intensity, long term1 Std. Mean Difference (IV, Random, 95% CI)Totals not selected
4.1 Versus exercises1 Std. Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
5 Disability, long term1 Mean Difference (IV, Random, 95% CI)Totals not selected
5.1 Versus exercises1 Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
6 Work ability, long term1 Mean Difference (IV, Random, 95% CI)Totals not selected
6.1 Versus exercises1 Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]
Analysis 6.1.

Comparison 6 Behavioural intervention versus active treatment controls, Outcome 1 Pain intensity, short term.

Analysis 6.2.

Comparison 6 Behavioural intervention versus active treatment controls, Outcome 2 Disability, short term.

Analysis 6.3.

Comparison 6 Behavioural intervention versus active treatment controls, Outcome 3 Work ability, short term.

Analysis 6.4.

Comparison 6 Behavioural intervention versus active treatment controls, Outcome 4 Pain intensity, long term.

Analysis 6.5.

Comparison 6 Behavioural intervention versus active treatment controls, Outcome 5 Disability, long term.

Analysis 6.6.

Comparison 6 Behavioural intervention versus active treatment controls, Outcome 6 Work ability, long term.

Appendices

Appendix 1. Search strategies

The Cochrane Central Register of Controlled Trials (Wiley InterScience interface)

#1 MeSH descriptor Cumulative Trauma Disorders explode all trees
#2 MeSH descriptor Occupational Diseases, this term only
#3 MeSH descriptor Hand-Arm Vibration Syndrome, this term only
#4 MeSH descriptor Occupational Health, this term only
#5 ((occupational overuse or tension neck) NEXT syndrome):ti,ab
#6 (cumulative trauma*):ti,ab
#7 (work related):ti,ab
#8 (repetit* NEXT (strain or stress or industr* or motion or movement or trauma)):ti,ab
#9 (vibration NEXT (induced or related or syndrome*)):ti,ab
#10 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9)
#11 MeSH descriptor Neck Pain, this term only
#12 MeSH descriptor Shoulder Pain, this term only
#13 MeSH descriptor Hand Injuries explode all trees
#14 MeSH descriptor Wrist Injuries, this term only
#15 MeSH descriptor Musculoskeletal Diseases, this term only
#16 (neck* or shoulder* or arm* or upper limb* or upper extremit* or elbow* or forearm* or wrist* or hand* or finger*):ti,ab
#17 (carpal tunnel syndrome*):ti,ab
#18 (#11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17)
#19 (#10 AND #18) 

MEDLINE (Ovid interface)

1. exp Cumulative Trauma Disorders/
2. Occupational Diseases/ or Hand-Arm Vibration Syndrome/
3. Occupational Health/
4. ((occupational overuse or tension neck) adj syndrome).tw.
5. cumulative trauma$.tw.
6. work related.tw.
7. (repetit$ adj (strain or stress or industr$ or motion or movement or trauma)).tw.
8. (vibration adj (induced or related or syndrome$)).tw.
9. or/1-8
10. Neck Pain/ or Shoulder Pain/ or exp Hand Injuries/ or Wrist Injuries/
11. Musculoskeletal Diseases/
12. (neck$1 or shoulder$1 or arm$1 or upper limb$1 or upper extremit$ or elbow$1 or forearm$1 or wrist$1 or hand$1 or finger$1).tw.
13. Carpal Tunnel Syndrome/ or carpal tunnel syndrome$.tw.
14. or/10-13
15. and/9,14
16. Randomized Controlled Trial.pt.
17. Controlled Clinical Trial.pt.
18. randomized.ab.
19. placebo.ab.
20. Clinical Trials as Topic/
21. randomly.ab.
22. trial.ti.
23. or/16-22
24. exp animals/ not humans/
25. 23 not 24
26. and/15,25

EMBASE (Elsevier)

('Cumulative Trauma Disorder'/exp OR ('Occupational Disease':de OR 'Hand Arm Vibration Syndrome':de) OR 'Occupational Health':de OR (('occupational overuse' OR 'tension neck') NEAR/1 syndrome*):ti,ab,de OR (cumulative NEAR/1 trauma*):ti,ab,de OR 'work related':ti,ab,de OR (repetitive NEAR/1 (strain* OR stress* OR industr* OR motion* OR movement* OR trauma*)):ti,ab,de OR (vibration NEAR/1 (induced OR related OR syndrome*)):ti,ab,de) AND ('Neck Pain':de OR 'Shoulder Pain':de OR 'Hand Injury':de OR 'Wrist Injury':de OR 'Musculoskeletal Disease':de OR neck:ti,ab,de OR shoulder:ti,ab,de OR arm:ti,ab,de OR 'upper limb':ti,ab,de OR (upper NEAR/1 extremit*):ti,ab,de OR elbow*:ti,ab,de OR forearm:ti,ab,de OR wrist:ti,ab,de OR hand:ti,ab,de OR finger:ti,ab,de OR thumb:ti,ab,de OR necks:ti,ab,de OR shoulders:ti,ab,de OR arms:ti,ab,de OR 'upper limbs':ti,ab,de OR elbow*s:ti,ab,de OR forearms:ti,ab,de OR wrists:ti,ab,de OR hands:ti,ab,de OR fingers:ti,ab,de OR thumbs:ti,ab,de OR ('carpal tunnel' NEAR/1 syndrome*):ti,ab,de) AND ('randomized controlled trial'/de OR 'controlled clinical trial'/de OR random*:ti,ab OR placebo:ti,ab OR 'clinical trial'/de OR trial:ti) NOT ('animal'/exp NOT 'human'/exp)

Appendix 2. Criteria for a judgement of 'Yes' for the sources of risk of bias (see Table 1)

1. Was the method of randomisation adequate?

A random (unpredictable) assignment sequence. Examples of adequate methods are coin toss (for studies with two groups), rolling of a dice (for studies with two or more groups), drawing of balls of different colours, drawing of ballots with the study group labels from a dark bag, computer-generated random sequence, pre-ordered sealed envelopes, sequentially ordered vials, telephone call to a central office and pre-ordered list of treatment assignments.

Examples of inadequate methods include alternation, birth date, social insurance/security number, date on which they are invited to participate in the study and hospital registration number.

2. Was the treatment allocation concealed?

Assignment was generated by an independent person not responsible for determining the eligibility of patients. This person has no information about the persons included in the trial and has no influence on the assignment sequence or on the decision about eligibility of the patient.

Was knowledge of the allocated interventions adequately prevented during the study?

3. Was the participant blinded to the intervention?

This item should be scored 'Yes' if index and control groups were indistinguishable for the participants, or if the success of blinding was tested among the participants and it was successful.

4. Was the care provider blinded to the intervention?

This item should be scored 'Yes' if index and control groups were indistinguishable for the care providers, or if the success of blinding was tested among the care providers and it was successful.

5. Was the outcome assessor blinded to the intervention?

Adequacy of blinding should be assessed for the primary outcomes. This item should be scored 'Yes' if the success of blinding was tested among the outcome assessors and it was successful, or:

  • For participant-reported outcomes for which the participant is the outcome assessor (e.g. pain, disability): The blinding procedure is adequate for outcome assessors if participant blinding is scored 'Yes'.

  • For outcome criteria assessed during scheduled visit and that suppose a contact between participants and outcome assessors (e.g. clinical examination): The blinding procedure is adequate if participants are blinded, and if the treatment or adverse effects of the treatment cannot be noticed during clinical examination.

  • For outcome criteria that do not suppose a contact with participants (e.g. radiography, magnetic resonance imaging): The blinding procedure is adequate if the treatment or adverse effects of the treatment cannot be noticed when the main outcome is assessed.

  • For outcome criteria that are clinical or therapeutic events that will be determined by the interaction between participants and care providers (e.g. co-interventions, hospitalisation length, treatment failure), in which the care provider is the outcome assessor: The blinding procedure is adequate for outcome assessors if item 'E' is scored 'Yes'.

