Exercise therapy and work-related musculoskeletal disorders in sedentary workers

Exercise therapy and work-related musculoskeletal disorders in sedentary workers Abstract Background Work-related upper limb disorders (WRULDs) are a syndrome of symptoms affecting the upper quadrant of the body and are a significant cause of pain, disability and sickness absence among workers. Exercise therapy is considered to be a clinical and cost-effective strategy in WRULD management. Aims To evaluate the effectiveness of exercise therapy for WRULDs in sedentary workers. Methods This review follows an a priori protocol to maintain internal validity describing essential procedures to be followed (e.g. a comprehensive search strategy, duel extraction and critical appraisal). The methodological quality of the studies were assessed using Cochrane Risk of Bias Tool for all randomized controlled trials and the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool for systematic reviews. Results A total of 11 articles were selected for inclusion. There was moderate evidence to suggest exercise is effective in reducing the symptoms of pain and improved function in WRULDs in sedentary workers when compared to a control group. Conclusions The results were comparable to recent systematic reviews, which have found evidence to support the use of exercise therapy, in mixed populations of workers. There is a need for further research to highlight the most effective form of exercise, optimal dosage and delivery method. Exercise, sedentary, WRULD Introduction Work-related musculoskeletal disorders are a significant cause of pain and disability among sedentary workers [1]. Work-related upper limb disorders (WRULDs) is an umbrella term used to cover a wide range of musculoskeletal symptoms and pathological states of the upper quadrant from proximal joints (cervicothoracic, scapulothoracic, glenohumeral) to distal (elbow, wrist and hand). Symptoms may include pain, stiffness, loss of strength and neuromuscular control, paraesthesia, anaesthesia and loss of co-ordination. Specific WRULDs incorporate underlying specific diagnoses such as lateral epicondylitis and de Quervain’s tenosynovitis [2]. These disorders are understood to be as a result of repetitive or increased biomechanical overload of the upper limb during occupational activities [3–6]. However, there is a lack of consensus on an accepted definition for these conditions [7,8]. There are many interchangeable definitions or classifications used which include WRULD/work-related upper extremity disorder (WRUED), repetitive strain injury and complaints of the arm, neck and shoulder (CANS). There does appear to be a distinction in the literature between specific and non-specific WRULDs. The loss of function and continuing disability can result from the painful symptoms of WRULDs [2]. Recent figures from the Labour Force Survey (2016) estimate the prevalence of WRULDs in Great Britain in 2015/16 at 222000 total cases (case rate of 690 per 100000 people employed). In 2015/16 3138000 working days were lost due to WRULDs in Great Britain; equating to 14.1 days per case [9]. It is, therefore, a challenge for employers and occupational health departments to effectively manage these conditions to reduce the prevalence and increase overall productivity. Conservative interventions with physiotherapy at the forefront play an important role in the management of these conditions [10, 11] with exercise therapy suggested as an effective and cost-effective tool [12–14]. Exercise has been shown to effectively improve symptoms of musculoskeletal pain in all body regions of office workers previously [15] and, with the drive to promote physical activity in the sedentary population [16], may prove an effective solution. However, there has been conflicting evidence to support the effectiveness of exercise therapy for the treatment of WRULDs [17]. There is also a dearth of evidence on the effectiveness of exercise for specific populations of workers [18] and to the knowledge of the authors, no studies have reviewed its efficacy with regards to the targeted population of sedentary workers. This systematic review, therefore, aimed to evaluate the effectiveness of exercise therapy in the management of WRULDs in the population of sedentary workers. Methods The methodology of this review followed specific systematic review development guidelines [18] and reported the review in accordance with the PRISMA statement for reporting systematic reviews [19, 20]. Additionally, the review was constructed based upon an a priori protocol which described essential procedures to be followed (e.g. dual extraction and critical appraisal). Ethical approval was not required due to the review of previously published literature. A literature search was conducted of the following databases; EMBASE, EMBASE CLASSIC, HMIC, MEDLINE, PsycINFO, CINAHL, PEDro, Social Policy and Practice to identify both published and unpublished studies from 1966 to present. The key terms used for the search were as follows; exercise, work related upper limb disorders, WRULD, WRUED, CANS, physiotherapy, management, office/computer workers, sedentary workers. The search was supplemented by a grey literature search of the reference list of any relevant articles sourced. Inclusion criteria were as follows: • The study design was either a randomized controlled trial (RCT) or systematic review. • The article was a full report published in English. • The participants included in each study were sedentary/office/computer screen workers. • Exercise therapy was the primary intervention used as treatment for any symptoms under the umbrella term of WRULD. • Reporting of a primary functional or pain variable (e.g. Numerical Pain Rating Scale (NPRS)/Neck Disability Index (NDI)). Studies were excluded if they did not meet the above criteria. The search results were filtered for duplicates and the lead reviewer (D.K.) screened remaining titles and abstracts using the inclusion criteria. All full articles obtained were then reviewed independently by D.K. and F.S. and a predetermined and piloted data extraction table was used to extract the appropriate and relevant findings. The main characteristics for data extraction was as follows: • study population, size and gender; • aspects of the intervention, exercise type, supervision, frequency; • outcome measures used—specifically pain and functional variables and any work-related outcomes and • reported results The methodological quality of the included RCTs was assessed using the Cochrane Risk of Bias Tool (Modified) and the AMSTAR (Assessing the Methodological Quality of Systematic Reviews) tool for use with systematic reviews. The AMSTAR is scored out of 11 items. Two reviewers (D.K./F.S.) examined the studies for risk of bias and internal validity. A third reviewer was available to resolve disagreements (C.T.). Inter-observer agreement of the risk of bias between reviewers was assessed using the Kappa statistic [21]. A scoring system including five levels of evidence was used to synthesize the evidence [22]. The system considers the number and methodological quality of the studies as follows: • strong evidence: provided by consistent findings in two or more high-quality RCTs; • moderate evidence: provided by consistent findings in one high-quality RCT and one or more low-quality RCTs, or by consistent findings in multiple low-quality RCTs; • limited evidence: only one high-quality RCT or multiple low-quality RCTs; • conflicting evidence: inconsistent findings in multiple RCTs and • absent evidence: no RCT. Results A total of 11 articles were selected to be analysed based on the inclusion criteria. This consisted of nine RCTs and two systematic reviews (Figure 1). Results of the methodological assessment are shown in Table 1. While the percentage agreement between reviewers when examining risk of bias was high (81%), the inter-observer agreement regarding the risk of bias was considered ‘substantial’ (k = 0.67) according to the Kappa interpretation model [21].This was used to demonstrate the critical appraisal findings representing the risk of bias accurately. Figure 1. View largeDownload slide Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart showing study selection process. Figure 1. View largeDownload slide Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart showing study selection process. Table 1. Characteristics of the included studies Study Design Risk of bias Population Intervention Outcomes Results Ma et al. [24] RCT High Daily computer users from two Chinese universities and nearby outpatient clinics with past/present history of computer-related neck/shoulder discomfort (n = 60, DO = 22) 1. Biofeedback group (BG); 2 h daily exercise while at computer 2. Active exercise group (AG); daily strength and stretch program 3. Passive treatment group (PG); interferential therapy and hot packs ×2/week. 4. Control group (CG); education booklet on office ergonomics VAS NDI EMG surface during typing task Significantly greater decrease in VAS, NDI and EMG in BG compared with other groups at 6/52 and 6/12 (P < 0.05). However significant decrease in VAS and NDI in AG and PG not in CG. Andersen et al. [28] RCT Low Computer users with frequent neck/shoulder muscle pain (n = 198, DO = 6) 1. Two-min group; one single set of exercise to failure up to 2 min 2. Twelve-min group; 5–6 sets of 8–12 repetitions progressing to a total of 25–30 sets per week 3. CG; received weekly emailed information on various aspects of general health VAS Palpable tenderness of neck/shoulder muscles Isometric strength Significant pain reduction in exercise groups compared with control. No significant difference between exercise groups. Significant reduction in palpable tenderness in exercise groups compared with control. Viljanen et al. [29] RCT High Female office workers with chronic non-specific pain >12/52 (n = 393, DO = 55) 1. Dynamic muscle training group; exercise 3/week for 30 min for 12/52 physio led initially, then performed themselves with feedback 2. Relaxation group; taught participants to activate only those muscles needed for specific activities and relax others 3. CG; told not to change any activity for 12/52 Cervical ROM Dynamic muscle strength in the neck/shoulder NDI Depression Work stress No significant differences between two training groups and control for changes in pain, NDI, ROM or dynamic muscle strength (no P value available). van Eijsden et al. [26] RCT High Computer screen workers with non-specific WRULD (n = 88, DO = 6) 1. Postural exercise group (PE); posture awareness education through exercise—1 hour treatments ×2 per week 1–3, then 1/week then 1/2 h for 2/52 2. Regular physio group (RP); who attended WRULD course of active muscle training and fitness—3 × 1/2 h for 3 weeks, 2 × 1/2 for 2 weeks, 1 × 1/2 h for 2 weeks 10-week treatment duration Groningen Fitness Questionnaire Job stress survey STAI VAS DASH EQ5D QALY showed no significant difference between groups. VAS was significantly different in RP group at 3 months but not maintained at 6 months. No significant difference in outcomes between groups at 1 year. No statistical significant difference between groups regarding cost effectiveness. Sihawong et al. [31] SR Amstar 7/11 Office workers with non-specific neck pain (n = 9 studies) Exercise therapy Incidence and prevalence of neck pain Discomfort PPT Frequency, duration, severity Productivity Work ability index sick leave Recovery, disability Strong evidence positive effect of strengthening and endurance exercise for treating neck pain. Three high-quality trials suggested muscle strengthening significantly reduced intensity of neck pain. One high-quality trial: no significant difference in neck pain in workers who received strength and stretching compared with no intervention. Conflicting evidence for stretching exercises. Conflicting evidence for non-specific exercises. Blangsted et al. [23] RCT High Office workers (symptomatic and asymptomatic) (n = 549) 1. Specific resistance training (SRT); resistance exercise for neck/shoulder 3/week 20 min supervised, dynamic resistance for arm/shoulders, static exercise for neck and row exercise for arms/shoulders 2. All-round physical exercise (APE); motivated for any exercise, organized groups for running/walking, given step counters. Bike to work 3. Reference groups (REF); advice given re ergonomics food, work organization health promotion Modified Noridc Questionnaire Work ability index Mean intensity of pain Statistically significant differences between SRT and APE compared with REF, in the intensity and the duration of symptoms. SRT not more effective than APE in reducing duration/intensity of symptoms. Andersen et al. [25] RCT High Female computer workers (n = 48, DO = 6) 1. Specific strength training (SST); supervised high intensity strength training shoulder/neck, load progressively increased 2. General fitness training (GFT); leg bicycling 3. REF; health promotion, relaxation stress management 1 h per week for each group VAS Aerobic fitness Isometric muscle strength shoulder elevation and abduction Isometric muscle strength increased significantly in the SST group during shoulder elevation and abduction. Significant decrease in VAS in the SST group, no significant change over time was observed in the GFT and REF groups. Sjorgen et al. [32] RCT High Office workers reporting headache/shoulder/neck pain <12/12 (n = 53) Two treatment sequence groups; group 1 had intervention for 15/52 while group 2 had nothing, then groups swapped Physical exercise intervention consisted of progressive light resistance training performed 1/day in working week, then after 5/52 1–2/day 20 repetitions of 30% RM Guidance: physio provided training instructions and general guidance on posture and movement control BORG CR10 1 RM Physical activity Physical ex intervention significantly decreased intensity of headache and neck symptoms, no effect in the shoulder. Ylinen et al. [27] RCT High Female office workers referred from occupational health (n = 180) 1. Strength training groups; Theraband to train neck muscles 15 repetitions all directions 2. Endurance training group; neck flexor muscles 20 × 3 Both groups performed dynamic exercise for shoulders and UE 3. CG Five sessions per week 45 min long VAS Modified neck and shoulder disability index Isometric neck strength and ROM Grip strength Neck pain and disability significantly decreased in both exercise groups compared with control at 12/12 follow-up. ROM significantly increased in both training groups. Andersen et al. [30] RCT High Office workers (n = 549, DO = 109) 1 h per week for intervention 1. SRT: 2–3 sets 10–15 repetitions of dynamic strengthening exercise for shoulder and static exercise for neck 2. APE: motivated to increase physical activity levels, steppers, punch bags, Nordic walking 3. Reference intervention (REF); health promotion activities Isometric muscle strength shoulder elevation and abduction Questionnaire regarding neck and shoulder symptoms For participants with neck pain, there was a significant decrease in intensity in SRT and APE compared to REF. Coury et al. [22] SR AMSTAR 7/11 Sedentary workers (nine studies) Mixture of heavy and light strength training with comparison groups VAS, NDI, shoulder pain index, PPT, Modified Nordic Questionnaire. Borg CR10 Three high-quality studies showed strong evidence for the effect of exercise for neck symptoms. Three high-quality studies showed strong evidence for ineffectiveness of workplace exercise for shoulder symptoms. Study Design Risk of bias Population Intervention Outcomes Results Ma et al. [24] RCT High Daily computer users from two Chinese universities and nearby outpatient clinics with past/present history of computer-related neck/shoulder discomfort (n = 60, DO = 22) 1. Biofeedback group (BG); 2 h daily exercise while at computer 2. Active exercise group (AG); daily strength and stretch program 3. Passive treatment group (PG); interferential therapy and hot packs ×2/week. 4. Control group (CG); education booklet on office ergonomics VAS NDI EMG surface during typing task Significantly greater decrease in VAS, NDI and EMG in BG compared with other groups at 6/52 and 6/12 (P < 0.05). However significant decrease in VAS and NDI in AG and PG not in CG. Andersen et al. [28] RCT Low Computer users with frequent neck/shoulder muscle pain (n = 198, DO = 6) 1. Two-min group; one single set of exercise to failure up to 2 min 2. Twelve-min group; 5–6 sets of 8–12 repetitions progressing to a total of 25–30 sets per week 3. CG; received weekly emailed information on various aspects of general health VAS Palpable tenderness of neck/shoulder muscles Isometric strength Significant pain reduction in exercise groups compared with control. No significant difference between exercise groups. Significant reduction in palpable tenderness in exercise groups compared with control. Viljanen et al. [29] RCT High Female office workers with chronic non-specific pain >12/52 (n = 393, DO = 55) 1. Dynamic muscle training group; exercise 3/week for 30 min for 12/52 physio led initially, then performed themselves with feedback 2. Relaxation group; taught participants to activate only those muscles needed for specific activities and relax others 3. CG; told not to change any activity for 12/52 Cervical ROM Dynamic muscle strength in the neck/shoulder NDI Depression Work stress No significant differences between two training groups and control for changes in pain, NDI, ROM or dynamic muscle strength (no P value available). van Eijsden et al. [26] RCT High Computer screen workers with non-specific WRULD (n = 88, DO = 6) 1. Postural exercise group (PE); posture