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A Systematic Review of Workplace

Interventions to Rehabilitate

Musculoskeletal Disorders Among

Employees with Physical Demanding Work

Emil Sundstrup, Karina Glies Vincents

Seeberg, Elizabeth Bengtsen & Lars Louis

Andersen

Journal of Occupational

Rehabilitation

ISSN 1053-0487

J Occup Rehabil

DOI 10.1007/s10926-020-09879-x

1 23

BEU, Alm.del - 2019-20 - Bilag 229: Orientering om publicering af NFA artikel om et review over arbejdspladsindsatser der kan reducere muskel- og skeletbesvær blandt arbejdstagere med fysisk belastende arbejde, fra beskæftigelsesministeren

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Journal of Occupational Rehabilitation

https://doi.org/10.1007/s10926-020-09879-x

REVIEW

A Systematic Review of Workplace Interventions to Rehabilitate

Musculoskeletal Disorders Among Employees with Physical

Demanding Work

Emil Sundstrup

· Karina Glies Vincents Seeberg

· Elizabeth Bengtsen

· Lars Louis Andersen

1,2

Abstract

Purpose

This systematic review investigates the effectiveness of workplace interventions to rehabilitate musculoskeletal

disorders (MSDs) among employees with physically demanding work.

Methods

A systematic search was conducted in biblio-

graphic databases including PubMed and Web of Science Core Collection for English articles published from 1998 to 2018.

The PICO strategy guided the assessment of study relevance and the bibliographical search for randomized controlled trials

(RCTs) and non-RCTs in which (1) participants were adult workers with physically demanding work and MSD (including

specific and non-specific MSD and musculoskeletal pain, symptoms, and discomfort), (2) interventions were initiated and/

or carried out at the workplace, (3) a comparison group was included, and (4) a measure of MSD was reported (including

musculoskeletal pain, symptoms, prevalence or discomfort). The quality assessment and evidence synthesis adhered to the

guidelines developed by the Institute for Work & Health (Toronto, Canada) focusing on developing practical recommenda-

tions for stakeholders. Relevant stakeholders were engaged in the review process.

Results

Level of evidence from 54 high

and medium quality studies showed moderate evidence of a positive effect of physical exercise. Within this domain, there

was strong evidence of a positive effect of workplace strength training. There was limited evidence for ergonomics and

strong evidence for no benefit of participatory ergonomics, multifaceted interventions, and stress management. No interven-

tion domains were associated with “negative effects”.

Conclusions

The evidence synthesis recommends that implementing

strength training at the workplace can reduce MSD among workers with physically demanding work. In regard to workplace

ergonomics, there was not enough evidence from the scientific literature to guide current practices. Based on the scientific

literature, participatory ergonomics and multifaceted workplace interventions seem to have no beneficial effect on reducing

MSD among this group of workers. As these interventional domains were very heterogeneous, it should also be recognized

that general conclusions about their effectiveness should be done with care.

Systematic review registration

PROSPERO CRD42018116752(https

://www.crd.york.ac.uk/prosp ero/displ ay_recor

d.php?RecordID=116752).

Keywords

Occupational health · Pain · Physical demands · Physical exercise · Strength training · Participatory ergonomics ·

Ergonomics · Stress management

Emil Sundstrup

[email protected]

Karina Glies Vincents Seeberg

[email protected]

Elizabeth Bengtsen

[email protected]

Lars Louis Andersen

[email protected]

National Research Centre for the Working Environment

(NRCWE), Lersø Parkallé 105, 2100 Copenhagen Ø,

Denmark

Sport Sciences, Department of Health Science

and Technology, Aalborg University, 9220 Aalborg, Denmark

Vol.:(0123456789)