  • For outcome criteria that are assessed from data extracted from the medical forms: The blinding procedure is adequate if the treatment or adverse effects of the treatment cannot be noticed in the extracted data.

Were incomplete outcome data adequately addressed?

6. Was the dropout rate described and acceptable?

The number of participants included in the study but who did not complete the observation period or were not included in the analysis must be described and reasons given. If the percentage of withdrawals and dropouts does not exceed 20% for short-term follow-up and 30% for long-term follow-up and does not lead to substantial bias, a 'Yes' is scored. (N.B. These percentages are arbitrary, not supported by literature.)

7. Were all randomly assigned participants analysed in the group to which they were allocated?

All randomly assigned participants are reported/analysed in the group to which they were allocated by randomisation for the most important moments of effect measurement (minus missing values), irrespective of non-compliance and co-interventions.   

8. Are reports of the study free of suggestion of selective outcome reporting?

To receive a ‘Yes’, the review author determines whether all results from all prespecified outcomes have been adequately reported in the published report of the trial. This information is obtained by comparing the protocol and the report or, in the absence of the protocol, by assessing that the published report includes enough information to make this judgement.

Other sources of potential bias

9.  Were the groups similar at baseline regarding the most important prognostic indicators?

To receive a 'Yes', groups have to be similar at baseline regarding demographic factors, duration and severity of complaints, percentage of participants with neurological symptoms and value of main outcome measure(s).

10. Were co-interventions avoided or similar?

This item should be scored 'Yes' if there were no co-interventions, or if they were similar between index and control groups.

11. Was the compliance acceptable in all groups?

The review author determines whether compliance with the interventions is acceptable, based on reported intensity, duration, number and frequency of sessions for both the index intervention and control intervention(s). For example, physiotherapy treatment is usually administered over several sessions; therefore, it is necessary to assess how many sessions each participant attended. For single-session interventions (e.g. surgery), this item is irrelevant.

12. Was the timing of the outcome assessment similar in all groups?

Timing of outcome assessment should be identical for all intervention groups and for all important outcome assessments.

Note: These instructions are adapted from Furlan 2009 and the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

Contributions of authors

APV, SMAB-Z, AB, HCWdV and BWK are responsible for drafting the protocol. The search was performed by APV, SMS, HCWdV and BWK, and selection of the studies and data extraction by APV, SMS and SMAB-Z. APV and AB are responsible for the analysis. All authors are responsible for the interpretation of results and for the final draft of the review.

Declarations of interest

None known.

Sources of support

Internal sources

  • Erasmus Medical Centre, University, Netherlands.

    Salary and time to enable the review authors to perform the review

External sources

  • No sources of support supplied

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Abasolo 2005

MethodsRCT: method of randomisation unclear. Intervention: control ratios of 1:1 in district seven and 2:3 in districts four and nine
Participants

All workers from three health districts who began sick leave with a diagnosis of an MSD during the study period (1998 to 2001) were included

Sick leave episodes secondary to trauma, surgery or work accidents were excluded 

Interventions

Intervention: Rheumatologists acted as principal care providers in regular visits

Interventions included education, pharmacological and non-pharmacological treatments and timing of diagnostic tests in a stepwise manner. Participants were seen as often as necessary (n = 5,272)

Control: Standard care was that provided by primary care physicians, with weekly administrative duties plus basic diagnostic and therapeutic procedures without prespecified protocols (n = 7,805) 

OutcomesEfficacy was defined as the difference between the intervention group and the control group in the number of days on sick leave per temporary work disability episode 
NotesNo separate data for CANS
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskUnclear randomisation procedure
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?High riskNo participant blinding
Blinding of caregivers?High riskCaregivers not blinded
Blinding of outcome assessment (detection bias)
All outcomes
High riskNot told who compiled the outcome data
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Unclear riskNot clear from this paper how many dropouts: 62.8% attended the programme, but was this post randomisation?
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Unclear riskUnclear: "Data was analyzed on an intent to treat basis", but no numbers were given in the paper
Selective reporting (reporting bias)Unclear riskUnclear whether selective outcome was reported
Similarity of baseline characteristics?High riskGroups were not similar at baseline
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided or were similar
Compliance acceptable ?Unclear riskUnclear compliance rate
Timing outcome assessment comparable?Unclear riskNot clear when outcome measure was calculated

Andersen 2008a

MethodsRCT, cluster-randomisation
ParticipantsForty-eight employed women with chronic neck muscle pain (defined as a clinical diagnosis of trapezius myalgia). Recruited participants from seven workplaces characterised by monotonous jobs (e.g. computer-intensive work) 
Interventions

Specific strength training (SST): 10 weeks of specific strength training locally for the affected muscle; n = 18

General fitness training (GFT): leg bicycling with relaxed shoulders; n = 16

Control: health counselling without physical activity; n = 14 

OutcomesPain intensity (VAS). aerobic fitness (Astrand)
NotesParticipants grouped as cases and controls post intervention. No analysis per intervention group
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Randomization at the cluster level .. in a balanced design..", but no specific details of method given
Allocation concealment (selection bias)Unclear riskDo not know who generated the assignment
Blinding of participants?Unclear riskBlinding was unlikely, but no info provided
Blinding of caregivers?Unclear riskBlinding was unlikely, but no info provided
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskBlinding was unlikely, but no info provided
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Unclear riskSix dropouts in the REF group not adequately described 
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Unclear riskUnclear whether ITT was used, but it looks like only 8/14 of the REF group were analysed
Selective reporting (reporting bias)Unclear riskUnclear
Similarity of baseline characteristics?Low riskGroups similar; see Table 1 and Table 2
Co-interventions avoided?Unclear riskUnclear whether cointerventions were addressed during the study
Compliance acceptable ?Low riskDuration similar in three groups, intensity similar in exercise groups and logbooks kept
Timing outcome assessment comparable?Low riskFigure 2: measures collected at each session and weekly in postintervention phase

Andersen 2008b

MethodsRCT, cluster-randomisation (n = 79 clusters)
ParticipantsOffice workers (n = 549) with neck/shoulder pain recruited from 12 geographically different units of a national Danish public administration authority 
Interventions

Specific resistance training (SRT) for the neck/shoulder muscles. Training was performed three times a week, and each session lasted 20 minutes. Two of the three weekly sessions were supervised by experienced instructors; n = 180

All-round physical exercise (APE) on a group level; n = 187

Reference intervention (REF) with counselling; n = 182

 

Interventions one hour per week for 12 months 

OutcomesPain (NRS)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskParticipants randomly assigned at cluster level, but no details of method given
Allocation concealment (selection bias)Unclear riskNot told who allocated treatment
Blinding of participants?Unclear riskBlinding was unlikely, but no info provided
Blinding of caregivers?Unclear riskBlinding was unlikely, but no info provided
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskSelf-reported participant outcomes, but we do not know whether participants were blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Unclear riskNo mention of dropouts
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Unclear riskNot clear from results how many participants were analysed after one year
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Unclear riskBaseline similarity unclear: only prevalence of pain symptoms reported
Co-interventions avoided?Unclear riskNo mention of avoiding co-interventions during this time
Compliance acceptable ?Unclear riskCompliance not reported
Timing outcome assessment comparable?Unclear riskTiming unclear

Bang 2000

MethodsRCT
ParticipantsFifty-two participants diagnosed with shoulder impingement syndrome. Cumulative microtraumata during overuse and repetitive load are the theorised causes of primary impingement 
Interventions

Manual therapy group: Standardised flexibility and strengthening programme under supervision of a physiotherapist and additional manual therapy directed at relevant movement limitations in the upper quarter; n = 28

Exercise group: Standardised flexibility and strengthening programme under supervision of a physiotherapist; n = 24

 