awareness education through exercise—1 hour treatments ×2 per week 1–3, then 1/week then 1/2 h for 2/52 2. Regular physio group (RP); who attended WRULD course of active muscle training and fitness—3 × 1/2 h for 3 weeks, 2 × 1/2 for 2 weeks, 1 × 1/2 h for 2 weeks 10-week treatment duration Groningen Fitness Questionnaire Job stress survey STAI VAS DASH EQ5D QALY showed no significant difference between groups. VAS was significantly different in RP group at 3 months but not maintained at 6 months. No significant difference in outcomes between groups at 1 year. No statistical significant difference between groups regarding cost effectiveness. Sihawong et al. [31] SR Amstar 7/11 Office workers with non-specific neck pain (n = 9 studies) Exercise therapy Incidence and prevalence of neck pain Discomfort PPT Frequency, duration, severity Productivity Work ability index sick leave Recovery, disability Strong evidence positive effect of strengthening and endurance exercise for treating neck pain. Three high-quality trials suggested muscle strengthening significantly reduced intensity of neck pain. One high-quality trial: no significant difference in neck pain in workers who received strength and stretching compared with no intervention. Conflicting evidence for stretching exercises. Conflicting evidence for non-specific exercises. Blangsted et al. [23] RCT High Office workers (symptomatic and asymptomatic) (n = 549) 1. Specific resistance training (SRT); resistance exercise for neck/shoulder 3/week 20 min supervised, dynamic resistance for arm/shoulders, static exercise for neck and row exercise for arms/shoulders 2. All-round physical exercise (APE); motivated for any exercise, organized groups for running/walking, given step counters. Bike to work 3. Reference groups (REF); advice given re ergonomics food, work organization health promotion Modified Noridc Questionnaire Work ability index Mean intensity of pain Statistically significant differences between SRT and APE compared with REF, in the intensity and the duration of symptoms. SRT not more effective than APE in reducing duration/intensity of symptoms. Andersen et al. [25] RCT High Female computer workers (n = 48, DO = 6) 1. Specific strength training (SST); supervised high intensity strength training shoulder/neck, load progressively increased 2. General fitness training (GFT); leg bicycling 3. REF; health promotion, relaxation stress management 1 h per week for each group VAS Aerobic fitness Isometric muscle strength shoulder elevation and abduction Isometric muscle strength increased significantly in the SST group during shoulder elevation and abduction. Significant decrease in VAS in the SST group, no significant change over time was observed in the GFT and REF groups. Sjorgen et al. [32] RCT High Office workers reporting headache/shoulder/neck pain <12/12 (n = 53) Two treatment sequence groups; group 1 had intervention for 15/52 while group 2 had nothing, then groups swapped Physical exercise intervention consisted of progressive light resistance training performed 1/day in working week, then after 5/52 1–2/day 20 repetitions of 30% RM Guidance: physio provided training instructions and general guidance on posture and movement control BORG CR10 1 RM Physical activity Physical ex intervention significantly decreased intensity of headache and neck symptoms, no effect in the shoulder. Ylinen et al. [27] RCT High Female office workers referred from occupational health (n = 180) 1. Strength training groups; Theraband to train neck muscles 15 repetitions all directions 2. Endurance training group; neck flexor muscles 20 × 3 Both groups performed dynamic exercise for shoulders and UE 3. CG Five sessions per week 45 min long VAS Modified neck and shoulder disability index Isometric neck strength and ROM Grip strength Neck pain and disability significantly decreased in both exercise groups compared with control at 12/12 follow-up. ROM significantly increased in both training groups. Andersen et al. [30] RCT High Office workers (n = 549, DO = 109) 1 h per week for intervention 1. SRT: 2–3 sets 10–15 repetitions of dynamic strengthening exercise for shoulder and static exercise for neck 2. APE: motivated to increase physical activity levels, steppers, punch bags, Nordic walking 3. Reference intervention (REF); health promotion activities Isometric muscle strength shoulder elevation and abduction Questionnaire regarding neck and shoulder symptoms For participants with neck pain, there was a significant decrease in intensity in SRT and APE compared to REF. Coury et al. [22] SR AMSTAR 7/11 Sedentary workers (nine studies) Mixture of heavy and light strength training with comparison groups VAS, NDI, shoulder pain index, PPT, Modified Nordic Questionnaire. Borg CR10 Three high-quality studies showed strong evidence for the effect of exercise for neck symptoms. Three high-quality studies showed strong evidence for ineffectiveness of workplace exercise for shoulder symptoms. 1RM, 1 repetition maximum; DASH, disability of arm, shoulder and hand; DO, drop out; EMG, electromyography; PPT, pain pressure threshold; ROM, range of movement; SR, systematic review; STAI, State-Trait Anxiety Inventory. View Large Table 1. Characteristics of the included studies Study Design Risk of bias Population Intervention Outcomes Results Ma et al. [24] RCT High Daily computer users from two Chinese universities and nearby outpatient clinics with past/present history of computer-related neck/shoulder discomfort (n = 60, DO = 22) 1. Biofeedback group (BG); 2 h daily exercise while at computer 2. Active exercise group (AG); daily strength and stretch program 3. Passive treatment group (PG); interferential therapy and hot packs ×2/week. 4. Control group (CG); education booklet on office ergonomics VAS NDI EMG surface during typing task Significantly greater decrease in VAS, NDI and EMG in BG compared with other groups at 6/52 and 6/12 (P < 0.05). However significant decrease in VAS and NDI in AG and PG not in CG. Andersen et al. [28] RCT Low Computer users with frequent neck/shoulder muscle pain (n = 198, DO = 6) 1. Two-min group; one single set of exercise to failure up to 2 min 2. Twelve-min group; 5–6 sets of 8–12 repetitions progressing to a total of 25–30 sets per week 3. CG; received weekly emailed information on various aspects of general health VAS Palpable tenderness of neck/shoulder muscles Isometric strength Significant pain reduction in exercise groups compared with control. No significant difference between exercise groups. Significant reduction in palpable tenderness in exercise groups compared with control. Viljanen et al. [29] RCT High Female office workers with chronic non-specific pain >12/52 (n = 393, DO = 55) 1. Dynamic muscle training group; exercise 3/week for 30 min for 12/52 physio led initially, then performed themselves with feedback 2. Relaxation group; taught participants to activate only those muscles needed for specific activities and relax others 3. CG; told not to change any activity for 12/52 Cervical ROM Dynamic muscle strength in the neck/shoulder NDI Depression Work stress No significant differences between two training groups and control for changes in pain, NDI, ROM or dynamic muscle strength (no P value available). van Eijsden et al. [26] RCT High Computer screen workers with non-specific WRULD (n = 88, DO = 6) 1. Postural exercise group (PE); posture awareness education through exercise—1 hour treatments ×2 per week 1–3, then 1/week then 1/2 h for 2/52 2. Regular physio group (RP); who attended WRULD course of active muscle training and fitness—3 × 1/2 h for 3 weeks, 2 × 1/2 for 2 weeks, 1 × 1/2 h for 2 weeks 10-week treatment duration Groningen Fitness Questionnaire Job stress survey STAI VAS DASH EQ5D QALY showed no significant difference between groups. VAS was significantly different in RP group at 3 months but not maintained at 6 months. No significant difference in outcomes between groups at 1 year. No statistical significant difference between groups regarding cost effectiveness. Sihawong et al. [31] SR Amstar 7/11 Office workers with non-specific neck pain (n = 9 studies) Exercise therapy Incidence and prevalence of neck pain Discomfort PPT Frequency, duration, severity Productivity Work ability index sick leave Recovery, disability Strong evidence positive effect of strengthening and endurance exercise for treating neck pain. Three high-quality trials suggested muscle strengthening significantly reduced intensity of neck pain. One high-quality trial: no significant difference in neck pain in workers who received strength and stretching compared with no intervention. Conflicting evidence for stretching exercises. Conflicting evidence for non-specific exercises. Blangsted et al. [23] RCT High Office workers (symptomatic and asymptomatic) (n = 549) 1. Specific resistance training (SRT); resistance exercise for neck/shoulder 3/week 20 min supervised, dynamic resistance for arm/shoulders, static exercise for neck and row exercise for arms/shoulders 2. All-round physical exercise (APE); motivated for any exercise, organized groups for running/walking, given step counters. Bike to work 3. Reference groups (REF); advice given re ergonomics food, work organization health promotion Modified Noridc Questionnaire Work ability index Mean intensity of pain Statistically significant differences between SRT and APE compared with REF, in the intensity and the duration of symptoms. SRT not more effective than APE in reducing duration/intensity of symptoms. Andersen et al. [25] RCT High Female computer workers (n = 48, DO = 6) 1. Specific strength training (SST); supervised high intensity strength training shoulder/neck, load progressively increased 2. General fitness training (GFT); leg bicycling 3. REF; health promotion, relaxation stress management 1 h per week for each group VAS Aerobic fitness Isometric muscle strength shoulder elevation and abduction Isometric muscle strength increased significantly in the SST group during shoulder elevation and abduction. Significant decrease in VAS in the SST group, no significant change over time was observed in the GFT and REF groups. Sjorgen et al. [32] RCT High Office workers reporting headache/shoulder/neck pain <12/12 (n = 53) Two treatment sequence groups; group 1 had intervention for 15/52 while group 2 had nothing, then groups swapped Physical exercise intervention consisted of progressive light resistance training performed 1/day in working week, then after 5/52 1–2/day 20 repetitions of 30% RM Guidance: physio provided training instructions and general guidance on posture and movement control BORG CR10 1 RM Physical activity Physical ex intervention significantly decreased intensity of headache and neck symptoms, no effect in the shoulder. Ylinen et al. [27] RCT High Female office workers referred from occupational health (n = 180) 1. Strength training groups; Theraband to train neck muscles 15 repetitions all directions 2. Endurance training group; neck flexor muscles 20 × 3 Both groups performed dynamic exercise for shoulders and UE 3. CG Five sessions per week 45 min long VAS Modified neck and shoulder disability index Isometric neck strength and ROM Grip strength Neck pain and disability significantly decreased in both exercise groups compared with control at 12/12 follow-up. ROM significantly increased in both training groups. Andersen et al. [30] RCT High Office workers (n = 549, DO = 109) 1 h per week for intervention 1. SRT: 2–3 sets 10–15 repetitions of dynamic strengthening exercise for shoulder and static exercise for neck 2. APE: motivated to increase physical activity levels, steppers, punch bags, Nordic walking 3. Reference intervention (REF); health promotion activities Isometric muscle strength shoulder elevation and abduction Questionnaire regarding neck and shoulder symptoms For participants with neck pain, there was a significant decrease in intensity in SRT and APE compared to REF. Coury et al. [22] SR AMSTAR 7/11 Sedentary workers (nine studies) Mixture of heavy and light strength training with comparison groups VAS, NDI, shoulder pain index, PPT, Modified Nordic Questionnaire. Borg CR10 Three high-quality studies showed strong evidence for the effect of exercise for neck symptoms. Three high-quality studies showed strong evidence for ineffectiveness of workplace exercise for shoulder symptoms. Study Design Risk of bias Population Intervention Outcomes Results Ma et al. [24] RCT High Daily computer users from two Chinese universities and nearby outpatient clinics with past/present history of computer-related neck/shoulder discomfort (n = 60, DO = 22) 1. Biofeedback group (BG); 2 h daily exercise while at computer 2. Active exercise group (AG); daily strength and stretch program 3. Passive treatment group (PG); interferential therapy and hot packs ×2/week. 4. Control group (CG); education booklet on office ergonomics VAS NDI EMG surface during typing task Significantly greater decrease in VAS, NDI and EMG in BG compared with other groups at 6/52 and 6/12 (P < 0.05). However significant decrease in VAS and NDI in AG and PG not in CG. Andersen et al. [28] RCT Low Computer users with frequent neck/shoulder muscle pain (n = 198, DO = 6) 1. Two-min group; one single set of exercise to failure up to 2 min 2. Twelve-min group; 5–6 sets of 8–12 repetitions progressing to a total of 25–30 sets per week 3. CG; received weekly emailed information on various aspects of general health VAS Palpable tenderness of neck/shoulder muscles Isometric strength Significant pain reduction in exercise groups compared with control. No significant difference between exercise groups. Significant reduction in palpable tenderness in exercise groups compared with control. Viljanen et al. [29] RCT High Female office workers with chronic non-specific pain >12/52 (n = 393, DO = 55) 1. Dynamic muscle training group; exercise 3/week for 30 min for 12/52 physio led initially, then performed themselves with feedback 2. Relaxation group; taught participants to activate only those muscles needed for specific activities and relax others 3. CG; told not to change any activity for 12/52 Cervical ROM Dynamic muscle strength in the neck/shoulder NDI Depression Work stress No significant differences between two training groups and control for changes in pain, NDI, ROM or dynamic muscle strength (no P value available). van Eijsden et al. [26] RCT High Computer screen workers with non-specific WRULD (n = 88, DO = 6) 1. Postural exercise group (PE); posture awareness education through exercise—1 hour treatments ×2 per week 1–3, then 1/week then 1/2 h for 2/52 2. Regular physio group (RP); who attended WRULD course of active muscle training and fitness—3 × 1/2 h for 3 weeks, 2 × 1/2 for 2 weeks, 1 × 1/2 h for 2 weeks 10-week treatment duration Groningen Fitness Questionnaire Job stress survey STAI VAS DASH EQ5D QALY showed no significant difference between groups. VAS was significantly different in RP group at 3 months but not maintained at 6 months. No significant difference in outcomes between groups at 1 year. No statistical significant difference between groups regarding cost effectiveness. Sihawong et al. [31] SR Amstar 7/11 Office workers with non-specific neck pain (n = 9 studies) Exercise therapy Incidence and prevalence of neck pain Discomfort PPT Frequency, duration, severity Productivity Work ability index sick leave Recovery, disability Strong evidence positive effect of strengthening and endurance exercise for treating neck pain. Three high-quality trials suggested muscle strengthening significantly reduced intensity of neck pain. One high-quality trial: no significant difference in neck pain in workers who received strength and stretching compared with no intervention. Conflicting evidence for stretching exercises. Conflicting evidence for non-specific exercises. Blangsted et al. [23] RCT High Office workers (symptomatic and asymptomatic) (n = 549) 1. Specific resistance training (SRT); resistance exercise for neck/shoulder 3/week 20 min supervised, dynamic resistance for arm/shoulders, static exercise for neck and row exercise for arms/shoulders 2. All-round physical exercise (APE); motivated for any exercise, organized groups for running/walking, given step counters. Bike to work 3. Reference groups (REF); advice given re ergonomics food, work organization health promotion Modified Noridc Questionnaire Work ability index Mean intensity of pain Statistically significant differences between SRT and APE compared with REF, in the intensity and the duration of symptoms. SRT not more effective than APE in reducing duration/intensity of symptoms. Andersen et al. [25] RCT High Female computer workers (n = 48, DO = 6) 1. Specific strength training (SST); supervised high intensity strength training shoulder/neck, load progressively increased 2. General fitness training (GFT); leg bicycling 3. REF; health promotion, relaxation stress management 1 h per week for each group VAS Aerobic fitness Isometric muscle strength shoulder elevation and abduction Isometric muscle strength increased significantly in the SST group during shoulder elevation and abduction. Significant decrease in VAS in the SST group, no significant change over time was observed in the GFT and REF groups. Sjorgen et al. [32] RCT High Office workers reporting headache/shoulder/neck pain <12/12 (n = 53) Two treatment sequence groups; group 1 had intervention for 15/52 while group 2 had nothing, then groups swapped Physical exercise intervention consisted of progressive light resistance training performed 1/day in working week, then after 5/52 1–2/day 20 repetitions of 30% RM Guidance: physio provided training instructions and general guidance on posture and movement control BORG CR10 1 RM Physical activity Physical ex intervention significantly decreased intensity of headache and neck symptoms, no effect in the shoulder. Ylinen et al. [27] RCT High Female office workers referred from occupational health (n = 180) 1. Strength training groups; Theraband to train neck muscles 15 repetitions all directions 2. Endurance training group; neck flexor muscles 20 × 3 Both groups performed dynamic exercise for shoulders and UE 3. CG Five sessions per week 45 min long VAS Modified neck and shoulder disability index Isometric neck strength and ROM Grip strength Neck pain and disability significantly decreased in both exercise groups compared with control at 12/12 follow-up. ROM significantly increased in both training groups. Andersen et al. [30] RCT High Office workers (n = 549, DO = 109) 1 h per week for intervention 1. SRT: 2–3 sets 10–15 repetitions of dynamic strengthening exercise for shoulder and static exercise for neck 2. APE: motivated to increase physical activity levels, steppers, punch bags, Nordic walking 3. Reference intervention (REF); health promotion activities Isometric muscle strength shoulder elevation and abduction Questionnaire regarding neck and shoulder symptoms For participants with neck pain, there was a significant decrease in intensity in SRT and APE compared to REF. Coury et al. [22] SR AMSTAR 7/11 Sedentary workers (nine studies) Mixture of heavy and light strength training with comparison groups VAS, NDI, shoulder pain index, PPT, Modified Nordic Questionnaire. Borg CR10 Three high-quality studies showed strong evidence for the effect of exercise for neck symptoms. Three high-quality studies showed strong evidence for ineffectiveness of workplace exercise for shoulder symptoms. 