Journal of Occupational Rehabilitation

Introduction

Although there has been a major focus on rehabilitating

musculoskeletal disorders (MSDs), it remains a significant

problem in many workplaces around the world. Data from

the Working Environment and Health study, representing

the general working population in Denmark, show that the

proportion with musculoskeletal pain several times a week

has increased from 31% in 2012 to 33% in 2018 [1]. Spe-

cifically, low back and neck pain is highly prevalent among

workers and the leading causes of disability in high-income

countries [2]. At a global level, disability caused by low back

pain has increased by more than 50% since 1990 [3]. MSD

has a multifactorial etiology and, in addition to individual

factors, is influenced by a complex interaction between both

physical and psychosocial factors in the working environ-

ment [4–7]. MSDs are especially a major problem among

workers with physically demanding work (i.e. certain physi-

cal tasks are required to perform the job e.g. lifting, pulling,

pushing, standing, walking, bending, forceful or fast repeti-

tive tasks, etc.), where pain can make it difficult to perform

daily work tasks. Importantly, physical demands at work

play an important role in both developing and sustaining

MSD. While some are able to work with an MSD, it can for

others lead to an imbalance between physical demands of

work and individual resources consequently increasing the

risk of poor work ability, sick leave and premature exit from

the labour market [8–11].

Risk factors and effective solutions for MSDs vary from

industry to industry (i.e. group of companies or workplaces

that are related based on their primary business activities),

and especially between workplaces constituting physical or

sedentary labour. Therefore, it is recommended that indi-

vidual workplaces address the risk factors that are most

important to them and chose solutions applicable to their

work context [12]. Compared to sedentary workplaces (i.e.

office-work), it may also be more challenging to successfully

implement effective solutions in workplaces with physically

demanding work due to the obvious differences in both the

nature of work, workstation design and work organization

[13]. Additionally, the workplaces motivation for employ-

ing evidence-based research in practice is higher the more

specific and tailored the recommendations are. Thus, general

advice about reducing MSDs at the workplace can be diffi-

cult to translate into practice by the Occupational Health and

Safety practitioners (OHS). Practitioners, therefore, request

evidence-based approaches to better identify and imple-

ment effective interventions for employees with physically

demanding work. Such evidence-based knowledge will give

relevant practitioners (e.g. OSH practitioners) a stronger

knowledge base to act on and may suit them better to choose

the best solution applicable to their context of work.

Currently, there are no known published systematic

reviews documenting and summarising the literature on

the effect of workplace-based interventions specifically

for workers with MSD and physically demanding employ-

ment. Previous systematic reviews within this topic have

mainly focused on MSD in one body region among either

the general working population (including both physically

demanding and sedentary employment) or among a specific

job group (such as health care workers or office workers). A

systematic review by Van Hoof et al. [14] only found four

relevant randomized controlled trials (RCTs) with low risk

of bias and concluded that there is no strong evidence for

any intervention in treating or preventing low back pain

in nurses. Further, Verbeek et al. [15] found no available

evidence from RCTs for the effectiveness of manual mate-

rial handling advice and training or manual material han-

dling assistive devices for treating back pain. Thus, they

concluded that more high-quality studies could further

reduce the remaining uncertainty. A systematic review by

Skamagki et al. [16] found that workplace interventions such

as high‐intensity strength exercises and/or integrated health

care can decrease pain and symptoms for employees who

experience long‐term musculoskeletal disorders. Overall,

these reviews base their evidence synthesis on RCTs, and

all concluded that current research is limited. Even though

RCTs are considered the most powerful experimental design

in clinical trials, solely including these may be too restric-

tive to understand effective workplace-based interventions

where randomized and carefully controlled trials (RCTs) are

not always possible. Furthermore, a high-quality RCT does

not guarantee that a workplace intervention has been imple-

mented in a good manner.