All treatments twice weekly for three weeks for a total of six visits 

OutcomesPain response for functional activities (VAS), shoulder function (modified Oswestry: 0 to 45 (no limitations)), isometric strength (dynamometer) 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskUnclear randomisation procedure
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Unclear riskUnclear
Blinding of caregivers?High riskNo blinding
Blinding of outcome assessment (detection bias)
All outcomes
Low riskTesters were blinded to group assignment
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskLess than 20% dropouts
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo intention-to-treat analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?High riskBaseline not considered similar between groups
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Low riskCompliance was acceptable
Timing outcome assessment comparable?Low riskTiming was acceptable

Bernaards 2006

Methods

RCT; independent statistician prepared randomisation using computer-generated random assignment. Block randomisation (blocks of three)

 

ParticipantsComputer workers (at least three days per week) with frequent or long-term pain in neck and upper limb last two weeks 
Interventions

Work style group (WS): focusing on behavioural change with regard to body posture, workplace adjustment, breaks and coping with high work demands; n = 152

Work style + physical activity group (WSPA): focusing on behavioural change with regard to body posture, workplace adjustment, breaks, coping with high work demands and additional physical activity; n = 156

Usual care group: These participants visited their occupational physician for neck and upper limb symptoms; they received usual care; n = 158

 

Interventions for the two intervention groups consisted of six interactive group meetings over a six-month period. All group meetings took place at the workplace, during work time

 

Intervention period of six month and measurements at baseline and after six and 12 months of follow-up 

OutcomesRecovery (7-point scale), pain intensity (11-point NRS), disability (11-point NRS)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskAdequate randomisation procedure
Allocation concealment (selection bias)Low riskPrepared by an independent statistician, but researchers informed participants about their allocation 
Blinding of participants?High riskParticipant not blinded
Blinding of caregivers?High riskCaregivers not blinded
Blinding of outcome assessment (detection bias)
All outcomes
High riskParticipant not blinded for participant-reported outcomes. Unblinded counsellors who also performed part of the follow-up measurements
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
High riskFigure 1: 32% dropout for long-term follow-up and differences in pain and activity levels may introduce bias
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Low riskITT analysis was used
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskGroups similar: see Table 1 and Table 3
Co-interventions avoided?Unclear riskPossibility of co-interventions not addressed
Compliance acceptable ?High riskTable 2: differences in attendance at meetings between groups
Timing outcome assessment comparable?Low riskTiming comparable

Bru 1994

MethodsRCT; no information on randomisation procedure
ParticipantsHospital staff with various degrees of musculoskeletal pain from neck, shoulders and/or low back; n = 119 
Interventions

I1: Relaxation training: relaxation exercise + autogenic training; n = 15

I2: Cognitive training: education, relationship, personality, work and complaints; n = 19

I3: Combination I1 + I2: n = 24

C: Waiting list controls: n = 53

10 sessions in ? weeks. Follow-up: four months 

OutcomesPain intensity (5-point Likert), pain duration (4-point Likert)
NotesNo data available
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskUnclear randomisation procedure
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Unclear riskUnclear
Blinding of caregivers?Unclear riskUnclear
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
High risk34% dropout
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo intention-to-treat analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskGroups similar at baseline
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance
Timing outcome assessment comparable?Low riskTiming comparable

Cheng 2007

MethodsRCT; no information on randomisation procedure
ParticipantsWorkers recruited from workers' compensation insurance companies. Prevalent work-related rotator cuff tendinitis; all sick listed > 90 days; n = 103
Interventions

Clinical-based work hardening (CWH): mobilisation, strength and endurance training; n = 52

I2: Workplace-based work hardening (WWT): ergonomic education, stretching and strengthening exercises; n = 51

 

Training sessions three times per week for four weeks 

OutcomesShoulder Pain and Disability Index (SPADI): functional capacity (FCE); return to work 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNo details of randomisation method given
Allocation concealment (selection bias)Unclear riskNo details of who performed treatment allocation
Blinding of participants?Unclear riskWe do not know whether participants were blinded
Blinding of caregivers?Unclear riskUnclear
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskSelf-report outcome—we do not know whether patient was blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low risk9/103 dropouts. < 20%. Reasons given
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High risk94/103 analysed: no ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskGroups similar: see Table 1 and Table 2
Co-interventions avoided?Unclear risk"Contaminating effect from collateral workplace based efforts was not investigated"
Compliance acceptable ?Unclear riskThree sessions a week but no record of attendance at sessions
Timing outcome assessment comparable?Low riskTiming comparable

Dellve 2011

MethodsRCT
ParticipantsFemale human service organisation workers (35 to 60 years old) on long-term (60 days) sick leave and with chronic neck pain. Reduction in degree of working should be at least 50%; n = 73
Interventions

Myofeedback training: harness to muscle activity (EMG) from the upper trapezius muscles on the right and left sides; eight hours per week; n = 25; lost five

Intensive strength training: two warm-up movements, followed by four exercises for strengthening and coordinating upper extremities; five- to 10-minute programme to be performed twice a day for six days/wk; n = 27; lost seven

Control: n = 21

Intervention: one month; follow-up: three months

OutcomesSelf-reported (work ability, pain (VAS)) and laboratory-observed data on health, pain, muscular activation and work ability
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskRandomisation method is unclear
Allocation concealment (selection bias)Unclear riskConcealed randomisation is stated, but procedure is unclear
Blinding of participants?Unclear riskNo mention of participant blinding
Blinding of caregivers?High riskOne caregiver for all interventions, therefore not blinded
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear blinding and outcome assessment
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
High risk23/73 lost, > 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskNo differences
Co-interventions avoided?Unclear riskUnclear
Compliance acceptable ?Unclear riskUnclear
Timing outcome assessment comparable?Low riskTiming comparable

Esmaeilzadeh 2012

MethodsRCT; randomisation at department level, block randomisation
ParticipantsWork-related upper extremity musculoskeletal disorders (WUEMSDs) among computer workers
Interventions

Ergonomic intervention: to improve the computer user’s knowledge of office ergonomics, to teach workstation self-assessment and to enable self-adjustment and rearrangement of the office environment by comprehensive ergonomic training, ergonomic training brochure and workstation evaluation; n = 47; 12 dropouts; n = 35

Control group with no intervention/treatment; n = 47; 13 dropouts; n = 34

OutcomesPain (VAS), duration of symptoms, Nordic musculoskeletal questionnaire, ergonomic questionnaire, medication use, sick leave
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskAn independent blinded research assistant prepared the randomisation by using a computer-generated random block sequence
Allocation concealment (selection bias)Low riskAn independent blinded research assistant prepared the randomisation by using a computer-generated random block sequence
Blinding of participants?High riskInvestigators informed participants about their allocation directly after they completed their baseline assessment
Blinding of caregivers?Unclear riskNo information
Blinding of outcome assessment (detection bias)
All outcomes
High riskParticipant was not blinded; therefore outcome assessment was not blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
High riskDropouts (n = 25; > 20%)
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskStatistical analysis was performed with 69 (of 94) participants
Selective reporting (reporting bias)Unclear riskUnknown
Similarity of baseline characteristics?Low riskNo significant difference was noted between the two groups at baseline assessment in terms of all outcome measures
Co-interventions avoided?Unclear riskUnclear
Compliance acceptable ?Unclear riskUnclear
Timing outcome assessment comparable?Low riskFollow-up at six months

Ferguson 1976

MethodsRCT; allocated randomly in turn, cross-over trial; observer blinded in part
ParticipantsPrevalent neck/shoulder complaints (non-specific); only men; n = 40. Full-time operating telegraphists
Interventions

Group A: active exercise + ultrasound

Group B: proprioceptive neuromuscular facilitation (PNF training) + ice

Group C: massage

 

Four-week intervention, cross-over after two, four months 

OutcomesInterview, observation of keyboard operation, self-assessment, fear
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High riskAllocation randomly in turn
Allocation concealment (selection bias)Unclear riskUnclear whether allocation is concealed
Blinding of participants?High riskParticipants were not blinded
Blinding of caregivers?Unclear riskUnclear whether caregivers were blinded
Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment is regarded as blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskVarying dropout rates, all < 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?High riskGroups not similar at baseline
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance rate
Timing outcome assessment comparable?Low riskTiming comparable