1RM, 1 repetition maximum; DASH, disability of arm, shoulder and hand; DO, drop out; EMG, electromyography; PPT, pain pressure threshold; ROM, range of movement; SR, systematic review; STAI, State-Trait Anxiety Inventory. View Large Table 1 shows the characteristics of the included studies in the review which includes the study design, risk of bias, study population, intervention, outcomes used and specific results for sedentary workers. To aid interpretation of the results, this review further categorized relevant characteristics from the included studies. If results were not classified as pre-test and post-test (or were not available), they were not included in the tables. The results from one particular study could not be extrapolated from the available graphs and were not presented in table format [23]. Table 2 demonstrates the numerical results of pain outcomes for those studies which had the available data reported. The Visual Analogue Scale (VAS) was the predominant outcome measure used to evaluate symptoms of pain in the included studies [22–27]. Table 3 highlights the numerical results of the functional variables for the studies included. With regards to the measurement of function, the most commonly used evaluation tools were the NDI [25,28,29] and muscle strength (Nm) [26,28,30]. Table 2. Numerical results of outcomes for pain variables for included studies Study Pain variable Evaluation tool Pre-test Post-test Ma et al. [24] VAS BG: 5.12 ± 1.65 BG: 1.87 ± 0.74 AG: 4.75 ± 1.59 AG: 2.10 ± 1.34 PG: 5.69 ± 1.54 PG: 3.60 ± 1.18 CG: 5.27 ± 1.27 CG: 4.75 ± 1.53 Andersen et al. [28] VAS (modified) 2G: −1.3 (−1.9 to −0.7) 12G: −1.8 (−2.4 to −1.2) CG: 0.1 (−0.3 to 0.5) Viljanen et al. [29] Pain intensity DG: 4.8 ± 2.3 DG: 2.9 ± 2.6 RG: 4.8 ± 2.3 RG: 2.9 ± 2.4 CG: 4.1 ± 2.2 CG: 2.7 ± 2.5 van Eijsden et al. [26] VAS Means (95% CI) PE: 2.88 (2.43, 3.33) PE: 1.90 (1.35, 2.45) RP: 2.59 (2.07, 3.11) RP: 1.13 (0.76, 1.51) Andersen et al. [25] VAS GFT: 50 ± 16 GFT: 45 ± 13 SST: 44 ± 25 SST: 10 ± 10 REF: 43 ± 27 REF: 35 ± 29 Sjorgen et al. [32] Borg CR10 Headache intensity (observed mean, SD) TG1: Intervention TG1: No intervention 2.30 (2.26)–1.42 (1.69) 1.42 (2.10)–1.29 (1.81) TG2: No intervention TG2: Intervention 2.21(2.82)–1.51 (1.65) 0.43 (1.34)–0.39 (1.08) Ylinen et al. [27] VAS SG: 58 (73–72) SG: −40 (−48 to −32) EG: 57(43–74) EG: −35 (−42 to −28) CG: 58 (42–74) CG: −16 (−22 to −9) Median IQR Median (95% CI) Andersen et al. [30] Neck pain SRT: 5.0 ± 0.2 SRT: 3.4 ± 0.2 APE: 5.0 ± 0.2 APE: 3.6 ± 0.2 Study Pain variable Evaluation tool Pre-test Post-test Ma et al. [24] VAS BG: 5.12 ± 1.65 BG: 1.87 ± 0.74 AG: 4.75 ± 1.59 AG: 2.10 ± 1.34 PG: 5.69 ± 1.54 PG: 3.60 ± 1.18 CG: 5.27 ± 1.27 CG: 4.75 ± 1.53 Andersen et al. [28] VAS (modified) 2G: −1.3 (−1.9 to −0.7) 12G: −1.8 (−2.4 to −1.2) CG: 0.1 (−0.3 to 0.5) Viljanen et al. [29] Pain intensity DG: 4.8 ± 2.3 DG: 2.9 ± 2.6 RG: 4.8 ± 2.3 RG: 2.9 ± 2.4 CG: 4.1 ± 2.2 CG: 2.7 ± 2.5 van Eijsden et al. [26] VAS Means (95% CI) PE: 2.88 (2.43, 3.33) PE: 1.90 (1.35, 2.45) RP: 2.59 (2.07, 3.11) RP: 1.13 (0.76, 1.51) Andersen et al. [25] VAS GFT: 50 ± 16 GFT: 45 ± 13 SST: 44 ± 25 SST: 10 ± 10 REF: 43 ± 27 REF: 35 ± 29 Sjorgen et al. [32] Borg CR10 Headache intensity (observed mean, SD) TG1: Intervention TG1: No intervention 2.30 (2.26)–1.42 (1.69) 1.42 (2.10)–1.29 (1.81) TG2: No intervention TG2: Intervention 2.21(2.82)–1.51 (1.65) 0.43 (1.34)–0.39 (1.08) Ylinen et al. [27] VAS SG: 58 (73–72) SG: −40 (−48 to −32) EG: 57(43–74) EG: −35 (−42 to −28) CG: 58 (42–74) CG: −16 (−22 to −9) Median IQR Median (95% CI) Andersen et al. [30] Neck pain SRT: 5.0 ± 0.2 SRT: 3.4 ± 0.2 APE: 5.0 ± 0.2 APE: 3.6 ± 0.2 12G, 12-min group; 2G, 2-min group; AG, active exercise group; APE, all-round physical exercise group; BG, biofeedback group; CG, control group; DG, dynamic muscle training group; EG, endurance training group; GFT, general fitness training; PE, postural exercise group; PG, passive treatment group; REF, reference groups; RG, relaxation group; RP, regular physio group; SG, strength training group; SRT, specific training group; SST, specific strength training; TG1, treatment group 1; TG2, treatment group 2. View Large Table 2. Numerical results of outcomes for pain variables for included studies Study Pain variable Evaluation tool Pre-test Post-test Ma et al. [24] VAS BG: 5.12 ± 1.65 BG: 1.87 ± 0.74 AG: 4.75 ± 1.59 AG: 2.10 ± 1.34 PG: 5.69 ± 1.54 PG: 3.60 ± 1.18 CG: 5.27 ± 1.27 CG: 4.75 ± 1.53 Andersen et al. [28] VAS (modified) 2G: −1.3 (−1.9 to −0.7) 12G: −1.8 (−2.4 to −1.2) CG: 0.1 (−0.3 to 0.5) Viljanen et al. [29] Pain intensity DG: 4.8 ± 2.3 DG: 2.9 ± 2.6 RG: 4.8 ± 2.3 RG: 2.9 ± 2.4 CG: 4.1 ± 2.2 CG: 2.7 ± 2.5 van Eijsden et al. [26] VAS Means (95% CI) PE: 2.88 (2.43, 3.33) PE: 1.90 (1.35, 2.45) RP: 2.59 (2.07, 3.11) RP: 1.13 (0.76, 1.51) Andersen et al. [25] VAS GFT: 50 ± 16 GFT: 45 ± 13 SST: 44 ± 25 SST: 10 ± 10 REF: 43 ± 27 REF: 35 ± 29 Sjorgen et al. [32] Borg CR10 Headache intensity (observed mean, SD) TG1: Intervention TG1: No intervention 2.30 (2.26)–1.42 (1.69) 1.42 (2.10)–1.29 (1.81) TG2: No intervention TG2: Intervention 2.21(2.82)–1.51 (1.65) 0.43 (1.34)–0.39 (1.08) Ylinen et al. [27] VAS SG: 58 (73–72) SG: −40 (−48 to −32) EG: 57(43–74) EG: −35 (−42 to −28) CG: 58 (42–74) CG: −16 (−22 to −9) Median IQR Median (95% CI) Andersen et al. [30] Neck pain SRT: 5.0 ± 0.2 SRT: 3.4 ± 0.2 APE: 5.0 ± 0.2 APE: 3.6 ± 0.2 Study Pain variable Evaluation tool Pre-test Post-test Ma et al. [24] VAS BG: 5.12 ± 1.65 BG: 1.87 ± 0.74 AG: 4.75 ± 1.59 AG: 2.10 ± 1.34 PG: 5.69 ± 1.54 PG: 3.60 ± 1.18 CG: 5.27 ± 1.27 CG: 4.75 ± 1.53 Andersen et al. [28] VAS (modified) 2G: −1.3 (−1.9 to −0.7) 12G: −1.8 (−2.4 to −1.2) CG: 0.1 (−0.3 to 0.5) Viljanen et al. [29] Pain intensity DG: 4.8 ± 2.3 DG: 2.9 ± 2.6 RG: 4.8 ± 2.3 RG: 2.9 ± 2.4 CG: 4.1 ± 2.2 CG: 2.7 ± 2.5 van Eijsden et al. [26] VAS Means (95% CI) PE: 2.88 (2.43, 3.33) PE: 1.90 (1.35, 2.45) RP: 2.59 (2.07, 3.11) RP: 1.13 (0.76, 1.51) Andersen et al. [25] VAS GFT: 50 ± 16 GFT: 45 ± 13 SST: 44 ± 25 SST: 10 ± 10 REF: 43 ± 27 REF: 35 ± 29 Sjorgen et al. [32] Borg CR10 Headache intensity (observed mean, SD) TG1: Intervention TG1: No intervention 2.30 (2.26)–1.42 (1.69) 1.42 (2.10)–1.29 (1.81) TG2: No intervention TG2: Intervention 2.21(2.82)–1.51 (1.65) 0.43 (1.34)–0.39 (1.08) Ylinen et al. [27] VAS SG: 58 (73–72) SG: −40 (−48 to −32) EG: 57(43–74) EG: −35 (−42 to −28) CG: 58 (42–74) CG: −16 (−22 to −9) Median IQR Median (95% CI) Andersen et al. [30] Neck pain SRT: 5.0 ± 0.2 SRT: 3.4 ± 0.2 APE: 5.0 ± 0.2 APE: 3.6 ± 0.2 12G, 12-min group; 2G, 2-min group; AG, active exercise group; APE, all-round physical exercise group; BG, biofeedback group; CG, control group; DG, dynamic muscle training group; EG, endurance training group; GFT, general fitness training; PE, postural exercise group; PG, passive treatment group; REF, reference groups; RG, relaxation group; RP, regular physio group; SG, strength training group; SRT, specific training group; SST, specific strength training; TG1, treatment group 1; TG2, treatment group 2. View Large Table 3. Numerical results of outcomes for functional variables for included studies Study Functional variable Evaluation tool Pre-test Post-test Ma et al. [22] NDI BG: 16.82 ± 6.21 BG: 7.00 ± 3.05 AG: 16.05 ± 5.13 AG: 10.33 ± 2.23 PG: 15.81 ± 4.97 PG: 12.33 ± 4.29 CG: 16.53 ± 5.95 CG: 14.82 ± 2.87 Andersen et al. [26] Muscle strength (Nm) 2G: 2.5 (1.4–3.6) 12G: 2.3 (1.1–3.3) CG: 0.5 (−0.5 to 1.5) Viljanen et al. [27] NDI DG: 29 ± 15.4 DG: 15 ± 4.6 RG: 29 ± 14.3 RG: 14 ± 12.5 CG: 26 ± 13.8 CG: 14 ± 13.8 van Eijsden et al. [24] DASH PE: 15.23 (12.18, 18.27) PE: 10.98 (8.06, 13.91) RP: 16.12 (12.47, 19.76) RP: 8.75 (5.89, 11.62) Andersen et al. [23] R shoulder elevation (Nm) GFT: 52 ± 18 GFT: 57 ± 21 SST: 58 ± 21 SST: 75 ± 19 REF: 48 ± 22 REF: 58 ± 18 Sjorgen et al. [30] Borg CR10 Intensity neck symptoms (observed mean SD) TG1: Intervention TG1: No intervention 2.46 (2.29)–0.67 (1.46) 0.47 (1.07)–1.00 (1.41) TG2: No intervention TG2: Intervention 2.17 (1.96)–1.50 (1.68) 0.42 (1.0)–0.24 (0.72) Ylinen et al. [25] NDI SG: 21 (16–26) SG: −9 (−11 to −7) EG: 22 (16–28) EG: −8 (−11 to −6) CG: 22 (16–31) CG: −3 (−6 to 0) Median IQR Median (95% CI) Andersen et al. [28] Muscle strength Elevation (N) SRT: 516 ± 19 SRT: 573 ± 19 APE: 586 ± 25 APE: 641 ± 26 REF: 584 ± 23 REF: 605 ± 22 Study Functional variable Evaluation tool Pre-test Post-test Ma et al. [22] NDI BG: 16.82 ± 6.21 BG: 7.00 ± 3.05 AG: 16.05 ± 5.13 AG: 10.33 ± 2.23 PG: 15.81 ± 4.97 PG: 12.33 ± 4.29 CG: 16.53 ± 5.95 CG: 14.82 ± 2.87 Andersen et al. [26] Muscle strength (Nm) 2G: 2.5 (1.4–3.6) 12G: 2.3 (1.1–3.3) CG: 0.5 (−0.5 to 1.5) Viljanen et al. [27] NDI DG: 29 ± 15.4 DG: 15 ± 4.6 RG: 29 ± 14.3 RG: 14 ± 12.5 CG: 26 ± 13.8 CG: 14 ± 13.8 van Eijsden et al. [24] DASH PE: 15.23 (12.18, 18.27) PE: 10.98 (8.06, 13.91) RP: 16.12 (12.47, 19.76) RP: 8.75 (5.89, 11.62) Andersen et al. [23] R shoulder elevation (Nm) GFT: 52 ± 18 GFT: 57 ± 21 SST: 58 ± 21 SST: 75 ± 19 REF: 48 ± 22 REF: 58 ± 18 Sjorgen et al. [30] Borg CR10 Intensity neck symptoms (observed mean SD) TG1: Intervention TG1: No intervention 2.46 (2.29)–0.67 (1.46) 0.47 (1.07)–1.00 (1.41) TG2: No intervention TG2: Intervention 2.17 (1.96)–1.50 (1.68) 0.42 (1.0)–0.24 (0.72) Ylinen et al. [25] NDI SG: 21 (16–26) SG: −9 (−11 to −7) EG: 22 (16–28) EG: −8 (−11 to −6) CG: 22 (16–31) CG: −3 (−6 to 0) Median IQR Median (95% CI) Andersen et al. [28] Muscle strength Elevation (N) SRT: 516 ± 19 SRT: 573 ± 19 APE: 586 ± 25 APE: 641 ± 26 REF: 584 ± 23 REF: 605 ± 22 12G, 12-min group; 2G, 2-min group; AG, active exercise group; APE, all-round physical exercise group; BG, biofeedback group; Borg CR10, Borg category/ratio 10; CG, control group; DASH, disability of arm, shoulder and hand; DG, dynamic muscle training group; EG, endurance training group; GFT, general fitness training; IQR, interquartile range; PE, postural exercise group; PG, passive treatment group; REF, reference groups; RG, relaxation group; RP, regular physio group; SG, strength training group; SRT, specific training group; SST, specific strength training; TG1, treatment group 1; TG2, treatment group 2. View Large Table 3. Numerical results of outcomes for functional variables for included studies Study Functional variable Evaluation tool Pre-test Post-test Ma et al. [22] NDI BG: 16.82 ± 6.21 BG: 7.00 ± 3.05 AG: 16.05 ± 5.13 AG: 10.33 ± 2.23 PG: 15.81 ± 4.97 PG: 12.33 ± 4.29 CG: 16.53 ± 5.95 CG: 14.82 ± 2.87 Andersen et al. [26] Muscle strength (Nm) 2G: 2.5 (1.4–3.6) 12G: 2.3 (1.1–3.3) CG: 0.5 (−0.5 to 1.5) Viljanen et al. [27] NDI DG: 29 ± 15.4 DG: 15 ± 4.6 RG: 29 ± 14.3 RG: 14 ± 12.5 CG: 26 ± 13.8 CG: 14 ± 13.8 van Eijsden et al. [24] DASH PE: 15.23 (12.18, 18.27) PE: 10.98 (8.06, 13.91) RP: 16.12 (12.47, 19.76) RP: 8.75 (5.89, 11.62) Andersen et al. [23] R shoulder elevation (Nm) GFT: 52 ± 18 GFT: 57 ± 21 SST: 58 ± 21 SST: 75 ± 19 REF: 48 ± 22 REF: 58 ± 18 Sjorgen et al. [30] Borg CR10 Intensity neck symptoms (observed mean SD) TG1: Intervention TG1: No intervention 2.46 (2.29)–0.67 (1.46) 0.47 (1.07)–1.00 (1.41) TG2: No intervention TG2: Intervention 2.17 (1.96)–1.50 (1.68) 0.42 (1.0)–0.24 (0.72) Ylinen et al. [25] NDI SG: 21 (16–26) SG: −9 (−11 to −7) EG: 22 (16–28) EG: −8 (−11 to −6) CG: 22 (16–31) CG: −3 (−6 to 0) Median IQR Median (95% CI) Andersen et al. [28] Muscle strength Elevation (N) SRT: 516 ± 19 SRT: 573 ± 19 APE: 586 ± 25 APE: 641 ± 26 REF: 584 ± 23 REF: 605 ± 22 Study Functional variable Evaluation tool Pre-test Post-test Ma et al. [22] NDI BG: 16.82 ± 6.21 BG: 7.00 ± 3.05 AG: 16.05 ± 5.13 AG: 10.33 ± 2.23 PG: 15.81 ± 4.97 PG: 12.33 ± 4.29 CG: 16.53 ± 5.95 CG: 14.82 ± 2.87 Andersen et al. [26] Muscle strength (Nm) 2G: 2.5 (1.4–3.6) 12G: 2.3 (1.1–3.3) CG: 0.5 (−0.5 to 1.5) Viljanen et al. [27] NDI DG: 29 ± 15.4 DG: 15 ± 4.6 RG: 29 ± 14.3 RG: 14 ± 12.5 CG: 26 ± 13.8 CG: 14 ± 13.8 van Eijsden et al. [24] DASH PE: 15.23 (12.18, 18.27) PE: 10.98 (8.06, 13.91) RP: 16.12 (12.47, 19.76) RP: 8.75 (5.89, 11.62) Andersen et al. [23] R shoulder elevation (Nm) GFT: 52 ± 18 GFT: 57 ± 21 SST: 58 ± 21 SST: 75 ± 19 REF: 48 ± 22 REF: 58 ± 18 Sjorgen et al. [30] Borg CR10 Intensity neck symptoms (observed mean SD) TG1: Intervention TG1: No intervention 2.46 (2.29)–0.67 (1.46) 0.47 (1.07)–1.00 (1.41) TG2: No intervention TG2: Intervention 2.17 (1.96)–1.50 (1.68) 0.42 (1.0)–0.24 (0.72) Ylinen et al. [25] NDI SG: 21 (16–26) SG: −9 (−11 to −7) EG: 22 (16–28) EG: −8 (−11 to −6) CG: 22 (16–31) CG: −3 (−6 to 0) Median IQR Median (95% CI) Andersen et al. [28] Muscle strength Elevation (N) SRT: 516 ± 19 SRT: 573 ± 19 APE: 586 ± 25 APE: 641 ± 26 REF: 584 ± 23 REF: 605 ± 22 12G, 12-min group; 2G, 2-min group; AG, active exercise group; APE, all-round physical exercise group; BG, biofeedback group; Borg CR10, Borg category/ratio 10; CG, control group; DASH, disability of arm, shoulder and hand; DG, dynamic muscle training group; EG, endurance training group; GFT, general fitness training; IQR, interquartile range; PE, postural exercise group; PG, passive treatment group; REF, reference groups; RG, relaxation group; RP, regular physio group; SG, strength training group; SRT, specific training group; SST, specific strength training; TG1, treatment group 1; TG2, treatment group 2. View Large Overall, there was moderate evidence to suggest exercise is effective in reducing the symptoms of pain in WRULDs in sedentary workers when compared to a control group [22–27,30–32]. Two of these studies were high-quality systematic reviews [22,31]. This review found moderate evidence to suggest there are no significant differences between various types of exercise in relation to pain or functional outcomes in sedentary workers [23,26,29,32]. One high-quality systematic review identified strong evidence for the ineffectiveness of workplace exercise for shoulder symptoms [22]. One RCT investigating two different types of exercise therapy found no statistical difference between a postural exercise group and a regular physiotherapy group with regards to cost effectiveness; however, no control group was included in the study [26]. There was a wide variation in the prescription of exercise in each group across the studies, from as little as 2 min five times a week [28] to 2 h of daily biofeedback training [24]. All of the RCTs included in the study focused their investigations around sedentary workers with a primary complaint of neck or shoulder pain [23–30,32]. Seven RCTS [23–27,29,30] used a control group in their investigations. The majority of RCTs included in this study had high numbers of participants, with five studies reaching between 100 to nearly 400 participants [23,27–30]. Although one of the systematic reviews included results on low back pain, these data were omitted from our study based on the inclusion criteria [22]. This review found strong evidence to support the effectiveness of physical exercise in controlling neck pain among sedentary workers; however, there were no positive results to indicate effectiveness of exercise with regards to shoulder pain. A high-quality systematic review [31] reported strong evidence to support the use of muscle strengthening and endurance exercises in treating neck pain and endurance exercises in reducing disability. Discussion This systematic review found moderate evidence supporting the positive effect of exercise therapy for both pain and function in the treatment of WRULDs in sedentary workers. This conclusion is based on the relevant data extrapolated from the included studies (nine RCTs and two systematic reviews). These results are comparable to recent systematic reviews, which found strong evidence to support the use of exercise therapy, in mixed populations of workers [22,31]. In contrast, earlier studies in populations with variable occupations (e.g. sedentary and industrial) found conflicting evidence for the effectiveness of exercises over