Previous reviews have dealt with this methodological

challenge by including both RCTs and non-RCTs. To fur-

ther increase the relevance for practice, these reviews have

also employed the quality assessment and evidence syn-

thesis developed by the Institute for Work & Health (IWH,

Toronto, Canada) which focuses on the development of

practical guidelines for stakeholders. In such a review pro-

cess, Van Eerd et al. [13] investigated the effectiveness of

workplace interventions in the prevention of upper extrem-

ity MSDs and symptoms. They found strong evidence for

the intervention category resistance training (one among

30 categories), leading to the following recommendation

for stakeholders: “Implementing a workplace-based resist-

ance training exercise program can help prevent and man-

age upper extremity MSDs and symptoms” [13]. The review

also reported moderate evidence for the effect of stretching,

mouse use feedback and forearm supports and moderate evi-

dence for no effect of EMG biofeedback, job stress manage-

ment training, and office workstation adjustment. Further,

Hossain et al. (2019) investigated the evidence on the effec-

tiveness of workplace-based rehabilitative interventions in

Journal of Occupational Rehabilitation

workers with upper-limb conditions also by including RCTs

and non-RCTs along with the review process developed by

the IWH [17]. They found that the largest body of evidence

supported workplace physical exercise programs, but also

reported positive effects for ergonomic training and worksta-

tion adjustments, and mixed-effects for ergonomic controls.

The aim of this systematic review is to investigate the

effectiveness of workplace interventions to rehabilitate mus-

culoskeletal disorders among employees with physically

demanding work. Workplace interventions are here defined

as interventions that are initiated by the workplace, sup-

ported by the workplace, and/or carried out at the workplace.

Level of evidence will be synthesized within several broad

intervention domains such as physical exercise, ergonomics,

participatory ergonomics, and multifaceted interventions. If

possible, due to a data-driven approach, each domain will

further be divided into more specific intervention catego-

ries. Based on the evidence synthesis, practical messages

for stakeholders will be developed. To introduce a more

practical approach, relevant stakeholders are engaged in the

review process and both RCTs and non-RCTs are eligible

for inclusion.

the stakeholders were involved in the conception of the

study through involvement in the preparation of the research

application. This ensured that the topic was practical and

relevant to our stakeholders. When funding for the study

was obtained, the stakeholders participated in a meeting to

discuss and finalize the research question, and they provided

practical input to the search strategy. This helped to ensure

that the literature search was comprehensive. At the meet-

ing, the researchers also gave the stakeholders a short intro-

duction to the systematic review steps and evidence syn-

thesis methodology. This was done to increase the research

capacity of the engaged stakeholders and to prepare them to

better understand, interpret and disseminate the results of

the review. After the forming of the evidence synthesis, the

results were presented for the stakeholders and they provided

input to the recommendations and the dissemination of the

results.

The review has been registered in the International Pro-

spective Register of Systematic Reviews (PROSPERO)

number CRD42018116752 and a protocol paper has previ-

ously been published [19].

Eligibility Criteria

Methods

Study Design and Registration

This systematic review followed the ‘Preferred Reporting

Items for Systematic reviews and Meta-Analyses’ (PRISMA)

guidelines for reporting systematic reviews and the IWH

guideline for workplace-based interventions. Inspired by the

IWH Systematic Review Programme [18], relevant stake-

holders were engaged in parts of the review process. The

stakeholders were members of two industry communities

for work environment representing workers with physically

demanding work within construction and manufacturing.

The communities, which consist of relevant representatives

from both employers’, managers’ and employees’ labour

market organizations, support the workplaces with informa-

tion and guidance on the working environment by, among

other things, making guidelines, conferences and education.

To ensure maximal practical relevance of the present work,

Eligibility criteria can be seen in Table 1 illustrating the

PICO employed for the present review. The PICO strategy

guided the assessment of study relevance and the biblio-

graphical search for studies in which (1) participants were

adult workers with physically demanding work and MSD

(including specific and non-specific MSD and musculo-

skeletal pain, symptoms, and discomfort), (2) interventions

were initiated and/or carried out at the workplace, (3) a com-

parison group was included, and (4) a measure of MSD was

reported (including musculoskeletal pain, symptoms, preva-

lence or discomfort). In addition, both RCTs and non-RCTs

were included and the publication language of included stud-

ies was English. If it was not possible to identify whether

individual studies were workplace-based or not, authors

were contacted for clarification. Physically demanding

work was defined as work that is physically demanding on a

whole-body level or for specific body parts and where cer-

tain physical tasks are required to perform the job (e.g. lift-

ing, pulling, pushing, standing, walking, bending, forceful

Table 1

Illustration of the PICO used for the present review

Adult workers with physically demanding work and MSD (including specific and non-specific MSD and musculoskeletal pain,

symptoms, and discomfort)