Goldman 2010

MethodsRCT; randomisation by uninvolved assistant using envelopes; double-blind, placebo-controlled
ParticipantsAdults with upper extremity pain due to repetitive use or prolonged static postures; n = 118
Interventions

Amitriptyline (25 mg): n = 59

Placebo pill: n = 59

Treatment: six weeks, follow-up at 10 weeks 

OutcomesPain intensity (NRS), Levine Symptom Severity Scale (0 to 55), Upper Extremity Function Scale (8 to 88) 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskA permuted block randomisation with variable block sizes and assignments sealed in sequentially numbered opaque envelopes
Allocation concealment (selection bias)Low risk"Person performing randomization .. was at a separate site .. and had nothing to do with the study participants or collection of data" 
Blinding of participants?Low riskParticipant blinded
Blinding of caregivers?Low riskCaregivers blinded
Blinding of outcome assessment (detection bias)
All outcomes
Low risk"Research assistants involved in data collection were also blinded to treatment assignment"; participant blinded for participant-reported outcomes
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low risk51/59 amitriptyline and 55/59 placebo returned for post-treatment assessment. < 20% dropouts
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Low riskTable 4: ITT analysis—imputed missing values
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low risk "Well balanced on all variables (Table 1); no clinically significant differences"
Co-interventions avoided?Low riskPlacebo versus active pill but no mention of advising participants to refrain from co-interventions
Compliance acceptable ?Low riskAdherence:  "... figures at the end of treatment were 87% and 89% ..."
Timing outcome assessment comparable?Low riskTiming comparable

Hagberg 2000

MethodsRCT; concealed randomisation, multi-centre trial; n = 3
ParticipantsWoman industrial workers seeking medical attention for neck or shoulder pain. Chronic (three-month) neck/shoulder complaints (non-specific; n = 77). Industrial workers with gradual onset of symptoms during work 
Interventions

Endurance training: isometric shoulder endurance training; n = 43

Strength training: isometric shoulder strength training; n = 34

 

Training once a week supervised by physiotherapist for 12 weeks. Follow-up at 24 weeks 

OutcomesPain (VAS), ROM, sick leave, strength (dynamometer), endurance (RPE)
NotesNo data available
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskAllocation by chance (dice)
Allocation concealment (selection bias)Low riskPrincipal investigator blinded for allocation
Blinding of participants?Unclear riskUnclear whether participant is blinded
Blinding of caregivers?High riskNot blinded
Blinding of outcome assessment (detection bias)
All outcomes
High riskOutcome assessment not blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskEight dropouts, reasons given, < 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskGroups similar at baseline
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance rate
Timing outcome assessment comparable?Low riskTiming comparable

Heuvel 2003

MethodsRCT; cluster-randomisation (n = 22 clusters). Randomisation by spreadsheet
Participants Participants were recruited from a large office organisation dealing with social security allowances. Neck, shoulder or arm pain > two weeks; non-specific; n = 286. Workers from an office organisation who considered complaints work-related 
Interventions

Breaks: stimulated to take extra breaks of five minutes every 35 minutes; n = 97

Breaks + exercises: stimulated to perform exercises during the extra breaks (45 seconds) at the start of each break; n = 81

Control: no intervention; n = 90

 

Treatment during eight weeks 

OutcomesPerceived recovery (7-point Likert), pain (11-point NRS), sick leave (days)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskCluster-randomisation, procedure unknown
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Unclear riskUnclear participant blinding
Blinding of caregivers?Unclear riskUnclear
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear blinding outcome assessment
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskDropout rate < 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskGroups similar at baseline
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance rate
Timing outcome assessment comparable?Low riskTiming comparable

Kamwendo 1991

MethodsRCT
ParticipantsMedical secretaries currently working. Chronic (> 12 months) neck/shoulder complaints (non-specific); medical secretaries currently working (women); n = 79 
Interventions

Traditional neck school: Four-hour traditional neck school conducted by a physiotherapist. Advice + exercises; n = 25

Traditional neck school + ergonomic changes: Four-hour traditional neck school conducted by a physiotherapist and additional visit of the physiotherapist at the workplace; n = 28

Controls: not offered any intervention; n = 26

 

Two sessions/wk, four weeks. Follow-up: six months 

OutcomesPain (VAS), workload (VAS), fatigue (VAS), ROM (goniometer), sick leave, expectation
NotesNo data available
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskUnclear randomisation procedure
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Unclear riskUnclear blinding of participants
Blinding of caregivers?Unclear riskUnclear blinding of caregivers
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear blinding of outcome assessment
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskDropout rate < 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Unclear riskUnclear baseline similarity
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance rate
Timing outcome assessment comparable?Unclear riskTiming comparable

Ketola 2002

MethodsRCT; no info on randomisation procedure; ‘care-giver’ blinded
ParticipantsEmployees working with video display units (VDUs). Neck/shoulder complaint > one month; non-specific; n = 124. Employees who use the mouse currently
Interventions

Intensive ergonomics: two physiotherapists visited the worksite and changed worksite according to checklist; n = 39

Education ergonomics: workers attended a one-hour training session in ergonomics; n = 35

Control group: one-page leaflet; n = 35

 

Two- and 10-month follow-up 

OutcomesDiscomfort (6-point Likert), strain (6-point Likert), pain (yes/no)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Using stratified random sampling—The three administrational units were used as a stratum. The success of the randomization was checked.."
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Unclear riskParticipants unclear whether blinded
Blinding of caregivers?Unclear riskUnclear whether care provider blinded
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskTwo blinded experts used to detect changes in workstations, but diary and questionnaires provided self-reported outcomes; participants not fully blinded 
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskSeven dropouts: < 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskGroups similar at baseline
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance rate
Timing outcome assessment comparable?Low riskTiming comparable

Leboeuf 1987

MethodsRCT; no info on randomisation procedure.
ParticipantsThirty-eight participants with repetitive strain injury of the upper limbs. Chronic (> three months) complaints of upper extremity (non-specific; n = 38; 35 women). Symptoms were considered due to repetitive strain 
Interventions

Spinal manipulative therapy + soft tissue therapy (massage): n = 21

Spinal manipulative therapy (SMT): n = 17

Five weeks, two sessions/wk. Follow-up: at three and 12 months 

OutcomesSeverity of symptoms, frequency of symptoms (Likert) 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskUnclear randomisation procedure
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Unclear riskUnclear blinding of participant
Blinding of caregivers?High riskNo blinding
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskOutcome assessment self-reported, so blinding unclear
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskNo dropouts mentioned
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Low riskITT analysis assumed
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskGroups similar at baseline
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance rate
Timing outcome assessment comparable?Low riskTiming comparable

Levoska 1993

MethodsRCT, no info on randomisation procedure
ParticipantsPrevalent neck/shoulder complaints (non-specific); female office workers employed by a local bank or social insurance institution; n = 47
Interventions

Active physiotherapy: stretching and dynamic muscle training exercise and daily home training exercise programme for 60 minutes; n = 23

Passive physiotherapy: massage, heat and exercises, each for 20 minutes; n = 24

 

Five weeks, three sessions/wk. Follow-up three months 

OutcomesPain, tender points, symptoms (Q), strength (dynamometer), endurance 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskUnclear randomisation procedure
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Unclear riskUnclear
Blinding of caregivers?Unclear riskUnclear
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskThree dropouts: < 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Unclear riskUnclear baseline similarity
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance rate
Timing outcome assessment comparable?Low riskTiming comparable

Lundblad 1999

MethodsRCT; no info on randomisation procedure
ParticipantsPrevalent neck/shoulder complaints (non-specific); female employees currently working; n = 97
Interventions

Physiotherapy: group-based physiotherapy programme with an ergonomic programme and home exercises; n = 32; two sessions of 50 minutes/wk

Feldenkrais: using sensory awareness with movements/exercises and home exercises; n = 33; one session of 50 minutes/wk

Control group: no intervention; n = 32

 