no treatment or as an adjunct [17,33]. It is, therefore, difficult to accurately compare with these earlier reviews due to the apparent population homogeneity. Clinical utility is lost for the specific population of sedentary workers. Strengths of this study include its comprehensive literature search using a number of databases generous inclusion criteria and good inter-rater agreement. Potential bias within this review was minimized by reviewers using a standardized critical appraisal tool to reach consensus regarding the risk of bias of each study. With regards to the most appropriate types of exercise for the treatment of WRULDs in sedentary workers, this review found moderate evidence to suggest there are no significant differences between various types of exercise in relation to pain or functional outcomes. This is in agreement with a previous study which found no significant differences between strength and endurance exercises for treating work-related complaints of the arm, neck or shoulder [17]. However, a recent systematic review [31] found moderate evidence for the positive effect on reduction of disability with exercise using muscular endurance training parameters on the neck flexor muscles (e.g. three sets of 20 repetitions, five times per week over 12 months). They did, however, find dynamic training with light resistance to be ineffective in treating neck pain. There is a slight disparity in the research regarding the effectiveness of exercise in WRULDs specifically aimed at shoulder pathologies. A recently published systematic review [18] concluded there is moderate evidence that exercise in workers suffering from a rotator cuff tendinopathy is an effective modality in terms of pain reduction, improvement in work ability and return-to-work when compared with a control intervention or to a placebo. This is in agreement with the current review but in contrast to an earlier systematic review which found no positive results supporting the use of exercise in shoulder symptoms from WRULD [22]. The main limitations of this review are based on the high risk of bias of the included RCTs. This was mainly due to lack of blinding, which is historically found to be an effective method of reducing selection bias [34]. Subsequently, a literature base of reduced methodological quality from which to extrapolate conclusions can lead to misinterpretation of the evidence [35]. The reviewed evidence base in this study is impacted by reporting bias, where the trial reports fail to follow CONSORT guidelines and subsequently may influence the internal validity of each study’s conclusions [35]. Specifically low-quality studies are considered to inflate effect estimates [36] and this should be considered when reading the results of this review. Also, the initial search was limited to studies published in the English language, which may have excluded relevant studies. However, as a large majority of clinical trials are published in English, this is considered to be an unlikely source of bias. Due to the heterogeneous nature of the reported results and different variables across the included studies, it was deemed inappropriate to conduct a meta-analysis of the results. The lack of consensus regarding a definition of WRULDs through the included studies may also contribute to the results of this paper. There was a wide variety of terminology used which only adds to the heterogeneous nature of the studies. Reasons why this review may have found merely moderate evidence as opposed to strong evidence may be the limitations of the included studies. There was a high risk of bias in the majority of the included RCTs, mainly due to a lack of participant blinding. Some studies include asymptomatic individuals as well as symptomatic [24]. There was also very little information from each study classifying their diagnosis or definition of WRULDs. Unfortunately, it is difficult from this review to comment on specific pathologies under the umbrella term of WRULDs. It is pertinent to note that the majority of the included studies focussed mainly on symptoms regarding the neck and shoulder. It would be inaccurate of this study to comment on the effectiveness of exercise with regards to other complaints associated with WRULDs such as lateral epidcondylagia. However, a recent systematic review has found inconclusive evidence to support the role of strengthening exercises specifically in the management of persistent lateral epicondylitis, although it is more effective than a wait-and-see approach [37]. The results from this study highlight the positive evidence to support the use of exercise therapy in the management of WRULDs. This has relevant implications for employers as exercise is a cost-effective treatment modality which can be carried out without the need for expensive equipment, highlighted by the included studies. Cost efficiency is paramount to the success of any business, as well as maximizing productivity and reducing sickness absence lost to WRULD [27]. The findings of this study can help medical professionals working in occupational health understand the effectiveness of exercise as a treatment modality for sedentary workers. It is important to highlight that in clinical practice, exercise in isolation is not used as a stand-alone treatment for any condition. This is even more relevant in specific populations suffering from chronic pain. A multimodal treatment approach has been highlighted as a central part of managing these conditions [38]. The use of reported outcome measures in the included studies is clinically relevant to those used in current practice (e.g. VAS, NDI and muscle strength). Further research is required to provide additional information on the most effective treatments for the management of WRULDs in sedentary workers. It would be appropriate to define WRULDs in terms of specific and non-specific conditions in future research, so management for conditions may be as precise as can be. Identifying the most effective type of exercise for each specific and non-specific condition would be useful to clinicians, in order to rationalize treatment based on not only the worker but site and specificity of their conditions. Further research may also explore the optimal dosage of treatment, based on the wide range included in the studies in this review. Research may also look further into the most optimal delivery of exercise programmes in sedentary workers, whether this is a work place intervention or a prescribed home exercise programme. The design of future research is an important consideration, RCTs would be most effective in eliminating the various sources of bias. Additionally trials assessing the multimodal management of WRULDs would be useful. The management of these conditions clinically very often utilizes a multimodal approach, consisting of more than just exercise. It would be beneficial to understand the most suitable combinations of therapy for specific conditions to yield greater reductions in pain and disability. In conclusion, this review found moderate evidence to support the effectiveness of exercise therapy in the management of WRULDs in sedentary workers. This has clinical implications for physiotherapists and other occupational health professionals. Exercise is a common and useful prescription not only for specific diagnoses but for the overall health and well-being of the patient. The results of this study may also have positive implications with regards to cost effectiveness for employers in terms of the potential to influence the management of these conditions. In the current climate, exercise may also prove effective with regards to health promotion and physical activity in sedentary workers. Key points • This review found moderate evidence for the effectiveness in the treatment of work-related upper limb disorders in sedentary workers. • This results of this study showed positive implications for those working in occupational health as a potential cost-effective treatment tool. • Further research is needed to clarify the most beneficial type of exercise and frequency. Competing interests No funding was provided nor sought for this work. References 1. Juul-Kristensen B , Søgaard K , Støyer J , Jensen C . Computer users’ risk factors for developing shoulder, elbow and back symptoms . Scand J Work Environ Health 2004 ; 1 : 390 – 398 . Google Scholar CrossRef Search ADS 2. Visser B , van Dieën JH . Pathophysiology of upper extremity muscle disorders . J Electromyography Kinesiol 2006 ; 16 : 1 – 16 . Google Scholar CrossRef Search ADS 3. Bernard BP. Musculoskeletal Disorders and Workplace Factors: A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back . DHHS (NIOSH) Publication No. 97-141. Washington, DC : US Department of Health and Human Services, National Institute of Occupational Safety and Health , 1997 . 4. van Rijn RM , Huisstede BM , Koes BW , Burdorf A . Associations between work-related factors and the carpal tunnel syndrome: a systematic review . Scand J Work Environ Health 2009 ; 35 : 19 – 36 . Google Scholar CrossRef Search ADS PubMed 5. van Rijn RM , Huisstede BM , Koes BW , Burdorf A . Associations between work-related factors and specific disorders at the elbow: a systematic literature review . Rheumatology (Oxford) 2009 ; 48 : 528 – 536 . Google Scholar CrossRef Search ADS PubMed 6. van Rijn RM , Huisstede BM , Koes BW , Burdorf A . Associations between work-related factors and specific disorders of the shoulder: a systematic literature review . Scand J Work Environ Health 2010 ; 36 : 189 – 201 . Google Scholar CrossRef Search ADS PubMed 7. Boocock MG , Collier JM , McNair PJ , Simmonds M , Larmer , PJ , Armstrong B . A framework for the classification and diagnosis of work-related upper extremity conditions: systematic review . Sem Arth and Rheum 2009;38: 296 – 311 . CrossRef Search ADS 8. Staal JB , De Bie RA , Hendriks EJM . Aetiology and management of work-related upper extremity disorders . Best Pract Res Clin Rheumatol 2007 ; 21 : 123 – 133 . Google Scholar CrossRef Search ADS PubMed 9. Health & Safety Executive . Work-Related Musculoskeletal Disorder (WRMSDs) Statistics . London, UK Health & Safety Executive , 2016 . http://www.hse.gov.uk/statistics/causdis/musculoskeletal/msd.pdf (13 March 2018, date last accessed). 10. Strazdins L , Bammer G . Women, work and musculoskeletal health . Soc Sci Med 2004 ; 58 : 997 – 1005 . Google Scholar CrossRef Search ADS PubMed 11. Piligian G , Herbert R , Hearns M , Dropkin J , Landsbergis P , Cherniack M . Evaluation and management of chronic work‐related musculoskeletal disorders of the distal upper extremity . Am J Ind Med 2000 ; 37 : 75 – 93 . Google Scholar CrossRef Search ADS PubMed 12. Haahr JP , Østergaard S , Dalsgaard J et al. Exercises versus arthroscopic decompression in patients with subacromial impingement: a randomised, controlled study in 90 cases with a one year follow up . Ann Rheum Dis 2005 ; 64 : 760 – 764 . Google Scholar CrossRef Search ADS PubMed 13. Hagberg M , Harms-Ringdahl K , Nisell R , Hjelm EW . Rehabilitation of neck-shoulder pain in women industrial workers: a randomized trial comparing isometric shoulder endurance training with isometric shoulder strength training . Arch Phys Med Rehabil 2000 ; 81 : 1051 – 1058 . Google Scholar CrossRef Search ADS PubMed 14. Randløv A , Østergaard M , Manniche C et al. Intensive dynamic training for females with chronic neck/shoulder pain. A randomized controlled trial . Clin Rehabil 1998 ; 12 : 200 – 210 . Google Scholar CrossRef Search ADS PubMed 15. Lewis BA , Napolitano MA , Buman MP , Williams DM , Nigg CR . Future directions in physical activity intervention research: expanding our focus to sedentary behaviors, technology, and dissemination . J Behav Med 2017 ; 40 : 112 – 126 . Google Scholar CrossRef Search ADS PubMed 16. Andersen LL , Christensen KB , Holtermann A et al. Effect of physical exercise interventions on musculoskeletal pain in all body regions among office workers: a one-year randomized controlled trial . Man Ther 2010 ; 15 : 100 – 104 . Google Scholar CrossRef Search ADS PubMed 17. Verhagen AP , Karels C , Bierma-Zeinstra SM et al. Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults . Cochrane Database Syst Rev 2006 ; 3 :1–48. 18. Desmeules F , Boudreault J , Dionne CE et al. Efficacy of exercise therapy in workers with rotator cuff tendinopathy: a systematic review . J Occup Health 2016 ; 58 : 389 – 403 . Google Scholar CrossRef Search ADS PubMed 19. Tacconelli E. Systematic reviews: CRD’s guidance for undertaking reviews in health care. The Lancet Infectious Diseases 2010;10:226. 20. Moher D , Shamseer L , Clarke M et al. Preferred Reporting Items for Systematic Review and Meta-Analysis protocols (PRISMA-P) 2015 statement . Syst Rev 2015 ; 4 : 1 . Google Scholar CrossRef Search ADS PubMed 21. Viera AJ , Garrett JM . Understanding interobserver agreement: the Kappa statistic . Fam Med 2005 ; 37 : 360 – 363 . Google Scholar PubMed 22. Coury HJ , Moreira RF , Dias NB . Evaluation of the effectiveness of workplace exercise in controlling neck, shoulder and low back pain: a systematic review . Braz J Phys Ther 2009 ; 13 : 461 – 479 . Google Scholar CrossRef Search ADS 23. Blangsted AK , Søgaard K , Hansen EA , Hannerz H , Sjøgaard G . One-year randomized controlled trial with different physical-activity programs to reduce musculoskeletal symptoms in the neck and shoulders among office workers . Scand J Work Environ Health 2008 ; 34:55 – 65 . 24. Ma C , Szeto GP , Yan T , Wu S , Lin C , Li L . Comparing biofeedback with active exercise and passive treatment for the management of work-related neck and shoulder pain: a randomized controlled trial . Arch Phys Med Rehabil 2011 ; 92 : 849 – 858 . Google Scholar CrossRef Search ADS PubMed 25. Andersen LL , Jørgensen MB , Blangsted AK , Pedersen MT , Hansen EA , Sjøgaard G . A randomized controlled intervention trial to relieve and prevent neck/shoulder pain . Med Sci Sports Exerc 2008 ; 40 : 983 – 990 . Google Scholar CrossRef Search ADS PubMed 26. van Eijsden MD , Gerhards SA , de Bie RA , Severens JL . Cost-effectiveness of postural exercise therapy versus physiotherapy in computer screen-workers with early non-specific work-related upper limb disorders (WRULD); a randomized controlled trial . Trials 2009 ; 10 : 103 . Google Scholar CrossRef Search ADS PubMed 27. Ylinen J , Takala EP , Nykänen M . Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial . J Am Med Assoc 2003 ; 289 : 2509 – 2516 . Google Scholar CrossRef Search ADS 28. Andersen LL , Saervoll CA , Mortensen OS , Poulsen OM , Hannerz H , Zebis MK . Effectiveness of small daily amounts of progressive resistance training for frequent neck/shoulder pain: randomised controlled trial . Pain 2011 ; 152 : 440 – 446 . Google Scholar CrossRef Search ADS PubMed 29. Viljanen M , Malmivaara A , Uitti J , Rinne M , Palmroos P , Laippala P . Effectiveness of dynamic muscle training , relaxation training , or ordinary activity for chronic neck pain: randomised controlled trial . Br Med J 2003 ; 327 : 475 . Google Scholar CrossRef Search ADS 30. Andersen LL , Kjaer M , SØgaard K , Hansen L , Kryger AI , Sjögaard G . Effect of two contrasting types of physical exercise on chronic neck muscle pain . Arthritis Care Res 2008 ; 59 : 84 . Google Scholar CrossRef Search ADS 31. Sihawong R , Janwantanakul P , Sitthipornvorakul E , Pensri P . Exercise therapy for office workers with nonspecific neck pain: a systematic review . J Manipulative Physiol Ther 2011 ; 34 : 62 – 71 . Google Scholar CrossRef Search ADS PubMed 32. Sjögren T , Nissinen KJ , Järvenpää SK , Ojanen MT , Vanharanta H , Mälkiä EA . Effects of a workplace physical exercise intervention on the intensity of headache and neck and shoulder symptoms and upper extremity muscular strength of office workers: a cluster randomized controlled cross-over trial . Pain 2005 ; 116 : 119 – 128 . Google Scholar CrossRef Search ADS PubMed 33. Verhagen AP , Bierma-Zeinstra SM , Burdorf A , Stynes SM , de Vet HC , Koes BW . Conservative interventions for treating work-related complaints of the arm, neck or shoulder in adults . Cochrane Database Syst Rev 2013 ; 12 : CD008742 . 34. Chalmers TC , Smith H , Blackburn B . A method for assessing the quality of a randomized control trial . Control Clin Trials 1981 ; 2 : 31 – 49 . Google Scholar CrossRef Search ADS PubMed 35. Schulz KF , Grimes DA , Altman DG , Hayes RJ . Blinding and exclusions after allocation in randomised controlled trials: survey of published parallel group trials in obstetrics and gynaecology . Br Med J 1996 ; 312 : 742 – 744 . Google Scholar CrossRef Search ADS 36. Verhagen AP , de Vet HC , de Bie RA , Boers M , van den Brandt PA . The art of quality assessment of RCTs included in systematic reviews . J Clin Epidemiol 2001 ; 54 : 651 – 654 . Google Scholar CrossRef Search ADS PubMed 37. Menta R , Randhawa K , Côté P et al. The effectiveness of exercise for the management of musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration . J Manipulative Physiol Ther 2015 ; 38 : 507 – 520 . Google Scholar CrossRef Search ADS PubMed 38. Burton AK , Kendall NA , Pearce BG , Birrell LN , Bainbridge LC . Management of work-relevant upper limb disorders: a review . Occup Med 2008 ; 59 : 44 – 52 . Google Scholar CrossRef Search ADS © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Occupational Medicine Oxford University Press

Exercise therapy and work-related musculoskeletal disorders in sedentary workers

Loading next page...
 
/lp/ou_press/exercise-therapy-and-work-related-musculoskeletal-disorders-in-SyLKC6gbxz
Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com
ISSN
0962-7480
eISSN
1471-8405
D.O.I.