I Intervention The intervention was initiated by the workplace, supported by the workplace and/or carried out at the workplace (i.e. work-

place-based)

C Comparison A comparison group was included (i.e. no treatment, treatment as usual, or another comparison treatment at the workplace)

O Outcome

Effective in decreasing a measure of MSD (including musculoskeletal pain, symptoms, prevalence or discomfort)

P Population

Journal of Occupational Rehabilitation

repetitive tasks, etc.). Thus, industries with mainly physical

demanding work—such as construction work, automotive

work, health care work, slaughterhouse work etc.—were

included in the review. If no specific industry was reported

in the paper, it should have been specifically stated that the

participants were engaged in physically demanding work

or rated their work as being physically demanding. Studies

where it was not possible to identify whether participants

had physically demanding work, or where the participants

constituted a mix of workers with sedentary and physi-

cal work (without a stratified effect evaluation) were not

included in the review.

previously been reported [19]. Manual searches were also

performed by employing the ‘Snowball’ method. Specifi-

cally, we pursued references of paramount references within

the field of MSD prevention at the workplace. Importantly,

the ‘Snowball’ method did not provide any additional papers

to the study after the search was conducted, but was used to

optimize the search strategy, making it more agile to identify

pre-defined key papers for this review. In addition, relevant

articles identified through personal knowledge and contacts

were also included in the review process (25).

Assessment of Relevance and Inclusion

The PRISMA flow-diagram illustrated in Fig. 1 summarizes

the study selection process. EndNote X8 was employed to

collect all potential studies from PubMed and Web of Sci-

ence Core Collection. The selected studies were exported to

the review software program Covidence. Abstracts of poten-

tial studies were thereafter independently assessed by the

first author (ES) and the coauthor (KGVS). Any disagree-

ments were discussed with the senior author (LLA) until a

consensus was achieved. Full-text publications of those stud-

ies deemed relevant by the abstract screening were thereafter

assessed in a similar manner. The studies, which adhered to

the eligibility criteria presented in the PICO (Table 1), were

Search Strategy

The systematic search was conducted in the following

bibliographic databases: PubMed (including the database

‘MEDLINE’) and Web of Science Core Collection (includ-

ing the databases ‘Science Citation Index Expanded’, ‘Social

Sciences Citation Index’ and ‘Arts & Humanities Citation

Index’). The search strategy consisted of combining the fol-

lowing four main components: (1) musculoskeletal diseases/

disorder AND (2) workers AND (3) workplace interven-

tion AND (4) date (published within the last 20 years: from

1998 to 2018). The search strategy for each database has

Fig. 1

Flow chart

Journal of Occupational Rehabilitation

included in the systematic review. Since the effectiveness of

interventions for workers with sedentary employment will

be reported in a separate paper, studies involving sedentary

workers were excluded in a separate step during the full-

text screening (Fig. 1). Thereafter, studies were assessed for

quality and the best evidence synthesis was formed. Only

high and medium quality studies were eligible for the evi-

dence synthesis, whereas studies with low quality were not

sufficient to move forward to data extraction.

Data Extraction

For each included study, systematic data extraction was

employed to collect the following general characteris-

tics: (1) author year and country, (2) study design, (3) study

population, (4) intervention and comparison, (5) number of

participants, (6) time-frames of outcome measurement, (7)

results, and (8) quality appraisal.

Since MSDs are a diverse group of conditions, several

different outcome measures have been employed in the lit-

erature. Thus, we decided not to exclude potential relevant

studies due to heterogeneity in outcomes, as long as they rep-

resented a measure related to MSD. The outcomes employed

for the quality appraisal and evidence synthesis, therefore,

included any change in musculoskeletal pain, symptoms,

prevalence or discomfort from baseline to follow-up (see the

PICO illustrated in Table 1). Thus, outcomes employed were

not only primary outcome measures, but could also reflect

secondary or tertiary measures. If several follow-up periods

were reported, data from the longest follow-up time-period

was employed for the evidence synthesis (unless specifically

stated in the study aim that a given follow-up time was the

primary focus of the study). If a study reported on several

MSD outcome-measures (for instance pain in many differ-

ent body regions) the outcome of interest for the present

review was the one that was predefined as the primary MSD-

related outcome in the aim/methods. If no such definition

was provided, the outcome measure for the evidence syn-

thesis adhered to the body-region with the highest intensity

or frequency of MSD (pain, symptoms or discomfort) or the

region with the highest prevalence of MSD at baseline (if

intensity or frequency was not reported).