Treatment duration of 16 weeks. Follow-up of one year 

OutcomesPain (VAS), function (?), complaints (?), ROM, sick leave (days)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskUnclear randomisation procedure
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Unclear riskUnclear
Blinding of caregivers?Unclear riskUnclear
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
High riskHigh dropout rate: 40%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskGroups similar at baseline
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance rate
Timing outcome assessment comparable?Low riskTiming comparable

Ma 2011

MethodsRCT; simple computer-based randomisation
ParticipantsDaily computer users with a history of computer-related neck and shoulder discomfort; n = 72
Interventions

Biofeedback: portable biofeedback, two hours daily for two weeks; n = 15

Exercise: standardised exercise programme with stretching and strengthening exercises using Thera-band, 20 minutes four times a day; n = 15

Passive treatment: interferential therapy (20 minutes) and hotpacks 15 minutes two times per week; n = 15

Control: standard educational booklet; n = 15

Intervention period: six weeks, follow-up at six months

OutcomesPain (VAS), disability (NDI)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskSimple computer-based randomisation
Allocation concealment (selection bias)Unclear riskUnclear
Blinding of participants?Unclear riskUnclear
Blinding of caregivers?Unclear riskUnclear
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
High riskDropout at follow-up > 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskBaseline similarity
Co-interventions avoided?Low riskCo-interventions avoided
Compliance acceptable ?Unclear riskUnclear compliance
Timing outcome assessment comparable?Low riskTiming comparable

Marangoni 2010

MethodsRCT; randomisation by listing order
ParticipantsComputer workers (88% female); n = 68
Interventions

CAMP (computer-assisted stretching programme): stretch via a computer programme; 10-minute computer breaks/h; n = 22

FLIP (facsimile lessons with instructional pictures): stretching using a hard copy version of the stretches with pictures and written instructions (paper version of CASP); n = 23

Control: no intervention; n = 23

 

Both interventions stretched once every six minutes 

OutcomesPain (VAS)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High risk"Alternating the interventions by assigning the CASP intervention to the first caller..."
Allocation concealment (selection bias)High riskAllocation done by using the list with date and time order from callers and emailers
Blinding of participants?High riskNo blinding
Blinding of caregivers?High risk"The same physical therapist performed the intake and outtake evaluations"
Blinding of outcome assessment (detection bias)
All outcomes
High risk"The same physical therapist performed the intake and outtake evaluations"
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskFigure 7: < 20% dropout
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Unclear riskNo breakdown of group prognostic indicators given
Co-interventions avoided?Unclear riskNo details of any possible co-interventions given
Compliance acceptable ?Unclear riskNo details of compliance with the intervention given
Timing outcome assessment comparable?Unclear riskIntervention was 15 days, but author does not state when outcome assessment was completed

Martimo 2010

MethodsRCT; randomisation using sealed envelopes in three blocks
ParticipantsWorkers with upper extremity disorders; n = 177
Interventions

Ergonomic improvements at workplace: n = 91

Current best practice: n = 86

 

Follow-up: eight and 12 weeks 

OutcomesPain (VAS), sick leave, job strain (Job Content Questionnaire), production loss (yes/no)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Randomization using tables of random numbers in three blocks… Sealed envelopes were used"
Allocation concealment (selection bias)Low riskAssignment generated by the physician, who had information about persons included in the trial, as he/she had contacted each employee supervisor by phone 
Blinding of participants?High riskUnblinded participants
Blinding of caregivers?High riskUnblinded caregiver
Blinding of outcome assessment (detection bias)
All outcomes
High risk"Researcher conducting the interviews at 8 and 12 weeks follow up was not aware of the group assignment", but unblinded participant for participant-reported outcome
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskDropout rate 12% to 13%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskGroups comparable at baseline
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear whether compliance was assessed
Timing outcome assessment comparable?Low riskTiming comparable

Meijer 2006

MethodsRCT; cost-effectiveness analysis. Concealed randomisation
ParticipantsBank employees, sick-listed workers with non-specific upper extremity musculoskeletal complaints. Prevalent non-specific upper extremity musculoskeletal disorders; n = 38 
Interventions

I: Multidisciplinary treatment (Mt): outpatient training programme; physical and psychological sessions and relaxation exercises; n = 23

Sessions for two months, 13 full days, five return-to-work sessions and one feedback session

C: Usual care (Uc): guidance by occupational physician or general practitioner; n = 15

 

Follow-up one year (two, six and 12 months) 

OutcomesPain (VAS), function (DASH), return-to-work, kinaesiophobia (TAMPA), costs 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskBlock randomisation computer-generated random sequence table. Envelopes allocated on the basis of participants' consecutive registration numbers
Allocation concealment (selection bias)Low riskOpaque sealed envelopes kept by "researcher with no contact with therapists, physicians or patients"
Blinding of participants?High riskParticipants were not blinded
Blinding of caregivers?High riskNo blinding
Blinding of outcome assessment (detection bias)
All outcomes
High riskDoes not mention who carried out objective outcome measures, but participants were unblinded for self-reported outcome measures
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskFigure 1:  4/38 dropouts (< 20%)
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Low riskIntention-to-treat analyses conducted
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskGroups similar at baseline: see Table 2
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Low risk18/21 of intervention group showed good compliance
Timing outcome assessment comparable?Low riskTiming comparable

Moore 1996

MethodsRCT; no info on randomisation procedure
ParticipantsRecent complaints upper extremity (non-specific); n = 32 (28 women). Diagnosed as having upper extremity RSI, referred from occupational medicine department 
Interventions

HVT (hypnotically induced vasodilatation treatment): relaxation training, biofeedback, hypnosis; n = 15; 45 minutes/wk, six weeks

Waiting list controls: n = 17 

OutcomesComfort (VAS), temperature (hand) 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskAssigned by following a list of random numbers
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Unclear riskUnclear
Blinding of caregivers?Unclear riskUnclear
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear whether outcome assessment was blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskNo dropout mentioned
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Low riskITT analysis assumed
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskGroups similar at baseline
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance
Timing outcome assessment comparable?Low riskTiming comparable

Nourbakhsh 2008

MethodsRCT; randomisation by having participants draw a card out of a set of cards marked ‘Group A’ or ‘Group B’
ParticipantsParticipants were involved in heavy or repetitive arm movements as part of their job or during recreational activities. Chronic lateral epicondylitis; n = 18 
Interventions

Low-frequency electrical stimulation on trigger points; n = 10

Placebo: n = 8

 

Six sessions in two to three weeks; six months of follow-up 

OutcomesPain (NRS), functional status (Q)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Draw a card from a set of cards"
Allocation concealment (selection bias)High riskTreating therapist did the random assignment
Blinding of participants?Low riskParticipant was blinded
Blinding of caregivers?High riskTherapists were not blinded
Blinding of outcome assessment (detection bias)
All outcomes
Low riskMeasuring therapists were blinded to participants' group assignment, and participant blinded for participant-reported outcomes
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskTwo dropouts not described, but dropout rate does not exceed 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Low riskYes for post-test measurement, not for six-month follow-up
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?High riskGroups not similar in all outcome measures (e.g. grip strength); demographic features (e.g. age range, duration of symptoms)
Co-interventions avoided?Low risk"Subjects did not receive any other form of treatment"
Compliance acceptable ?Low riskAll participants received six treatment sessions over a two- to three-week period
Timing outcome assessment comparable?Low riskTiming comparable

Omer 2003

MethodsRCT; no info on randomisation procedure.
ParticipantsNeck and upper extremity complaints (non-specific); n = 50 (41 women). Computer operators > six hours a day 
Interventions

Education + Exercises: education (one hour) + mobilisation, stretching, strengthening and relaxation exercises

Education: education one hour

 

Three sessions a week, eight weeks training 

OutcomesPain (NRS, PDI), tiredness (TS), depression (BDI)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskUnclear randomisation procedure
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Unclear riskUnclear participant blinding
Blinding of caregivers?Unclear riskUnclear
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear whether outcome assessment was blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Unclear riskUnclear number of dropouts
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Unclear riskUnclear whether ITT analysis was performed
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskGroups similar at baseline
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance
Timing outcome assessment comparable?Unclear riskUnclear whether timing was comparable