10.1093/occmed/kqy054
Publisher site
See Article on Publisher Site

Abstract

Abstract Background Work-related upper limb disorders (WRULDs) are a syndrome of symptoms affecting the upper quadrant of the body and are a significant cause of pain, disability and sickness absence among workers. Exercise therapy is considered to be a clinical and cost-effective strategy in WRULD management. Aims To evaluate the effectiveness of exercise therapy for WRULDs in sedentary workers. Methods This review follows an a priori protocol to maintain internal validity describing essential procedures to be followed (e.g. a comprehensive search strategy, duel extraction and critical appraisal). The methodological quality of the studies were assessed using Cochrane Risk of Bias Tool for all randomized controlled trials and the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool for systematic reviews. Results A total of 11 articles were selected for inclusion. There was moderate evidence to suggest exercise is effective in reducing the symptoms of pain and improved function in WRULDs in sedentary workers when compared to a control group. Conclusions The results were comparable to recent systematic reviews, which have found evidence to support the use of exercise therapy, in mixed populations of workers. There is a need for further research to highlight the most effective form of exercise, optimal dosage and delivery method. Exercise, sedentary, WRULD Introduction Work-related musculoskeletal disorders are a significant cause of pain and disability among sedentary workers [1]. Work-related upper limb disorders (WRULDs) is an umbrella term used to cover a wide range of musculoskeletal symptoms and pathological states of the upper quadrant from proximal joints (cervicothoracic, scapulothoracic, glenohumeral) to distal (elbow, wrist and hand). Symptoms may include pain, stiffness, loss of strength and neuromuscular control, paraesthesia, anaesthesia and loss of co-ordination. Specific WRULDs incorporate underlying specific diagnoses such as lateral epicondylitis and de Quervain’s tenosynovitis [2]. These disorders are understood to be as a result of repetitive or increased biomechanical overload of the upper limb during occupational activities [3–6]. However, there is a lack of consensus on an accepted definition for these conditions [7,8]. There are many interchangeable definitions or classifications used which include WRULD/work-related upper extremity disorder (WRUED), repetitive strain injury and complaints of the arm, neck and shoulder (CANS). There does appear to be a distinction in the literature between specific and non-specific WRULDs. The loss of function and continuing disability can result from the painful symptoms of WRULDs [2]. Recent figures from the Labour Force Survey (2016) estimate the prevalence of WRULDs in Great Britain in 2015/16 at 222000 total cases (case rate of 690 per 100000 people employed). In 2015/16 3138000 working days were lost due to WRULDs in Great Britain; equating to 14.1 days per case [9]. It is, therefore, a challenge for employers and occupational health departments to effectively manage these conditions to reduce the prevalence and increase overall productivity. Conservative interventions with physiotherapy at the forefront play an important role in the management of these conditions [10, 11] with exercise therapy suggested as an effective and cost-effective tool [12–14]. Exercise has been shown to effectively improve symptoms of musculoskeletal pain in all body regions of office workers previously [15] and, with the drive to promote physical activity in the sedentary population [16], may prove an effective solution. However, there has been conflicting evidence to support the effectiveness of exercise therapy for the treatment of WRULDs [17]. There is also a dearth of evidence on the effectiveness of exercise for specific populations of workers [18] and to the knowledge of the authors, no studies have reviewed its efficacy with regards to the targeted population of sedentary workers. This systematic review, therefore, aimed to evaluate the effectiveness of exercise therapy in the management of WRULDs in the population of sedentary workers. Methods The methodology of this review followed specific systematic review development guidelines [18] and reported the review in accordance with the PRISMA statement for reporting systematic reviews [19, 20]. Additionally, the review was constructed based upon an a priori protocol which described essential procedures to be followed (e.g. dual extraction and critical appraisal). Ethical approval was not required due to the review of previously published literature. A literature search was conducted of the following databases; EMBASE, EMBASE CLASSIC, HMIC, MEDLINE, PsycINFO, CINAHL, PEDro, Social Policy and Practice to identify both published and unpublished studies from 1966 to present. The key terms used for the search were as follows; exercise, work related upper limb disorders, WRULD, WRUED, CANS, physiotherapy, management, office/computer workers, sedentary workers. The search was supplemented by a grey literature search of the reference list of any relevant articles sourced. Inclusion criteria were as follows: • The study design was either a randomized controlled trial (RCT) or systematic review. • The article was a full report published in English. • The participants included in each study were sedentary/office/computer screen workers. • Exercise therapy was the primary intervention used as treatment for any symptoms under the umbrella term of WRULD. • Reporting of a primary functional or pain variable (e.g. Numerical Pain Rating Scale (NPRS)/Neck Disability Index (NDI)). Studies were excluded if they did not meet the above criteria. The search results were filtered for duplicates and the lead reviewer (D.K.) screened remaining titles and abstracts using the inclusion criteria. All full articles obtained were then reviewed independently by D.K. and F.S. and a predetermined and piloted data extraction table was used to extract the appropriate and relevant findings. The main characteristics for data extraction was as follows: • study population, size and gender; • aspects of the intervention, exercise type, supervision, frequency; • outcome measures used—specifically pain and functional variables and any work-related outcomes and • reported results The methodological quality of the included RCTs was assessed using the Cochrane Risk of Bias Tool (Modified) and the AMSTAR (Assessing the Methodological Quality of Systematic Reviews) tool for use with systematic reviews. The AMSTAR is scored out of 11 items. Two reviewers (D.K./F.S.) examined the studies for risk of bias and internal validity. A third reviewer was available to resolve disagreements (C.T.). Inter-observer agreement of the risk of bias between reviewers was assessed using the Kappa statistic [21]. A scoring system including five levels of evidence was used to synthesize the evidence [22]. The system considers the number and methodological quality of the studies as follows: • strong evidence: provided by consistent findings in two or more high-quality RCTs; • moderate evidence: provided by consistent findings in one high-quality RCT and one or more low-quality RCTs, or by consistent findings in multiple low-quality RCTs; • limited evidence: only one high-quality RCT or multiple low-quality RCTs; • conflicting evidence: inconsistent findings in multiple RCTs and • absent evidence: no RCT. Results A total of 11 articles were selected to be analysed based on the inclusion criteria. This consisted of nine RCTs and two systematic reviews (Figure 1). Results of the methodological assessment are shown in Table 1. While the percentage agreement between reviewers when examining risk of bias was high (81%), the inter-observer agreement regarding the risk of bias was considered ‘substantial’ (k = 0.67) according to the Kappa interpretation model [21].This was used to demonstrate the critical appraisal findings representing the risk of bias accurately. Figure 1. View largeDownload slide Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart showing study selection process. Figure 1. View largeDownload slide Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart showing study selection process. Table 1. Characteristics of the included studies Study Design Risk of bias Population Intervention Outcomes Results Ma et al. [24] RCT High Daily computer users from two Chinese universities and nearby outpatient clinics with past/present history of computer-related neck/shoulder discomfort (n = 60, DO = 22) 1. Biofeedback group (BG); 2 h daily exercise while at computer 2. Active exercise group (AG); daily strength and stretch program 3. Passive treatment group (PG); interferential therapy and hot packs ×2/week. 4. Control group (CG); education booklet on office ergonomics VAS NDI EMG surface during typing task Significantly greater decrease in VAS, NDI and EMG in BG compared with other groups at 6/52 and 6/12 (P < 0.05). However significant decrease in VAS and NDI in AG and PG not in CG. Andersen et al. [28] RCT Low Computer users with frequent neck/shoulder muscle pain (n = 198, DO = 6) 1. Two-min group; one single set of exercise to failure up to 2 min 2. Twelve-min group; 5–6 sets of 8–12 repetitions progressing to a total of 25–30 sets per week 3. CG; received weekly emailed information on various aspects of general health VAS Palpable tenderness of neck/shoulder muscles Isometric strength Significant pain reduction in exercise groups compared with control. No significant difference between exercise groups. Significant reduction in palpable tenderness in exercise groups compared with control. Viljanen et al. [29] RCT High Female office workers with chronic non-specific pain >12/52 (n = 393, DO = 55) 1. Dynamic muscle training group; exercise 3/week for 30 min for 12/52 physio led initially, then performed themselves with feedback 2. Relaxation group; taught participants to activate only those muscles needed for specific activities and relax others 3. CG; told not to change any activity for 12/52 Cervical ROM Dynamic muscle strength in the neck/shoulder NDI Depression Work stress No significant differences between two training groups and control for changes in pain, NDI, ROM or dynamic muscle strength (no P value available). van Eijsden et al. [26] RCT High Computer screen workers with non-specific WRULD (n = 88, DO = 6) 1. Postural exercise group (PE); posture awareness education through exercise—1 hour treatments ×2 per week 1–3, then 1/week then 1/2 h for 2/52 2. Regular physio group (RP); who attended WRULD course of active muscle training and fitness—3 × 1/2 h for 3 weeks, 2 × 1/2 for 2 weeks, 1 × 1/2 h for 2 weeks 10-week treatment duration Groningen Fitness Questionnaire Job stress survey STAI VAS DASH EQ5D QALY showed no significant difference between groups. VAS was significantly different in RP group at 3 months but not maintained at 6 months. No significant difference in outcomes between groups at 1 year. No statistical significant difference between groups regarding cost effectiveness. Sihawong et al. [31] SR Amstar 7/11 Office workers with non-specific neck pain (n = 9 studies) Exercise therapy Incidence and prevalence of neck pain Discomfort PPT Frequency, duration, severity Productivity Work ability index sick leave Recovery, disability Strong evidence positive effect of strengthening and endurance exercise for treating neck pain. Three high-quality trials suggested muscle strengthening significantly reduced intensity of neck pain. One high-quality trial: no significant difference in neck pain in workers who received strength and stretching compared with no intervention. Conflicting evidence for stretching exercises. Conflicting evidence for non-specific exercises. Blangsted et al. [23] RCT High Office workers (symptomatic and asymptomatic) (n = 549) 1. Specific resistance training (SRT); resistance exercise for neck/shoulder 3/week 20 min supervised, dynamic resistance for arm/shoulders, static exercise for neck and row exercise for arms/shoulders 2. All-round physical exercise (APE); motivated for any exercise, organized groups for running/walking, given step counters. Bike to work 3. Reference groups (REF); advice given re ergonomics food, work organization health promotion Modified Noridc Questionnaire Work ability index Mean intensity of pain Statistically significant differences between SRT and APE compared with REF, in the intensity and the duration of symptoms. SRT not more effective than APE in reducing duration/intensity of symptoms. Andersen et al. [25] RCT High Female computer workers (n = 48, DO = 6) 1. Specific strength training (SST); supervised high intensity strength training shoulder/neck, load progressively increased 2. General fitness training (GFT); leg bicycling 3. REF; health promotion, relaxation stress management 1 h per week for each group VAS Aerobic fitness Isometric muscle strength shoulder elevation and abduction Isometric muscle strength increased significantly in the SST group during shoulder elevation and abduction. Significant decrease in VAS in the SST group, no significant change over time was observed in the GFT and REF groups. Sjorgen et al. [32] RCT High Office workers reporting headache/shoulder/neck pain <12/12 (n = 53) Two treatment sequence groups; group 1 had intervention for 15/52 while group 2 had nothing, then groups swapped Physical exercise intervention consisted of progressive light resistance training performed 1/day in working week, then after 5/52 1–2/day 20 repetitions of 30% RM Guidance: physio provided training instructions and general guidance on posture and movement control BORG CR10 1 RM Physical activity Physical ex intervention significantly decreased intensity of headache and neck symptoms, no effect in the shoulder. Ylinen et al. [27] RCT High Female office workers referred from occupational health (n = 180) 1. Strength training groups; Theraband to train neck muscles 15 repetitions all directions 2. Endurance training group; neck flexor muscles 20 × 3 Both groups performed dynamic exercise for shoulders and UE 3. CG Five sessions per week 45 min long VAS Modified neck and shoulder disability index Isometric neck strength and ROM Grip strength Neck pain and disability significantly decreased in both exercise groups compared with control at 12/12 follow-up. ROM significantly increased in both training groups. Andersen et al. [30] RCT High Office workers (n = 549, DO = 109) 1 h per week for intervention 1. SRT: 2–3 sets 10–15 repetitions of dynamic strengthening exercise for shoulder and static exercise for neck 2. APE: motivated to increase physical activity levels, steppers, punch bags, Nordic walking 3. Reference intervention (REF); health promotion activities Isometric muscle strength shoulder elevation and abduction Questionnaire regarding neck and shoulder symptoms For participants with neck pain, there was a significant decrease in intensity in SRT and APE compared to REF. Coury et al. [22] SR AMSTAR 7/11 Sedentary workers (nine studies) Mixture of heavy and light strength training with comparison groups VAS, NDI, shoulder pain index, PPT, Modified Nordic Questionnaire. Borg CR10 Three high-quality studies showed strong evidence for the effect of exercise for neck symptoms. Three high-quality studies showed strong evidence for ineffectiveness of workplace exercise for shoulder symptoms. Study Design Risk of bias Population Intervention Outcomes Results Ma et al. [24] RCT High Daily computer users from two Chinese universities and nearby outpatient clinics with past/present history of computer-related neck/shoulder discomfort (n = 60, DO = 22) 1. Biofeedback group (BG); 2 h daily exercise while at computer 2. Active exercise group (AG); daily strength and stretch program 3. Passive treatment group (PG); interferential therapy and hot packs ×2/week. 4. Control group (CG); education booklet on office ergonomics VAS NDI EMG surface during typing task Significantly greater decrease in VAS, NDI and EMG in BG compared with other groups at 6/52 and 6/12 (P < 0.05). However significant decrease in VAS and NDI in AG and PG not in CG. Andersen et al. [28] RCT Low Computer users with frequent neck/shoulder muscle pain (n = 198, DO = 6) 1. Two-min group; one single set of exercise to failure up to 2 min 2. Twelve-min group; 5–6 sets of 8–12 repetitions progressing to a total of 25–30 sets per week 3. CG; received weekly emailed information on various aspects of general health VAS Palpable tenderness of neck/shoulder muscles Isometric strength Significant pain reduction in exercise groups compared with control. No significant difference between exercise groups. Significant reduction in palpable tenderness in exercise groups compared with control. Viljanen et al. [29] RCT High Female office workers with chronic non-specific pain >12/52 (n = 393, DO = 55) 1. Dynamic muscle training group; exercise 3/week for 30 min for 12/52 physio led initially, then performed themselves with feedback 2. Relaxation group; taught participants to activate only those muscles needed for specific activities and relax others 3. CG; told not to change any activity for 12/52 Cervical ROM Dynamic muscle strength in the neck/shoulder NDI Depression Work stress No significant differences between two training groups and control for changes in pain, NDI, ROM or dynamic muscle strength (no P value available). van Eijsden et al. [26] RCT High Computer screen workers with non-specific WRULD (n = 88, DO = 6) 1. Postural exercise group (PE); posture awareness education through exercise—1 hour