Rempel 1999

MethodsRCT; no info on randomisation procedure. Matched pairs; participant and observer blinded
ParticipantsPrevalent carpal tunnel syndrome (CTS) (specific); n = 24 (16 women). Full-time laboratory personnel using a computer for > two hours a day, referred from an occupational medicine clinic for hand and wrist problems 
Interventions

I: Keyboard A (Protouch): n = 12

C: Keyboard B (MacProPlus): control group with standard keyboard: n = 12

 

12 weeks, one hour of training 

OutcomesPain (Likert), nerve conduction (electromyography), function and keyboard characteristics (Q) 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskUnclear randomisation procedure
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Low riskParticipant was blinded
Blinding of caregivers?Low riskCaregiver was blinded
Blinding of outcome assessment (detection bias)
All outcomes
Low riskParticipants self-reported outcome, so outcome assessment was blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskFour dropouts < 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskGroups similar at baseline
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance
Timing outcome assessment comparable?Low riskTiming was comparable

Rempel 2007

MethodsRCT; no info on randomisation procedure
ParticipantsChronic neck and shoulder pain in sewing machine operators; n = 277. Performed sewing machine work for more than 20 hours per week 
Interventions

Chair with flat seat: n = 72

Chair with curved seat: n = 100

Control: n = 105

Miscellaneous items provided to all participants were a footrest, a small table-top storage box for items such as scissors, a side table, a task lamp and reading glasses

 

Four months of follow-up 

OutcomesPain, job content (job content questionnaire)
NotesNo data available
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNo details of randomisation method
Allocation concealment (selection bias)Unclear riskNo details on treatment allocation
Blinding of participants?High riskParticipant not blinded
Blinding of caregivers?Unclear riskUnclear whether caregiver was blinded
Blinding of outcome assessment (detection bias)
All outcomes
High riskParticipant-reported outcomes and participant not blinded 
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
High risk209/277 completed the study (25% dropout rate)
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Unclear riskComparison of baseline outcome measures not given
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance
Timing outcome assessment comparable?Low riskTiming was comparable

Ripat 2006

MethodsRCT; no information on randomisation procedure
ParticipantsSymptomatic workers employed by a single company recruited through public and/or electronic mail. Workers with two or more symptoms of work-related upper extremity disorder (WRUED; n = 68) 
Interventions

Modified keyboard (light touch): modified version of the same keyboard designed to reduce activation force, vibration and key travel; n = 43

Standard keyboard: commercially available ergonomic keyboard; n = 25

 

Keyboard use for 24 weeks 

OutcomesSymptom severity scale (SSS), functional status scale (FSS) 
NotesNo data available
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNo details of method used
Allocation concealment (selection bias)High riskSome participants were placed in the adapted keyboard group as an "exception to the randomization process"
Blinding of participants?High riskParticipants unblinded
Blinding of caregivers?High riskCaregivers not blinded
Blinding of outcome assessment (detection bias)
All outcomes
High riskNot told who did the outcome measures, but likely to be research assistant, who was not blinded. Also participants unblinded for participant-reported outcomes
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Unclear riskNot told of any dropouts
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Unclear riskUnclear whether ITT analysis was performed
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskBaseline comparable: see Table 2
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance
Timing outcome assessment comparable?Low riskTiming was comparable

Sandsjö 2010

MethodsRCT; block randomisation (block size 2)
ParticipantsFemales; > 20-hour computer work/wk with neck/shoulder pain; n = 65
Interventions

Myofeedback teletreatment: four weeks of myofeedback-based teletreatment. Participants had to use the myofeedback system for at least eight hours a week distributed over at least two days a week and during longer continuous (preferably two hours) sessions each day; n = 33

Control (usual care): not receive any intervention; n = 32

 

Follow-up three months after intervention 

OutcomesClinical improvement in pain (VAS > 13 mm), clinical improvement in disability (PDI > 7), clinical improvement in work ability (1 cm) 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High riskBlock randomisation—one participant randomly assigned to intervention, one to control. Alternation method therefore inadequate
Allocation concealment (selection bias)Unclear riskNo details given about treatment allocation method
Blinding of participants?Unclear riskUnclear blinding
Blinding of caregivers?Unclear riskUnclear blinding
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskSelf-reported outcome measures, unclear blinding
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
High riskLarge dropout rate: four weeks 19/65 dropped out = 30%, three months 26/65 dropped out = 40%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskBaseline comparable
Co-interventions avoided?Low riskCo-interventions: traced each participant's background activities via questionnaire
Compliance acceptable ?Unclear riskUnclear compliance
Timing outcome assessment comparable?Low riskTiming was comparable

Sjögren 2005

MethodsRCT; cluster-randomised, cross-over trial; four clusters
ParticipantsOffice workers with headache, neck or shoulder pain; n = 53
Interventions

I: Physical exercise: progressive light resistance training and guidance; n = 36

C: No intervention: n = 17

 

Treatment period: 15 weeks; cross-over at 15 weeks 

OutcomesPain (Borg CR10 Scale), strength
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskCluster-randomisation, but method of randomisation not specified
Allocation concealment (selection bias)Low risk"Blind measurers allocated the workers into the two treatment sequences"
Blinding of participants?High riskParticipants not blinded
Blinding of caregivers?Unclear riskUnclear
Blinding of outcome assessment (detection bias)
All outcomes
High riskSelf-reported outcomes used and participants not blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskTwo participants lost to follow-up: < 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Low riskFigure 1: main analysis intention-to-treat, none excluded from analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskBaseline comparable: see Table 1
Co-interventions avoided?Low risk"Other physical activity performed outside the intervention was controlled by a structured interview"
Compliance acceptable ?Low riskCompliance: Participants maintained a weekly diary: 78% to 68%
Timing outcome assessment comparable?Low riskTiming was comparable

Spence 1989

MethodsRCT; no info on randomisation procedure
ParticipantsChronic (> 10 months) occupational pain of the upper limbs (non-specific); n = 45 (44 women). Upper extremity CTD and repetitive tasks in workplace 
Interventions

ICBT: individual cognitive-behavioural therapy: n = 15

GCBT: group cognitive-behavioural therapy: n = 14

WCL: waiting list controls: n = 16

 

Nine weeks, nine sessions. Follow-up: six months two years in intervention groups 

OutcomesPain (McGill), function (SIP), return to work, satisfaction, fear (STAI), depression (BDI), coping (CSQ) 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskNo info on randomisation procedure
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Unclear riskUnclear
Blinding of caregivers?High riskCare provider not blinded
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear whether outcome assessment was blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskSeven dropouts: < 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskBaseline comparable
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance
Timing outcome assessment comparable?Low riskTiming was comparable

Spence 1995

MethodsRCT; no info on randomisation procedure
ParticipantsChronic (> 10 months) complaints, upper extremity (non-specific) associated with repetitive tasks in the workplace; n = 48 (40 women)
Interventions

EMG biofeedback (EMG): auditory feedback on muscle tension levels + home-based assignments; n = 12

EMG + relaxation (CO): combined treatment of EMG and ART; n = 12

Relaxation training (ART): consists of a range of relaxation techniques + home-based assignments; n = 12

Waiting list controls (WCL): n = 12

 

Eight weeks. Follow-up six months 

OutcomesPain (Whimpy, Likert, PBQ), depression (BDI), ADL
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskUnclear randomisation procedure
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Unclear riskUnclear
Blinding of caregivers?Unclear riskUnclear
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear whether outcome assessment was blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
High riskThree dropouts at short term; eight at long term (> 20%)
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?High riskBaseline groups were regarded as not comparable
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear compliance
Timing outcome assessment comparable?Low riskTiming was comparable