treatments ×2 per week 1–3, then 1/week then 1/2 h for 2/52 2. Regular physio group (RP); who attended WRULD course of active muscle training and fitness—3 × 1/2 h for 3 weeks, 2 × 1/2 for 2 weeks, 1 × 1/2 h for 2 weeks 10-week treatment duration Groningen Fitness Questionnaire Job stress survey STAI VAS DASH EQ5D QALY showed no significant difference between groups. VAS was significantly different in RP group at 3 months but not maintained at 6 months. No significant difference in outcomes between groups at 1 year. No statistical significant difference between groups regarding cost effectiveness. Sihawong et al. [31] SR Amstar 7/11 Office workers with non-specific neck pain (n = 9 studies) Exercise therapy Incidence and prevalence of neck pain Discomfort PPT Frequency, duration, severity Productivity Work ability index sick leave Recovery, disability Strong evidence positive effect of strengthening and endurance exercise for treating neck pain. Three high-quality trials suggested muscle strengthening significantly reduced intensity of neck pain. One high-quality trial: no significant difference in neck pain in workers who received strength and stretching compared with no intervention. Conflicting evidence for stretching exercises. Conflicting evidence for non-specific exercises. Blangsted et al. [23] RCT High Office workers (symptomatic and asymptomatic) (n = 549) 1. Specific resistance training (SRT); resistance exercise for neck/shoulder 3/week 20 min supervised, dynamic resistance for arm/shoulders, static exercise for neck and row exercise for arms/shoulders 2. All-round physical exercise (APE); motivated for any exercise, organized groups for running/walking, given step counters. Bike to work 3. Reference groups (REF); advice given re ergonomics food, work organization health promotion Modified Noridc Questionnaire Work ability index Mean intensity of pain Statistically significant differences between SRT and APE compared with REF, in the intensity and the duration of symptoms. SRT not more effective than APE in reducing duration/intensity of symptoms. Andersen et al. [25] RCT High Female computer workers (n = 48, DO = 6) 1. Specific strength training (SST); supervised high intensity strength training shoulder/neck, load progressively increased 2. General fitness training (GFT); leg bicycling 3. REF; health promotion, relaxation stress management 1 h per week for each group VAS Aerobic fitness Isometric muscle strength shoulder elevation and abduction Isometric muscle strength increased significantly in the SST group during shoulder elevation and abduction. Significant decrease in VAS in the SST group, no significant change over time was observed in the GFT and REF groups. Sjorgen et al. [32] RCT High Office workers reporting headache/shoulder/neck pain <12/12 (n = 53) Two treatment sequence groups; group 1 had intervention for 15/52 while group 2 had nothing, then groups swapped Physical exercise intervention consisted of progressive light resistance training performed 1/day in working week, then after 5/52 1–2/day 20 repetitions of 30% RM Guidance: physio provided training instructions and general guidance on posture and movement control BORG CR10 1 RM Physical activity Physical ex intervention significantly decreased intensity of headache and neck symptoms, no effect in the shoulder. Ylinen et al. [27] RCT High Female office workers referred from occupational health (n = 180) 1. Strength training groups; Theraband to train neck muscles 15 repetitions all directions 2. Endurance training group; neck flexor muscles 20 × 3 Both groups performed dynamic exercise for shoulders and UE 3. CG Five sessions per week 45 min long VAS Modified neck and shoulder disability index Isometric neck strength and ROM Grip strength Neck pain and disability significantly decreased in both exercise groups compared with control at 12/12 follow-up. ROM significantly increased in both training groups. Andersen et al. [30] RCT High Office workers (n = 549, DO = 109) 1 h per week for intervention 1. SRT: 2–3 sets 10–15 repetitions of dynamic strengthening exercise for shoulder and static exercise for neck 2. APE: motivated to increase physical activity levels, steppers, punch bags, Nordic walking 3. Reference intervention (REF); health promotion activities Isometric muscle strength shoulder elevation and abduction Questionnaire regarding neck and shoulder symptoms For participants with neck pain, there was a significant decrease in intensity in SRT and APE compared to REF. Coury et al. [22] SR AMSTAR 7/11 Sedentary workers (nine studies) Mixture of heavy and light strength training with comparison groups VAS, NDI, shoulder pain index, PPT, Modified Nordic Questionnaire. Borg CR10 Three high-quality studies showed strong evidence for the effect of exercise for neck symptoms. Three high-quality studies showed strong evidence for ineffectiveness of workplace exercise for shoulder symptoms. 1RM, 1 repetition maximum; DASH, disability of arm, shoulder and hand; DO, drop out; EMG, electromyography; PPT, pain pressure threshold; ROM, range of movement; SR, systematic review; STAI, State-Trait Anxiety Inventory. View Large Table 1. Characteristics of the included studies Study Design Risk of bias Population Intervention Outcomes Results Ma et al. [24] RCT High Daily computer users from two Chinese universities and nearby outpatient clinics with past/present history of computer-related neck/shoulder discomfort (n = 60, DO = 22) 1. Biofeedback group (BG); 2 h daily exercise while at computer 2. Active exercise group (AG); daily strength and stretch program 3. Passive treatment group (PG); interferential therapy and hot packs ×2/week. 4. Control group (CG); education booklet on office ergonomics VAS NDI EMG surface during typing task Significantly greater decrease in VAS, NDI and EMG in BG compared with other groups at 6/52 and 6/12 (P < 0.05). However significant decrease in VAS and NDI in AG and PG not in CG. Andersen et al. [28] RCT Low Computer users with frequent neck/shoulder muscle pain (n = 198, DO = 6) 1. Two-min group; one single set of exercise to failure up to 2 min 2. Twelve-min group; 5–6 sets of 8–12 repetitions progressing to a total of 25–30 sets per week 3. CG; received weekly emailed information on various aspects of general health VAS Palpable tenderness of neck/shoulder muscles Isometric strength Significant pain reduction in exercise groups compared with control. No significant difference between exercise groups. Significant reduction in palpable tenderness in exercise groups compared with control. Viljanen et al. [29] RCT High Female office workers with chronic non-specific pain >12/52 (n = 393, DO = 55) 1. Dynamic muscle training group; exercise 3/week for 30 min for 12/52 physio led initially, then performed themselves with feedback 2. Relaxation group; taught participants to activate only those muscles needed for specific activities and relax others 3. CG; told not to change any activity for 12/52 Cervical ROM Dynamic muscle strength in the neck/shoulder NDI Depression Work stress No significant differences between two training groups and control for changes in pain, NDI, ROM or dynamic muscle strength (no P value available). van Eijsden et al. [26] RCT High Computer screen workers with non-specific WRULD (n = 88, DO = 6) 1. Postural exercise group (PE); posture awareness education through exercise—1 hour treatments ×2 per week 1–3, then 1/week then 1/2 h for 2/52 2. Regular physio group (RP); who attended WRULD course of active muscle training and fitness—3 × 1/2 h for 3 weeks, 2 × 1/2 for 2 weeks, 1 × 1/2 h for 2 weeks 10-week treatment duration Groningen Fitness Questionnaire Job stress survey STAI VAS DASH EQ5D QALY showed no significant difference between groups. VAS was significantly different in RP group at 3 months but not maintained at 6 months. No significant difference in outcomes between groups at 1 year. No statistical significant difference between groups regarding cost effectiveness. Sihawong et al. [31] SR Amstar 7/11 Office workers with non-specific neck pain (n = 9 studies) Exercise therapy Incidence and prevalence of neck pain Discomfort PPT Frequency, duration, severity Productivity Work ability index sick leave Recovery, disability Strong evidence positive effect of strengthening and endurance exercise for treating neck pain. Three high-quality trials suggested muscle strengthening significantly reduced intensity of neck pain. One high-quality trial: no significant difference in neck pain in workers who received strength and stretching compared with no intervention. Conflicting evidence for stretching exercises. Conflicting evidence for non-specific exercises. Blangsted et al. [23] RCT High Office workers (symptomatic and asymptomatic) (n = 549) 1. Specific resistance training (SRT); resistance exercise for neck/shoulder 3/week 20 min supervised, dynamic resistance for arm/shoulders, static exercise for neck and row exercise for arms/shoulders 2. All-round physical exercise (APE); motivated for any exercise, organized groups for running/walking, given step counters. Bike to work 3. Reference groups (REF); advice given re ergonomics food, work organization health promotion Modified Noridc Questionnaire Work ability index Mean intensity of pain Statistically significant differences between SRT and APE compared with REF, in the intensity and the duration of symptoms. SRT not more effective than APE in reducing duration/intensity of symptoms. Andersen et al. [25] RCT High Female computer workers (n = 48, DO = 6) 1. Specific strength training (SST); supervised high intensity strength training shoulder/neck, load progressively increased 2. General fitness training (GFT); leg bicycling 3. REF; health promotion, relaxation stress management 1 h per week for each group VAS Aerobic fitness Isometric muscle strength shoulder elevation and abduction Isometric muscle strength increased significantly in the SST group during shoulder elevation and abduction. Significant decrease in VAS in the SST group, no significant change over time was observed in the GFT and REF groups. Sjorgen et al. [32] RCT High Office workers reporting headache/shoulder/neck pain <12/12 (n = 53) Two treatment sequence groups; group 1 had intervention for 15/52 while group 2 had nothing, then groups swapped Physical exercise intervention consisted of progressive light resistance training performed 1/day in working week, then after 5/52 1–2/day 20 repetitions of 30% RM Guidance: physio provided training instructions and general guidance on posture and movement control BORG CR10 1 RM Physical activity Physical ex intervention significantly decreased intensity of headache and neck symptoms, no effect in the shoulder. Ylinen et al. [27] RCT High Female office workers referred from occupational health (n = 180) 1. Strength training groups; Theraband to train neck muscles 15 repetitions all directions 2. Endurance training group; neck flexor muscles 20 × 3 Both groups performed dynamic exercise for shoulders and UE 3. CG Five sessions per week 45 min long VAS Modified neck and shoulder disability index Isometric neck strength and ROM Grip strength Neck pain and disability significantly decreased in both exercise groups compared with control at 12/12 follow-up. ROM significantly increased in both training groups. Andersen et al. [30] RCT High Office workers (n = 549, DO = 109) 1 h per week for intervention 1. SRT: 2–3 sets 10–15 repetitions of dynamic strengthening exercise for shoulder and static exercise for neck 2. APE: motivated to increase physical activity levels, steppers, punch bags, Nordic walking 3. Reference intervention (REF); health promotion activities Isometric muscle strength shoulder elevation and abduction Questionnaire regarding neck and shoulder symptoms For participants with neck pain, there was a significant decrease in intensity in SRT and APE compared to REF. Coury et al. [22] SR AMSTAR 7/11 Sedentary workers (nine studies) Mixture of heavy and light strength training with comparison groups VAS, NDI, shoulder pain index, PPT, Modified Nordic Questionnaire. Borg CR10 Three high-quality studies showed strong evidence for the effect of exercise for neck symptoms. Three high-quality studies showed strong evidence for ineffectiveness of workplace exercise for shoulder symptoms. Study Design Risk of bias Population Intervention Outcomes Results Ma et al. [24] RCT High Daily computer users from two Chinese universities and nearby outpatient clinics with past/present history of computer-related neck/shoulder discomfort (n = 60, DO = 22) 1. Biofeedback group (BG); 2 h daily exercise while at computer 2. Active exercise group (AG); daily strength and stretch program 3. Passive treatment group (PG); interferential therapy and hot packs ×2/week. 4. Control group (CG); education booklet on office ergonomics VAS NDI EMG surface during typing task Significantly greater decrease in VAS, NDI and EMG in BG compared with other groups at 6/52 and 6/12 (P < 0.05). However significant decrease in VAS and NDI in AG and PG not in CG. Andersen et al. [28] RCT Low Computer users with frequent neck/shoulder muscle pain (n = 198, DO = 6) 1. Two-min group; one single set of exercise to failure up to 2 min 2. Twelve-min group; 5–6 sets of 8–12 repetitions progressing to a total of 25–30 sets per week 3. CG; received weekly emailed information on various aspects of general health VAS Palpable tenderness of neck/shoulder muscles Isometric strength Significant pain reduction in exercise groups compared with control. No significant difference between exercise groups. Significant reduction in palpable tenderness in exercise groups compared with control. Viljanen et al. [29] RCT High Female office workers with chronic non-specific pain >12/52 (n = 393, DO = 55) 1. Dynamic muscle training group; exercise 3/week for 30 min for 12/52 physio led initially, then performed themselves with feedback 2. Relaxation group; taught participants to activate only those muscles needed for specific activities and relax others 3. CG; told not to change any activity for 12/52 Cervical ROM Dynamic muscle strength in the neck/shoulder NDI Depression Work stress No significant differences between two training groups and control for changes in pain, NDI, ROM or dynamic muscle strength (no P value available). van Eijsden et al. [26] RCT High Computer screen workers with non-specific WRULD (n = 88, DO = 6) 1. Postural exercise group (PE); posture awareness education through exercise—1 hour treatments ×2 per week 1–3, then 1/week then 1/2 h for 2/52 2. Regular physio group (RP); who attended WRULD course of active muscle training and fitness—3 × 1/2 h for 3 weeks, 2 × 1/2 for 2 weeks, 1 × 1/2 h for 2 weeks 10-week treatment duration Groningen Fitness Questionnaire Job stress survey STAI VAS DASH EQ5D QALY showed no significant difference between groups. VAS was significantly different in RP group at 3 months but not maintained at 6 months. No significant difference in outcomes between groups at 1 year. No statistical significant difference between groups regarding cost effectiveness. Sihawong et al. [31] SR Amstar 7/11 Office workers with non-specific neck pain (n = 9 studies) Exercise therapy Incidence and prevalence of neck pain Discomfort PPT Frequency, duration, severity Productivity Work ability index sick leave Recovery, disability Strong evidence positive effect of strengthening and endurance exercise for treating neck pain. Three high-quality trials suggested muscle strengthening significantly reduced intensity of neck pain. One high-quality trial: no significant difference in neck pain in workers who received strength and stretching compared with no intervention. Conflicting evidence for stretching exercises. Conflicting evidence for non-specific exercises. Blangsted et al. [23] RCT High Office workers (symptomatic and asymptomatic) (n = 549) 1. Specific resistance training (SRT); resistance exercise for neck/shoulder 3/week 20 min supervised, dynamic resistance for arm/shoulders, static exercise for neck and row exercise for arms/shoulders 2. All-round physical exercise (APE); motivated for any exercise, organized groups for running/walking, given step counters. Bike to work 3. Reference groups (REF); advice given re ergonomics food, work organization health promotion Modified Noridc Questionnaire Work ability index Mean intensity of pain Statistically significant differences between SRT and APE compared with REF, in the intensity and the duration of symptoms. SRT not more effective than APE in reducing duration/intensity of symptoms. Andersen et al. [25] RCT High Female computer workers (n = 48, DO = 6) 1. Specific strength training (SST); supervised high intensity strength training shoulder/neck, load progressively increased 2. General fitness training (GFT); leg bicycling 3. REF; health promotion, relaxation stress management 1 h per week for each group VAS Aerobic fitness Isometric muscle strength shoulder elevation and abduction Isometric muscle strength increased significantly in the SST group during shoulder elevation and abduction. Significant decrease in VAS in the SST group, no significant change over time was observed in the GFT and REF groups. Sjorgen et al. [32] RCT High Office workers reporting headache/shoulder/neck pain <12/12 (n = 53) Two treatment sequence groups; group 1 had intervention for 15/52 while group 2 had nothing, then groups swapped Physical exercise intervention consisted of progressive light resistance training performed 1/day in working week, then after 5/52 1–2/day 20 repetitions of 30% RM Guidance: physio provided training instructions and general guidance on posture and movement control BORG CR10 1 RM Physical activity Physical ex intervention significantly decreased intensity of headache and neck symptoms, no effect in the shoulder. Ylinen et al. [27] RCT High Female office workers referred from occupational health (n = 180) 1. Strength training groups; Theraband to train neck muscles 15 repetitions all directions 2. Endurance training group; neck flexor muscles 20 × 3 Both groups performed dynamic exercise for shoulders and UE 3. CG Five sessions per week 45 min long VAS Modified neck and shoulder disability index Isometric neck strength and ROM Grip strength Neck pain and disability significantly decreased in both exercise groups compared with control at 12/12 follow-up. ROM significantly increased in both training groups. Andersen et al. [30] RCT High Office workers (n = 549, DO = 109) 1 h per week for intervention 1. SRT: 2–3 sets 10–15 repetitions of dynamic strengthening exercise for shoulder and static exercise for neck 2. APE: motivated to increase physical activity levels, steppers, punch bags, Nordic walking 3. Reference intervention (REF); health promotion activities Isometric muscle strength shoulder elevation and abduction Questionnaire regarding neck and shoulder symptoms For participants with neck pain, there was a significant decrease in intensity in SRT and APE compared to REF. Coury et al. [22] SR AMSTAR 7/11 Sedentary workers (nine studies) Mixture of heavy and light strength training with comparison groups VAS, NDI, shoulder pain index, PPT, Modified Nordic Questionnaire. Borg CR10 Three high-quality studies showed strong evidence for the effect of exercise for neck symptoms. Three high-quality studies showed strong evidence for ineffectiveness of workplace exercise for shoulder symptoms. 