Stralka 1998

MethodsRCT; even/odd numbers. Care provider and participant blinded
ParticipantsPrevalent hand and wrist complaints (non-specific); factory employees (data processing); n = 120 (84 women). Cumulative trauma disorders 
Interventions

Energized splint: using a high-voltage pulsed current in the wrist splint; n = 60

Placebo splint: n = 60

 

Seven weeks; 30 minutes of stimulation/20 sessions 

OutcomesPain (VAS), ROM, strength (dynamometer), swelling (volume measurement) 
NotesNo data available
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High riskRandomsiation was performed by odd and even number distribution
Allocation concealment (selection bias)High riskAllocation was probably concealed
Blinding of participants?Low riskParticipant was blinded
Blinding of caregivers?Low riskCaregiver was blinded
Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment was blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskDropouts: 21/141; < 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Unclear riskUnclear baseline comparability
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Low riskCompliance was monitored
Timing outcome assessment comparable?Unclear riskTiming was comparable

Szcurko 2009

MethodsRCT; randomised using age- and sex-matched central computer randomisation 
ParticipantsPostal workers with rotator cuff tendinitis; n = 89
Interventions

PE: standardised physical exercises: range-of-motion exercises + placebo tablets; n = 42

NC: Naturopathic care: dietary counselling, acupuncture and Plogenzym; n = 43

 

12 weeks, one weekly session of 30 minutes 

OutcomesPain (VAS), function (SPADI), quality of life (SF-36) 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Participants were randomized using age and sex matched computer randomization"
Allocation concealment (selection bias)Low risk"Allocation concealment using central randomization was preserved up to the point of treatment"
Blinding of participants?High riskParticipant was not blinded
Blinding of caregivers?Unclear riskUnclear blinding
Blinding of outcome assessment (detection bias)
All outcomes
High risk"Primary outcome is measured by patient and participant blinding is 'no'"
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskOf 85 participants, 17 did not complete treatment (= 20%)
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Low riskMissing data at week 12 were replaced by values at week 8 for ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?High riskNo adequate baseline comparability: see Table 1
Co-interventions avoided?High riskCo-interventions not similar between groups
Compliance acceptable ?Low riskCompliance for pills > 80%. Same number and duration of sessions for other groups
Timing outcome assessment comparable?Low riskTiming was comparable

Takala 1994

MethodsRCT; matched, cross-over, observer-blinded
ParticipantsNeck/shoulder complaints (> one month; non-specific); female employees of security printing company; n = 44. All participants performed sedentary work and light repetitive tasks 
Interventions

Exercise: group gymnastics, whole body exercises, 45 minutes once a week for 10 weeks; n = 22

C: Controls: n = 22

 

After four months, cross-over 

OutcomesPain (VAS), pressure pain (algometer) 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskUnclear randomisation procedure
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?High riskParticipant was not blinded
Blinding of caregivers?High riskCaregiver was not blinded
Blinding of outcome assessment (detection bias)
All outcomes
High riskRater was blinded to treatment status (pain pressure); participant rated pain (VAS) and was not blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
High risk14/44 dropouts: > 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High riskNo ITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskBaseline comparable
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskCompliance unclear
Timing outcome assessment comparable?Low riskTiming was comparable

Tittiranonda 1999

MethodsRCT; placebo-controlled, random permuted block method, observer blinded 
ParticipantsCarpal tunnel syndrome (CTS) or tendinitis wrist (complaints > one week; specific; n = 80; 46 women). Laboratory employees, computer users 
Interventions

Kb1: Apple adjusted keyboard: n = 20

Kb2: Comfort keyboard system: n = 20

Kb3: Microsoft natural keyboard: n = 20

Placebo group: n = 20 

OutcomesPain (VAS), hand function (Q/VAS), physical examination, keyboard comfort (VAS) 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskRandom permuted block method
Allocation concealment (selection bias)Unclear riskUnclear randomisation concealment
Blinding of participants?Low riskParticipant was blinded
Blinding of caregivers?Low riskBlinding
Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome assessment blinded because participants were blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low risk14% dropouts mentioned
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Low riskITT analysis performed
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskBaseline comparable
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Low riskCompliance was assessed and adequate
Timing outcome assessment comparable?Low riskTiming was comparable

van Eijsden 2008

MethodsRCT; randomisation by independent research assistant; blocks of four were generated for each stratum (duration of complaints) using a computer-generated random sequence table 
ParticipantsVisual display unit workers with early non-specific work-related upper limb disorders. Participants were recruited by advertisement in local newspapers; n = 88 
Interventions

Postural exercises: postural exercises according to the Mensendieck/Cesar approach; n = 44

Strength and fitness exercises: strength and fitness exercises delivered by four physiotherapists, who attended a course for work-related upper limb disorders based on the latest evidence; n = 44

 

Intervention for 10 weeks; follow-up at three, six and 12 months 

OutcomesPain (VAS), disability (Disabilities of Arm, Shoulder and Hand Questionnaire), health-related quality of life (Short Form-36)
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"Blocks of four were generated for each stratum by means of a computer generated random sequence table"
Allocation concealment (selection bias)Low risk"Research assistant, who was not involved in the selection of participants, allocated participants to groups using a list of random numbers"
Blinding of participants?High riskNo blinding of participants
Blinding of caregivers?High riskNo blinding of caregivers
Blinding of outcome assessment (detection bias)
All outcomes
High risk"All outcome measures were self report so they were not blind"
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low risk"There were 6 drop outs" out of 88: < 20%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Low riskTable 4: "analyses carried out according to the ITT principle"
Selective reporting (reporting bias)Low riskNo selective reporting
Similarity of baseline characteristics?Low risk"Both groups were comparable at baseline for nearly all variables"
Co-interventions avoided?Low riskNo mention of co-interventions, but also no mention of asking participants to avoid co-interventions
Compliance acceptable ?Low risk"Compliance was 94% in the PE therapy group and 96% in the RP group"
Timing outcome assessment comparable?Low riskTiming comparable

Vasseljen 1995

MethodsRCT
ParticipantsChronic (> six months) neck/shoulder complaints (non-specific); female office workers; n = 24. Work-related complaints 
Interventions

IPT: individual physiotherapy: treated by local physiotherapist outside the workplace; massage, exercise, mobilisation, ergonomic adjustments; n = 12; 10 weeks, two sessions/ wk

GPT: group physiotherapy: exercise at workplace by experienced physiotherapist; n = 12; six weeks, three sessions/wk

 

Follow-up: six months 

OutcomesPain (VAS), trigger points (algometer), strength, muscle activity (EMG) 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskUnclear randomisation procedure
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Unclear riskUnclear participant blinding
Blinding of caregivers?Unclear riskUnclear
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear whether outcome assessment was blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskNo dropouts mentioned
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Low riskITT analysis assumed
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskBaseline comparable
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Low riskCompliance with treatment regime was good
Timing outcome assessment comparable?Low riskTiming was comparable

Viljanen 2003

MethodsRCT; concealed randomisation, random number table and numbered opaque envelopes, outcome assessor blinded 
ParticipantsChronic (> three months) neck/shoulder complaints (non-specific), female office workers; n = 393. Occupational complaints 
Interventions

Dynamic muscle training: dynamic training using dumbbells, instructed by physiotherapist; n = 135

Relaxation training: various relaxation techniques, instructed by physiotherapist; n = 128

Control: ordinary activity; n = 130

 

Training for 12 weeks, three times/wk. Follow-up three, six and 12 months 

OutcomesNeck pain (VAS), neck disability (Q), work ability (Likert), sick leave 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskUsing random number table
Allocation concealment (selection bias)Low riskAllocation was concealed using opaque sealed envelopes
Blinding of participants?Low riskParticipants were blinded
Blinding of caregivers?Unclear riskUnclear
Blinding of outcome assessment (detection bias)
All outcomes
Low riskOutcome was self-reported, participants were blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskDropout varies from 8% to 18%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Low riskITT analysis performed
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskBaseline comparable
Co-interventions avoided?Low riskCo-interventions were avoided
Compliance acceptable ?Low riskCompliance was assessed
Timing outcome assessment comparable?Low riskTiming was comparable