1RM, 1 repetition maximum; DASH, disability of arm, shoulder and hand; DO, drop out; EMG, electromyography; PPT, pain pressure threshold; ROM, range of movement; SR, systematic review; STAI, State-Trait Anxiety Inventory. View Large Table 1 shows the characteristics of the included studies in the review which includes the study design, risk of bias, study population, intervention, outcomes used and specific results for sedentary workers. To aid interpretation of the results, this review further categorized relevant characteristics from the included studies. If results were not classified as pre-test and post-test (or were not available), they were not included in the tables. The results from one particular study could not be extrapolated from the available graphs and were not presented in table format [23]. Table 2 demonstrates the numerical results of pain outcomes for those studies which had the available data reported. The Visual Analogue Scale (VAS) was the predominant outcome measure used to evaluate symptoms of pain in the included studies [22–27]. Table 3 highlights the numerical results of the functional variables for the studies included. With regards to the measurement of function, the most commonly used evaluation tools were the NDI [25,28,29] and muscle strength (Nm) [26,28,30]. Table 2. Numerical results of outcomes for pain variables for included studies Study Pain variable Evaluation tool Pre-test Post-test Ma et al. [24] VAS BG: 5.12 ± 1.65 BG: 1.87 ± 0.74 AG: 4.75 ± 1.59 AG: 2.10 ± 1.34 PG: 5.69 ± 1.54 PG: 3.60 ± 1.18 CG: 5.27 ± 1.27 CG: 4.75 ± 1.53 Andersen et al. [28] VAS (modified) 2G: −1.3 (−1.9 to −0.7) 12G: −1.8 (−2.4 to −1.2) CG: 0.1 (−0.3 to 0.5) Viljanen et al. [29] Pain intensity DG: 4.8 ± 2.3 DG: 2.9 ± 2.6 RG: 4.8 ± 2.3 RG: 2.9 ± 2.4 CG: 4.1 ± 2.2 CG: 2.7 ± 2.5 van Eijsden et al. [26] VAS Means (95% CI) PE: 2.88 (2.43, 3.33) PE: 1.90 (1.35, 2.45) RP: 2.59 (2.07, 3.11) RP: 1.13 (0.76, 1.51) Andersen et al. [25] VAS GFT: 50 ± 16 GFT: 45 ± 13 SST: 44 ± 25 SST: 10 ± 10 REF: 43 ± 27 REF: 35 ± 29 Sjorgen et al. [32] Borg CR10 Headache intensity (observed mean, SD) TG1: Intervention TG1: No intervention 2.30 (2.26)–1.42 (1.69) 1.42 (2.10)–1.29 (1.81) TG2: No intervention TG2: Intervention 2.21(2.82)–1.51 (1.65) 0.43 (1.34)–0.39 (1.08) Ylinen et al. [27] VAS SG: 58 (73–72) SG: −40 (−48 to −32) EG: 57(43–74) EG: −35 (−42 to −28) CG: 58 (42–74) CG: −16 (−22 to −9) Median IQR Median (95% CI) Andersen et al. [30] Neck pain SRT: 5.0 ± 0.2 SRT: 3.4 ± 0.2 APE: 5.0 ± 0.2 APE: 3.6 ± 0.2 Study Pain variable Evaluation tool Pre-test Post-test Ma et al. [24] VAS BG: 5.12 ± 1.65 BG: 1.87 ± 0.74 AG: 4.75 ± 1.59 AG: 2.10 ± 1.34 PG: 5.69 ± 1.54 PG: 3.60 ± 1.18 CG: 5.27 ± 1.27 CG: 4.75 ± 1.53 Andersen et al. [28] VAS (modified) 2G: −1.3 (−1.9 to −0.7) 12G: −1.8 (−2.4 to −1.2) CG: 0.1 (−0.3 to 0.5) Viljanen et al. [29] Pain intensity DG: 4.8 ± 2.3 DG: 2.9 ± 2.6 RG: 4.8 ± 2.3 RG: 2.9 ± 2.4 CG: 4.1 ± 2.2 CG: 2.7 ± 2.5 van Eijsden et al. [26] VAS Means (95% CI) PE: 2.88 (2.43, 3.33) PE: 1.90 (1.35, 2.45) RP: 2.59 (2.07, 3.11) RP: 1.13 (0.76, 1.51) Andersen et al. [25] VAS GFT: 50 ± 16 GFT: 45 ± 13 SST: 44 ± 25 SST: 10 ± 10 REF: 43 ± 27 REF: 35 ± 29 Sjorgen et al. [32] Borg CR10 Headache intensity (observed mean, SD) TG1: Intervention TG1: No intervention 2.30 (2.26)–1.42 (1.69) 1.42 (2.10)–1.29 (1.81) TG2: No intervention TG2: Intervention 2.21(2.82)–1.51 (1.65) 0.43 (1.34)–0.39 (1.08) Ylinen et al. [27] VAS SG: 58 (73–72) SG: −40 (−48 to −32) EG: 57(43–74) EG: −35 (−42 to −28) CG: 58 (42–74) CG: −16 (−22 to −9) Median IQR Median (95% CI) Andersen et al. [30] Neck pain SRT: 5.0 ± 0.2 SRT: 3.4 ± 0.2 APE: 5.0 ± 0.2 APE: 3.6 ± 0.2 12G, 12-min group; 2G, 2-min group; AG, active exercise group; APE, all-round physical exercise group; BG, biofeedback group; CG, control group; DG, dynamic muscle training group; EG, endurance training group; GFT, general fitness training; PE, postural exercise group; PG, passive treatment group; REF, reference groups; RG, relaxation group; RP, regular physio group; SG, strength training group; SRT, specific training group; SST, specific strength training; TG1, treatment group 1; TG2, treatment group 2. View Large Table 2. Numerical results of outcomes for pain variables for included studies Study Pain variable Evaluation tool Pre-test Post-test Ma et al. [24] VAS BG: 5.12 ± 1.65 BG: 1.87 ± 0.74 AG: 4.75 ± 1.59 AG: 2.10 ± 1.34 PG: 5.69 ± 1.54 PG: 3.60 ± 1.18 CG: 5.27 ± 1.27 CG: 4.75 ± 1.53 Andersen et al. [28] VAS (modified) 2G: −1.3 (−1.9 to −0.7) 12G: −1.8 (−2.4 to −1.2) CG: 0.1 (−0.3 to 0.5) Viljanen et al. [29] Pain intensity DG: 4.8 ± 2.3 DG: 2.9 ± 2.6 RG: 4.8 ± 2.3 RG: 2.9 ± 2.4 CG: 4.1 ± 2.2 CG: 2.7 ± 2.5 van Eijsden et al. [26] VAS Means (95% CI) PE: 2.88 (2.43, 3.33) PE: 1.90 (1.35, 2.45) RP: 2.59 (2.07, 3.11) RP: 1.13 (0.76, 1.51) Andersen et al. [25] VAS GFT: 50 ± 16 GFT: 45 ± 13 SST: 44 ± 25 SST: 10 ± 10 REF: 43 ± 27 REF: 35 ± 29 Sjorgen et al. [32] Borg CR10 Headache intensity (observed mean, SD) TG1: Intervention TG1: No intervention 2.30 (2.26)–1.42 (1.69) 1.42 (2.10)–1.29 (1.81) TG2: No intervention TG2: Intervention 2.21(2.82)–1.51 (1.65) 0.43 (1.34)–0.39 (1.08) Ylinen et al. [27] VAS SG: 58 (73–72) SG: −40 (−48 to −32) EG: 57(43–74) EG: −35 (−42 to −28) CG: 58 (42–74) CG: −16 (−22 to −9) Median IQR Median (95% CI) Andersen et al. [30] Neck pain SRT: 5.0 ± 0.2 SRT: 3.4 ± 0.2 APE: 5.0 ± 0.2 APE: 3.6 ± 0.2 Study Pain variable Evaluation tool Pre-test Post-test Ma et al. [24] VAS BG: 5.12 ± 1.65 BG: 1.87 ± 0.74 AG: 4.75 ± 1.59 AG: 2.10 ± 1.34 PG: 5.69 ± 1.54 PG: 3.60 ± 1.18 CG: 5.27 ± 1.27 CG: 4.75 ± 1.53 Andersen et al. [28] VAS (modified) 2G: −1.3 (−1.9 to −0.7) 12G: −1.8 (−2.4 to −1.2) CG: 0.1 (−0.3 to 0.5) Viljanen et al. [29] Pain intensity DG: 4.8 ± 2.3 DG: 2.9 ± 2.6 RG: 4.8 ± 2.3 RG: 2.9 ± 2.4 CG: 4.1 ± 2.2 CG: 2.7 ± 2.5 van Eijsden et al. [26] VAS Means (95% CI) PE: 2.88 (2.43, 3.33) PE: 1.90 (1.35, 2.45) RP: 2.59 (2.07, 3.11) RP: 1.13 (0.76, 1.51) Andersen et al. [25] VAS GFT: 50 ± 16 GFT: 45 ± 13 SST: 44 ± 25 SST: 10 ± 10 REF: 43 ± 27 REF: 35 ± 29 Sjorgen et al. [32] Borg CR10 Headache intensity (observed mean, SD) TG1: Intervention TG1: No intervention 2.30 (2.26)–1.42 (1.69) 1.42 (2.10)–1.29 (1.81) TG2: No intervention TG2: Intervention 2.21(2.82)–1.51 (1.65) 0.43 (1.34)–0.39 (1.08) Ylinen et al. [27] VAS SG: 58 (73–72) SG: −40 (−48 to −32) EG: 57(43–74) EG: −35 (−42 to −28) CG: 58 (42–74) CG: −16 (−22 to −9) Median IQR Median (95% CI) Andersen et al. [30] Neck pain SRT: 5.0 ± 0.2 SRT: 3.4 ± 0.2 APE: 5.0 ± 0.2 APE: 3.6 ± 0.2 12G, 12-min group; 2G, 2-min group; AG, active exercise group; APE, all-round physical exercise group; BG, biofeedback group; CG, control group; DG, dynamic muscle training group; EG, endurance training group; GFT, general fitness training; PE, postural exercise group; PG, passive treatment group; REF, reference groups; RG, relaxation group; RP, regular physio group; SG, strength training group; SRT, specific training group; SST, specific strength training; TG1, treatment group 1; TG2, treatment group 2. View Large Table 3. Numerical results of outcomes for functional variables for included studies Study Functional variable Evaluation tool Pre-test Post-test Ma et al. [22] NDI BG: 16.82 ± 6.21 BG: 7.00 ± 3.05 AG: 16.05 ± 5.13 AG: 10.33 ± 2.23 PG: 15.81 ± 4.97 PG: 12.33 ± 4.29 CG: 16.53 ± 5.95 CG: 14.82 ± 2.87 Andersen et al. [26] Muscle strength (Nm) 2G: 2.5 (1.4–3.6) 12G: 2.3 (1.1–3.3) CG: 0.5 (−0.5 to 1.5) Viljanen et al. [27] NDI DG: 29 ± 15.4 DG: 15 ± 4.6 RG: 29 ± 14.3 RG: 14 ± 12.5 CG: 26 ± 13.8 CG: 14 ± 13.8 van Eijsden et al. [24] DASH PE: 15.23 (12.18, 18.27) PE: 10.98 (8.06, 13.91) RP: 16.12 (12.47, 19.76) RP: 8.75 (5.89, 11.62) Andersen et al. [23] R shoulder elevation (Nm) GFT: 52 ± 18 GFT: 57 ± 21 SST: 58 ± 21 SST: 75 ± 19 REF: 48 ± 22 REF: 58 ± 18 Sjorgen et al. [30] Borg CR10 Intensity neck symptoms (observed mean SD) TG1: Intervention TG1: No intervention 2.46 (2.29)–0.67 (1.46) 0.47 (1.07)–1.00 (1.41) TG2: No intervention TG2: Intervention 2.17 (1.96)–1.50 (1.68) 0.42 (1.0)–0.24 (0.72) Ylinen et al. [25] NDI SG: 21 (16–26) SG: −9 (−11 to −7) EG: 22 (16–28) EG: −8 (−11 to −6) CG: 22 (16–31) CG: −3 (−6 to 0) Median IQR Median (95% CI) Andersen et al. [28] Muscle strength Elevation (N) SRT: 516 ± 19 SRT: 573 ± 19 APE: 586 ± 25 APE: 641 ± 26 REF: 584 ± 23 REF: 605 ± 22 Study Functional variable Evaluation tool Pre-test Post-test Ma et al. [22] NDI BG: 16.82 ± 6.21 BG: 7.00 ± 3.05 AG: 16.05 ± 5.13 AG: 10.33 ± 2.23 PG: 15.81 ± 4.97 PG: 12.33 ± 4.29 CG: 16.53 ± 5.95 CG: 14.82 ± 2.87 Andersen et al. [26] Muscle strength (Nm) 2G: 2.5 (1.4–3.6) 12G: 2.3 (1.1–3.3) CG: 0.5 (−0.5 to 1.5) Viljanen et al. [27] NDI DG: 29 ± 15.4 DG: 15 ± 4.6 RG: 29 ± 14.3 RG: 14 ± 12.5 CG: 26 ± 13.8 CG: 14 ± 13.8 van Eijsden et al. [24] DASH PE: 15.23 (12.18, 18.27) PE: 10.98 (8.06, 13.91) RP: 16.12 (12.47, 19.76) RP: 8.75 (5.89, 11.62) Andersen et al. [23] R shoulder elevation (Nm) GFT: 52 ± 18 GFT: 57 ± 21 SST: 58 ± 21 SST: 75 ± 19 REF: 48 ± 22 REF: 58 ± 18 Sjorgen et al. [30] Borg CR10 Intensity neck symptoms (observed mean SD) TG1: Intervention TG1: No intervention 2.46 (2.29)–0.67 (1.46) 0.47 (1.07)–1.00 (1.41) TG2: No intervention TG2: Intervention 2.17 (1.96)–1.50 (1.68) 0.42 (1.0)–0.24 (0.72) Ylinen et al. [25] NDI SG: 21 (16–26) SG: −9 (−11 to −7) EG: 22 (16–28) EG: −8 (−11 to −6) CG: 22 (16–31) CG: −3 (−6 to 0) Median IQR Median (95% CI) Andersen et al. [28] Muscle strength Elevation (N) SRT: 516 ± 19 SRT: 573 ± 19 APE: 586 ± 25 APE: 641 ± 26 REF: 584 ± 23 REF: 605 ± 22 12G, 12-min group; 2G, 2-min group; AG, active exercise group; APE, all-round physical exercise group; BG, biofeedback group; Borg CR10, Borg category/ratio 10; CG, control group; DASH, disability of arm, shoulder and hand; DG, dynamic muscle training group; EG, endurance training group; GFT, general fitness training; IQR, interquartile range; PE, postural exercise group; PG, passive treatment group; REF, reference groups; RG, relaxation group; RP, regular physio group; SG, strength training group; SRT, specific training group; SST, specific strength training; TG1, treatment group 1; TG2, treatment group 2. View Large Table 3. Numerical results of outcomes for functional variables for included studies Study Functional variable Evaluation tool Pre-test Post-test Ma et al. [22] NDI BG: 16.82 ± 6.21 BG: 7.00 ± 3.05 AG: 16.05 ± 5.13 AG: 10.33 ± 2.23 PG: 15.81 ± 4.97 PG: 12.33 ± 4.29 CG: 16.53 ± 5.95 CG: 14.82 ± 2.87 Andersen et al. [26] Muscle strength (Nm) 2G: 2.5 (1.4–3.6) 12G: 2.3 (1.1–3.3) CG: 0.5 (−0.5 to 1.5) Viljanen et al. [27] NDI DG: 29 ± 15.4 DG: 15 ± 4.6 RG: 29 ± 14.3 RG: 14 ± 12.5 CG: 26 ± 13.8 CG: 14 ± 13.8 van Eijsden et al. [24] DASH PE: 15.23 (12.18, 18.27) PE: 10.98 (8.06, 13.91) RP: 16.12 (12.47, 19.76) RP: 8.75 (5.89, 11.62) Andersen et al. [23] R shoulder elevation (Nm) GFT: 52 ± 18 GFT: 57 ± 21 SST: 58 ± 21 SST: 75 ± 19 REF: 48 ± 22 REF: 58 ± 18 Sjorgen et al. [30] Borg CR10 Intensity neck symptoms (observed mean SD) TG1: Intervention TG1: No intervention 2.46 (2.29)–0.67 (1.46) 0.47 (1.07)–1.00 (1.41) TG2: No intervention TG2: Intervention 2.17 (1.96)–1.50 (1.68) 0.42 (1.0)–0.24 (0.72) Ylinen et al. [25] NDI SG: 21 (16–26) SG: −9 (−11 to −7) EG: 22 (16–28) EG: −8 (−11 to −6) CG: 22 (16–31) CG: −3 (−6 to 0) Median IQR Median (95% CI) Andersen et al. [28] Muscle strength Elevation (N) SRT: 516 ± 19 SRT: 573 ± 19 APE: 586 ± 25 APE: 641 ± 26 REF: 584 ± 23 REF: 605 ± 22 Study Functional variable Evaluation tool Pre-test Post-test Ma et al. [22] NDI BG: 16.82 ± 6.21 BG: 7.00 ± 3.05 AG: 16.05 ± 5.13 AG: 10.33 ± 2.23 PG: 15.81 ± 4.97 PG: 12.33 ± 4.29 CG: 16.53 ± 5.95 CG: 14.82 ± 2.87 Andersen et al. [26] Muscle strength (Nm) 2G: 2.5 (1.4–3.6) 12G: 2.3 (1.1–3.3) CG: 0.5 (−0.5 to 1.5) Viljanen et al. [27] NDI DG: 29 ± 15.4 DG: 15 ± 4.6 RG: 29 ± 14.3 RG: 14 ± 12.5 CG: 26 ± 13.8 CG: 14 ± 13.8 van Eijsden et al. [24] DASH PE: 15.23 (12.18, 18.27) PE: 10.98 (8.06, 13.91) RP: 16.12 (12.47, 19.76) RP: 8.75 (5.89, 11.62) Andersen et al. [23] R shoulder elevation (Nm) GFT: 52 ± 18 GFT: 57 ± 21 SST: 58 ± 21 SST: 75 ± 19 REF: 48 ± 22 REF: 58 ± 18 Sjorgen et al. [30] Borg CR10 Intensity neck symptoms (observed mean SD) TG1: Intervention TG1: No intervention 2.46 (2.29)–0.67 (1.46) 0.47 (1.07)–1.00 (1.41) TG2: No intervention TG2: Intervention 2.17 (1.96)–1.50 (1.68) 0.42 (1.0)–0.24 (0.72) Ylinen et al. [25] NDI SG: 21 (16–26) SG: −9 (−11 to −7) EG: 22 (16–28) EG: −8 (−11 to −6) CG: 22 (16–31) CG: −3 (−6 to 0) Median IQR Median (95% CI) Andersen et al. [28] Muscle strength Elevation (N) SRT: 516 ± 19 SRT: 573 ± 19 APE: 586 ± 25 APE: 641 ± 26 REF: 584 ± 23 REF: 605 ± 22 12G, 12-min group; 2G, 2-min group; AG, active exercise group; APE, all-round physical exercise group; BG, biofeedback group; Borg CR10, Borg category/ratio 10; CG, control group; DASH, disability of arm, shoulder and hand; DG, dynamic muscle training group; EG, endurance training group; GFT, general fitness training; IQR, interquartile range; PE, postural exercise group; PG, passive treatment group; REF, reference groups; RG, relaxation group; RP, regular physio group; SG, strength training group; SRT, specific training group; SST, specific strength training; TG1, treatment group 1; TG2, treatment group 2. View Large Overall, there was moderate evidence to suggest exercise is effective in reducing the symptoms of pain in WRULDs in sedentary workers when compared to a control group [22–27,30–32]. Two of these studies were high-quality systematic reviews [22,31]. This review found moderate evidence to suggest there are no significant differences between various types of exercise in relation to pain or functional outcomes in sedentary workers [23,26,29,32]. One high-quality systematic review identified strong evidence for the ineffectiveness of workplace exercise for shoulder symptoms [22]. One RCT investigating two different types of exercise therapy found no statistical difference between a postural exercise group and a regular physiotherapy group with regards to cost effectiveness; however, no control group was included in the study [26]. There was a wide variation in the prescription of exercise in each group across the studies, from as little as 2 min five times a week [28] to 2 h of daily biofeedback training [24]. All of the RCTs included in the study focused their investigations around sedentary workers with a primary complaint of neck or shoulder pain [23–30,32]. Seven RCTS [23–27,29,30] used a control group in their investigations. The majority of RCTs included in this study had high numbers of participants, with five studies reaching between 100 to nearly 400 participants [23,27–30]. Although one of the systematic reviews included results on low back pain, these data were omitted from our study based on the inclusion criteria [22]. This review found strong evidence to support the effectiveness of physical exercise in controlling neck pain among sedentary workers; however, there were no positive results to indicate effectiveness of exercise with regards to shoulder pain. A high-quality systematic review [31] reported strong evidence to support the use of muscle strengthening and endurance exercises in treating neck pain and endurance exercises in reducing disability. Discussion This systematic review found moderate evidence supporting the positive effect of exercise therapy for both pain and function in the treatment of WRULDs in sedentary workers. This conclusion is based on the relevant data extrapolated from the included studies (nine RCTs and two systematic reviews). These results are comparable to recent systematic reviews, which found strong evidence to support the use of exercise therapy, in mixed populations of workers [22,31]. In contrast, earlier studies in populations with variable occupations (e.g. sedentary and industrial) found conflicting evidence for the effectiveness of exercises over no treatment or as an adjunct [17,33]. It is, therefore, difficult to accurately compare with these earlier reviews due to the apparent population homogeneity. Clinical utility is lost for the specific population of sedentary workers. Strengths of this study include its comprehensive literature search using a number of databases generous inclusion criteria and good inter-rater agreement. Potential bias within this review was minimized by reviewers using a standardized critical appraisal tool to reach consensus regarding the risk of bias of each study. With regards to the most appropriate types of exercise for the treatment of WRULDs in sedentary workers, this review found moderate evidence to suggest there are no significant differences between various types of exercise in relation to pain or functional outcomes. This is in agreement with a previous study which found no significant differences between strength and endurance exercises for treating work-related complaints of the arm, neck or shoulder [17]. However, a recent systematic review [31] found moderate evidence for the positive effect on reduction of disability with exercise using muscular endurance training parameters on the neck flexor muscles (e.g. three sets of 20 repetitions, five times per week over 12 months). They did, however, find dynamic training with light resistance to be ineffective in treating neck pain. There is a slight disparity in the research regarding the effectiveness of exercise in WRULDs specifically aimed at shoulder pathologies. A recently published systematic review [18] concluded there is moderate evidence that exercise in workers suffering from a rotator cuff tendinopathy is an effective modality in terms of pain reduction, improvement in work ability and return-to-work when compared with a control intervention or to a placebo. This is in agreement with the current review but in contrast to an earlier systematic review which found no positive results supporting the use of exercise in shoulder symptoms from WRULD [22]. The main limitations of this review are based on the high risk of bias of the included RCTs. This was mainly due to lack of blinding, which is historically found to be an effective method of reducing selection bias [34]. Subsequently, a literature base of reduced methodological quality from which to extrapolate conclusions can lead to misinterpretation of the evidence [35]. The reviewed evidence base in this study is impacted by reporting bias, where the trial reports fail to follow CONSORT guidelines and subsequently may influence the internal validity of each study’s conclusions [35]. Specifically low-quality studies are considered to inflate effect estimates [36] and this should be considered when reading the results of this review. Also, the initial search was limited to studies published in the English language, which may have excluded relevant studies. However, as a large majority of clinical trials are published in English, this is considered to be an unlikely source of bias. Due to the heterogeneous nature of the reported results and different variables across the included studies, it was deemed inappropriate to conduct a meta-analysis of the results. The lack of consensus regarding a definition of WRULDs through the included studies may also contribute to the results of this paper. There was a wide variety of terminology used which only adds to the heterogeneous nature of the studies. Reasons why this review may have found merely moderate evidence as opposed to strong evidence may be the limitations of the included studies. There was a high risk of bias in the majority of the included RCTs, mainly due to a lack of participant blinding. Some studies include asymptomatic individuals as well as symptomatic [24]. There was also very little information from each study classifying their diagnosis or definition of WRULDs. Unfortunately, it is difficult from this review to comment on specific pathologies under the umbrella term of WRULDs. It is pertinent to note that the majority of the included studies focussed mainly on symptoms regarding the neck and shoulder. It would be inaccurate of this study to comment on the effectiveness of exercise with regards to other complaints associated with WRULDs such as lateral epidcondylagia. However, a recent systematic review has found inconclusive evidence to support the role of strengthening exercises specifically in the management of persistent lateral epicondylitis, although it is more effective than a wait-and-see approach [37]. The results from this study highlight the positive evidence to support the use of exercise therapy in the management of WRULDs. This has relevant implications for employers as exercise is a cost-effective treatment modality which can be carried out without the need for expensive equipment, highlighted by the included studies. Cost efficiency is paramount to the success of any business, as well as maximizing productivity and reducing sickness absence lost to WRULD [27]. The findings of this study can help medical professionals working in occupational health understand the effectiveness of exercise as a treatment modality for sedentary workers. It is important to highlight that in clinical practice, exercise in isolation is not used as a stand-alone treatment for any condition. This is even more relevant in specific populations suffering from chronic pain. A multimodal treatment approach has been highlighted as a central part of managing these conditions [38]. The use of reported outcome measures in the included studies is clinically relevant to those used in current practice (e.g. VAS, NDI and muscle strength). Further research is required to provide additional information on the most effective treatments for the management of WRULDs in sedentary workers. It would be appropriate to define WRULDs in terms of specific and non-specific conditions in future research, so management for conditions may be as precise as can be. Identifying the most effective type of exercise for each specific and non-specific condition would be useful to clinicians, in order to rationalize treatment based on not only the worker but site and specificity of their conditions. Further research may also explore the optimal dosage of treatment, based on the wide range included in the studies in this review. Research may also look further into the most optimal delivery of exercise programmes in sedentary workers, whether this is a work place intervention or a prescribed home exercise programme. The design of future research is an important consideration, RCTs would be most effective in eliminating the various sources of bias. Additionally trials assessing the multimodal management of WRULDs would be useful. The management of these conditions clinically very often utilizes a multimodal approach, consisting of more than just exercise. It would be beneficial to understand the most suitable combinations of therapy for specific conditions to yield greater reductions in pain and disability. In conclusion, this review found moderate evidence to support the effectiveness of exercise therapy in the management of WRULDs in sedentary workers. This has clinical implications for physiotherapists and other occupational health professionals. Exercise is a common and useful prescription not only for specific diagnoses but for the overall health and well-being of the patient. The results of this study may also have positive implications with regards to cost effectiveness for employers in terms of the potential to influence the management of these conditions. In the current climate, exercise may also prove effective with regards to health promotion and physical activity in sedentary workers. Key points • This review found moderate evidence for the effectiveness in the treatment of work-related upper limb disorders in sedentary workers. • This results of this study showed positive implications for those working in occupational health as a potential cost-effective treatment tool. • Further research is needed to clarify the most beneficial type of exercise and frequency. Competing interests No funding was provided nor sought for this work. References 1. Juul-Kristensen B , Søgaard K , Støyer J , Jensen C . Computer users’ risk factors for developing shoulder, elbow and back symptoms . Scand J Work Environ Health 2004 ; 1 : 390 – 398 . Google Scholar CrossRef Search ADS 2. Visser B , van Dieën JH . Pathophysiology of upper extremity muscle disorders . J Electromyography Kinesiol 2006 ; 16 : 1 – 16 . Google Scholar CrossRef Search ADS 3. Bernard BP. Musculoskeletal Disorders and Workplace Factors: A Critical Review of Epidemiologic Evidence for Work-Related Musculoskeletal Disorders of the Neck, Upper Extremity, and Low Back . DHHS (NIOSH) Publication No. 97-141. Washington, DC : US Department of Health and Human Services, National Institute of Occupational Safety and Health , 1997 . 4. van Rijn RM , Huisstede BM , Koes BW , Burdorf A . Associations between work-related factors and the carpal tunnel syndrome: a systematic review . Scand J Work Environ Health 2009 ; 35 : 19 – 36 . Google Scholar CrossRef Search ADS PubMed 5. van Rijn RM , Huisstede BM , Koes BW , Burdorf A . Associations between work-related factors and specific disorders at the elbow: a systematic literature review . Rheumatology (Oxford) 2009 ; 48 : 528 – 536 . Google Scholar CrossRef Search ADS PubMed 6. van Rijn RM , Huisstede BM , Koes BW , Burdorf A . Associations between work-related factors and specific disorders of the shoulder: a systematic literature review . Scand J Work Environ Health 2010 ; 36 : 189 – 201 . Google Scholar CrossRef Search ADS PubMed 7. Boocock MG , Collier JM , McNair PJ , Simmonds M , Larmer , PJ , Armstrong B . A framework for the classification and diagnosis of work-related upper extremity conditions: systematic review . Sem Arth and Rheum 2009;38: 296 – 311 . CrossRef Search ADS 8. Staal JB , De Bie RA , Hendriks EJM . Aetiology and management of work-related upper extremity disorders . Best Pract Res Clin Rheumatol 2007 ; 21 : 123 – 133 . Google Scholar CrossRef Search ADS PubMed 9. Health & Safety Executive . Work-Related Musculoskeletal Disorder (WRMSDs) Statistics . London, UK Health & Safety Executive , 2016 . http://www.hse.gov.uk/statistics/causdis/musculoskeletal/msd.pdf (13 March 2018, date last accessed). 10. Strazdins L , Bammer G . Women, work and musculoskeletal health . Soc Sci Med 2004 ; 58 : 997 – 1005 . Google Scholar CrossRef Search ADS PubMed 11. Piligian G , Herbert R , Hearns M , Dropkin J , Landsbergis P , Cherniack M . Evaluation and management of chronic work‐related musculoskeletal disorders of the distal upper extremity . Am J Ind Med 2000 ; 37 : 75 – 93 . Google Scholar CrossRef Search ADS PubMed 12. Haahr JP , Østergaard S , Dalsgaard J et al. Exercises versus arthroscopic decompression in patients with subacromial impingement: a randomised, controlled study in 90 cases with a one year follow up . Ann Rheum Dis 2005 ; 64 : 760 – 764 . Google Scholar CrossRef Search ADS PubMed 13. Hagberg M , Harms-Ringdahl K , Nisell R , Hjelm EW . Rehabilitation of neck-shoulder pain in women industrial workers: a randomized trial comparing isometric shoulder endurance training with isometric shoulder strength training . Arch Phys Med Rehabil 2000 ; 81 : 1051 – 1058 . Google Scholar CrossRef Search ADS PubMed 14. Randløv A , Østergaard M , Manniche C et al. Intensive dynamic training for females with chronic neck/shoulder pain. A randomized controlled trial . Clin Rehabil 1998 ; 12 : 200 – 210 . Google Scholar CrossRef Search ADS PubMed 15. Lewis BA , Napolitano MA , Buman MP , Williams DM , Nigg CR . Future directions in physical activity intervention research: expanding our focus to sedentary behaviors, technology, and dissemination . J Behav Med 2017 ; 40 : 112 – 126 . Google Scholar CrossRef Search ADS PubMed 16. Andersen LL , Christensen KB , Holtermann A et al. Effect of physical exercise interventions on musculoskeletal pain in all body regions among office workers: a one-year randomized controlled trial . Man Ther 2010 ; 15 : 100 – 104 . Google Scholar CrossRef Search ADS PubMed 17. Verhagen AP , Karels C , Bierma-Zeinstra SM et al. Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults . Cochrane Database Syst Rev 2006 ; 3 :1–48. 18. Desmeules F , Boudreault J , Dionne CE et al. Efficacy of exercise therapy in workers with rotator cuff tendinopathy: a systematic review . J Occup Health 2016 ; 58 : 389 – 403 . Google Scholar CrossRef Search ADS PubMed 19. Tacconelli E. Systematic reviews: CRD’s guidance for undertaking reviews in health care. The Lancet Infectious Diseases 2010;10:226. 20. Moher D , Shamseer L , Clarke M et al. Preferred Reporting Items for Systematic Review and Meta-Analysis protocols (PRISMA-P) 2015 statement . Syst Rev 2015 ; 4 : 1 . Google Scholar CrossRef Search ADS PubMed 21. Viera AJ , Garrett JM . Understanding interobserver agreement: the Kappa statistic . Fam Med 2005 ; 37 : 360 – 363 . Google Scholar PubMed 22. Coury HJ , Moreira RF , Dias NB . Evaluation of the effectiveness of workplace exercise in controlling neck, shoulder and low back pain: a systematic review . Braz J Phys Ther 2009 ; 13 : 461 – 479 . Google Scholar CrossRef Search ADS 23. Blangsted AK , Søgaard K , Hansen EA , Hannerz H , Sjøgaard G . One-year randomized controlled trial with different physical-activity programs to reduce musculoskeletal symptoms in the neck and shoulders among office workers . Scand J Work Environ Health 2008 ; 34:55 – 65 . 24. Ma C , Szeto GP , Yan T , Wu S , Lin C , Li L . Comparing biofeedback with active exercise and passive treatment for the management of work-related neck and shoulder pain: a randomized controlled trial . Arch Phys Med Rehabil 2011 ; 92 : 849 – 858 . Google Scholar CrossRef Search ADS PubMed 25. Andersen LL , Jørgensen MB , Blangsted AK , Pedersen MT , Hansen EA , Sjøgaard G . A randomized controlled intervention trial to relieve and prevent neck/shoulder pain . Med Sci Sports Exerc 2008 ; 40 : 983 – 990 . Google Scholar CrossRef Search ADS PubMed 26. van Eijsden MD , Gerhards SA , de Bie RA , Severens JL . Cost-effectiveness of postural exercise therapy versus physiotherapy in computer screen-workers with early non-specific work-related upper limb disorders (WRULD); a randomized controlled trial . Trials 2009 ; 10 : 103 . Google Scholar CrossRef Search ADS PubMed 27. Ylinen J , Takala EP , Nykänen M . Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial . J Am Med Assoc 2003 ; 289 : 2509 – 2516 . Google Scholar CrossRef Search ADS 28. Andersen LL , Saervoll CA , Mortensen OS , Poulsen OM , Hannerz H , Zebis MK . Effectiveness of small daily amounts of progressive resistance training for frequent neck/shoulder pain: randomised controlled trial . Pain 2011 ; 152 : 440 – 446 . Google Scholar CrossRef Search ADS PubMed 29. Viljanen M , Malmivaara A , Uitti J , Rinne M , Palmroos P , Laippala P . Effectiveness of dynamic muscle training , relaxation training , or ordinary activity for chronic neck pain: randomised controlled trial . Br Med J 2003 ; 327 : 475 . Google Scholar CrossRef Search ADS 30. Andersen LL , Kjaer M , SØgaard K , Hansen L , Kryger AI , Sjögaard G . Effect of two contrasting types of physical exercise on chronic neck muscle pain . Arthritis Care Res 2008 ; 59 : 84 . Google Scholar CrossRef Search ADS 31. Sihawong R , Janwantanakul P , Sitthipornvorakul E , Pensri P . Exercise therapy for office workers with nonspecific neck pain: a systematic review . J Manipulative Physiol Ther 2011 ; 34 : 62 – 71 . Google Scholar CrossRef Search ADS PubMed 32. Sjögren T , Nissinen KJ , Järvenpää SK , Ojanen MT , Vanharanta H , Mälkiä EA . Effects of a workplace physical exercise intervention on the intensity of headache and neck and shoulder symptoms and upper extremity muscular strength of office workers: a cluster randomized controlled cross-over trial . Pain 2005 ; 116 : 119 – 128 . Google Scholar CrossRef Search ADS PubMed 33. Verhagen AP , Bierma-Zeinstra SM , Burdorf A , Stynes SM , de Vet HC , Koes BW . Conservative interventions for treating work-related complaints of the arm, neck or shoulder in adults . Cochrane Database Syst Rev 2013 ; 12 : CD008742 . 34. Chalmers TC , Smith H , Blackburn B . A method for assessing the quality of a randomized control trial . Control Clin Trials 1981 ; 2 : 31 – 49 . Google Scholar CrossRef Search ADS PubMed 35. Schulz KF , Grimes DA , Altman DG , Hayes RJ . Blinding and exclusions after allocation in randomised controlled trials: survey of published parallel group trials in obstetrics and gynaecology . Br Med J 1996 ; 312 : 742 – 744 . Google Scholar CrossRef Search ADS 36. Verhagen AP , de Vet HC , de Bie RA , Boers M , van den Brandt PA . The art of quality assessment of RCTs included in systematic reviews . J Clin Epidemiol 2001 ; 54 : 651 – 654 . Google Scholar CrossRef Search ADS PubMed 37. Menta R , Randhawa K , Côté P et al. The effectiveness of exercise for the management of musculoskeletal disorders and injuries of the elbow, forearm, wrist, and hand: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration . J Manipulative Physiol Ther 2015 ; 38 : 507 – 520 . Google Scholar CrossRef Search ADS PubMed 38. Burton AK , Kendall NA , Pearce BG , Birrell LN , Bainbridge LC . Management of work-relevant upper limb disorders: a review . Occup Med 2008 ; 59 : 44 – 52 . Google Scholar CrossRef Search ADS © The Author(s) 2018. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Occupational MedicineOxford University Press

Published: Apr 11, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off