Voerman 2007

MethodsRCT; no info on randomisation procedure 
ParticipantsFemale computer workers; age > 45. Prevalent non-specific neck/shoulder complaints; n = 79 
Interventions

Mfb: Ergonomic counselling + Myofeedback: Cinderella-based myofeedback on top of EC; four weeks for at least eight hours a week; n = 42

EC: Ergonomic counselling: diary, workplace investigation according to checklist, weekly visit by therapist; n = 37

 

Follow-up three and six months 

OutcomesPain intensity (VAS), pain disability (Pain Disability Index) 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Block randomization was used to assign subjects.." Inadequate detail given to randomisation method 
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?High riskParticipant was not blinded to intervention
Blinding of caregivers?High riskCaregivers were not blinded
Blinding of outcome assessment (detection bias)
All outcomes
High riskParticipant was outcome assessor and was not blinded to intervention
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low risk14/79 (approximately 18%) dropouts
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Unclear riskUnclear whether dropouts were included in analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskBaseline comparable: see Table 1 and Table 2
Co-interventions avoided?Unclear riskCo-interventions were not addressed
Compliance acceptable ?Unclear riskCompliance was partly assessed
Timing outcome assessment comparable?Low riskTiming was comparable

Waling 2000

MethodsRCT; group randomisation; women choose a group (?)
ParticipantsChronic (> 12 months) neck/shoulder complaints (non-specific); female employees; n = 126 (103). Work ‘contributed’ to the disorder 
Interventions

I1: Coordination training: body awareness therapy; n = 31 (25)

I2: Strength exercises: in a fitness centre with four different exercises; n = 34 (29)

I3: Endurance training: arm cycling on an arm ergometer; n = 34 (28)

C: Controls: discussion + stress management; n = 27 (21)

 

Ten weeks, three sessions/wk 

OutcomesPain (VAS), trigger points (algometer), function (Q), satisfaction (Q) 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear riskUnclear randomisation procedure
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?Unclear riskUnclear
Blinding of caregivers?Unclear riskUnclear
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnclear whether outcome assessment was blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
High risk20/82 dropouts (> 20%)
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Low riskITT analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskBaseline comparable
Co-interventions avoided?Unclear riskCo-interventions were not addressed
Compliance acceptable ?Low riskCompliance acceptable
Timing outcome assessment comparable?Low riskTiming was comparable

Werner 2005

MethodsRCT; randomisation based on the last digit of Social Security number (odd or even) 
ParticipantsActive workers with carpal tunnel syndrome; n = 161 
Interventions

Splint and video education: Customised wrist splints, which were worn at night for six weeks + ergonomic education; n = 86

Video education: ergonomic education alone by viewing a 20-minute video on CTS and ergonomic risk factors; n = 75

 

Follow-up: three, six and 12 months 

OutcomesPain (VAS), symptom severity scale 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)High riskOdd or even last digit Social Security number
Allocation concealment (selection bias)Unclear riskUnclear whether allocation was concealed
Blinding of participants?High riskParticipant not blinded
Blinding of caregivers?Unclear riskUnclear
Blinding of outcome assessment (detection bias)
All outcomes
High riskPrimary outcome was self-reported symptom severity scale; participants were not blinded
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
High riskInadequate description of reasons for dropout. 112/161 dropouts = 30%
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
High risk49 of original 161 randomly assigned participants not included in final analysis. Figure 1: almost half of participants did not complete three- and six-month questionnaires
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskBaseline comparable: see Table 1
Co-interventions avoided?Unclear riskNot clear whether participants were monitored for co-interventions or were asked to avoid
Compliance acceptable ?Unclear riskUnclear whether compliance was acceptable
Timing outcome assessment comparable?High riskTiming not comparable: 12 months of follow-up; ranged from seven to 15 months

Ylinen 2003

MethodsRCT; concealed randomisation: blinded block randomisation 
ParticipantsChronic neck pain (> six months); female office workers recruited from occupational health care services; n = 180. Work-related complaints 
Interventions

Strength exercises: 12-Day consecutive institutional rehabilitation period; used an elastic rubber band (Theraband) to train the neck flexor muscles in each session; n = 60

Endurance training: 12-Day consecutive institutional rehabilitation period; exercised neck flexor muscles by lifting the head up from the supine position in three series of 20 repetitions; n = 60

Controls: home stretching exercises; n = 60

Both training groups also underwent a multi-modal rehabilitation programme, which included relaxation training, aerobic training and behavioural support to reduce fear of pain and improve exercise motivation, as well as lectures and practical exercises in ergonomics

 

Five sessions/wk, nine sessions in total, one-month intervals during 12 months 

OutcomesNeck pain (VAS), disability (Q), depression, neck muscle strength, ROM 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"Block randomization into 3 grps of 10 persons was performed blind… from each block 1 patient was randomized to 1 of the 2 training groups or to control group"; unclear procedure
Allocation concealment (selection bias)Low riskBlock randomisation was performed blind
Blinding of participants?Unclear riskUnclear blinding
Blinding of caregivers?Unclear riskUnclear blinding
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskSelf-reported outcome assessment; unclear blinding
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskOnly three of 180 did not complete programme (< 20%)
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Low riskITT analysis performed
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskBaseline similarity
Co-interventions avoided?Low riskGroups given similar advice and other activities monitored by diaries
Compliance acceptable ?Low riskTraining adherence 86%, 93% and 65% for three groups based on training diaries
Timing outcome assessment comparable?Low riskTiming comparable

Ylinen 2007

MethodsRCT; examiner-blinded randomised cross-over trial 
ParticipantsHealth services; female office workers with non-specific neck pain; n = 125 
Interventions

Manual therapy, mobilisation and massage twice a week. No manipulation (i.e. high-velocity thrusts with low amplitude were applied); n = 62

Stretching exercises, five times a week; n = 63

 

Treatment: four weeks; cross-over after four weeks; follow-up: 12 weeks 

OutcomesBenefit, pain (VAS), average and night time, disability (NSPD, NDI) 
Notes 
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskTossing a coin
Allocation concealment (selection bias)Unclear riskRandomisation was performed by a person who had not seen the participants, but we do not know whether they had access to information about the participant
Blinding of participants?Unclear riskNo information on blinding procedures
Blinding of caregivers?Unclear riskNo information on blinding procedures
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo information on blinding procedures
Incomplete outcome data (attrition bias)
All outcomes - <20% drop-outs?
Low riskOnly two dropouts; therefore < 20%; they were not described
Incomplete outcome data (attrition bias)
All outcomes - ITT analysis performed?
Unclear riskUnable to tell from results what numbers were used in analysis
Selective reporting (reporting bias)Unclear riskNo protocol
Similarity of baseline characteristics?Low riskBaseline comparable: see Table 1
Co-interventions avoided?Unclear riskUnclear whether co-interventions were avoided
Compliance acceptable ?Unclear riskUnclear whether compliance was acceptable
Timing outcome assessment comparable?Low riskTiming was comparable

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Frost 2007No patients, mainly healthy people
Galinsky 2007No patients, only healthy people
Garg 2010No work-relatedness
Huis in't Veld 2007Not an RCT
Michalsen 2009No work-relatedness
Robertson 2013No patients, only healthy people
Shiri 2013No data separately on participants with upper extremity disorders
Spekle 2010Patients as well as healthy people were included; no subgroup analysis on participants
Tveito 2009No patients, only healthy people
von Thiele Schwarz 2008No patients, only healthy people
Zebis 2011No patients, only healthy people

Characteristics of ongoing studies [ordered by study ID]

Sundstrup 2013

Trial name or titleSundstrup 2013
MethodsRCT
ParticipantsSlaughterhouse workers
InterventionsStrength training; participatory ergonomics
OutcomesPain; disability
Starting dateUnclear
Contact informationE Sundstrup
NotesProtocol published in February 2013

Ancillary