Assessment of Quality

Two authors (ES and KVGS) independently assessed the

quality of each study and any disagreements were discussed

with the senior author (LLA) until a consensus was reached.

For the methodological appraisal, we used the quality

assessment methods developed by the IWH consisting of

16 unique questions (see Table 2). The IWH quality assess-

ment score for each article was based on a weighted sum

score [13,

20].

The weighting values of each question ranged

from 1 to 3. The rank score for each included study was

divided by the maximal weighted sum score and multiplied

by 100. Finally, the studies were divided into three groups

depending on the ranking score: low quality (below 50%),

medium quality (50–85%) and high quality (> 85%) [20,

21].

Only high and medium quality studies were eligible for the

evidence synthesis [20,

22].

Table 2

Assessing methodological quality ([20] adapted from Kennedy et al. 2010

Question

1. Is the research question clearly stated?

2. Were comparison group(s) used?

3. Was an intervention allocation described adequately? (and was it randomized?)

4. Was recruitment (or participation) rate reported?

5. Were pre-intervention characteristics described?

6. Was loss to follow-up (attrition) < 35%?

7. Did the author examine for important differences between the remaining and drop-out participants after the intervention?

8. Was the intervention process adequately described to allow for replication?

9. Were the effects of the intervention on some exposure parameters documented?

10. Was the participation in the intervention documented?

11. Were musculoskeletal pain, symptoms, discomfort and/or disorders described at baseline and at follow-up

12. Was the length of follow-up three months or greater?

13. Was there adjustment for pre-intervention differences (minimum threshold of three important covariates include age, gender and

primary outcome at baseline)?

14. Were the statistical analyses optimized for the best results?

15. Were all participants’ outcomes analyzed by the groups to which they were originally allocated (intention-to-treat analysis)?

16. Was there a direct between-group comparison?

Weight

3*2

Journal of Occupational Rehabilitation

Assessment of Evidence

We employed the IWH adapted “best evidence synthe-

sis approach” to clarify the evidence (see Table 3). The

approach considers the article’s quality, the quantity of

articles evaluating the same intervention and finding con-

sistency [20,

22].

Based on this, the level of evidence was

classified as ‘strong’, ‘moderate’, ‘limited’, ‘mixed’ or

‘insufficient’ based on the quality assessment of the included

studies. A strong level of evidence resulted in “recommenda-

tions” for practice and a moderate level of evidence resulted

in “practice recommendations” or practices to be considered

for workplace management of MSD [20,

22].

An evidence

level below moderate (i.e. limited, mixed or insufficient) led

to the following message for practice: “Not enough evidence

from the scientific literature to guide current policies/prac-

tices” [23]. Importantly, this does not mean that the interven-

tions may not be effective, but there is not enough scientific

evidence to extract conclusions [23].

To reach a strong level of evidence, a minimum of three

high-quality studies had to point in the same direction (i.e.

all showing either positive, negative or no effect of the given

intervention), or at least ¾ of all the studies within a specific

intervention category or domain (explained below) had to

have the same direction of effect [23,

23].

This is illustrated

in the best evidence synthesis in Table 3.

Level of evidence was synthesized for high and medium

quality studies within the following 5 broad interven-

tion domains agreed on by the authors: physical exercise,

ergonomics, participatory ergonomics, stress management,

and multifaceted. If deemed possible by the authors, due to

both a practical and a data-driven approach, each domain

was further divided into relevant intervention categories. For

instance, the domain of physical exercise was divided into

strength training at the workplace, aerobic training at the

workplace, and stretching at the workplace. This allowed

for a more specific and stakeholder-friendly evidence syn-

thesis. When consensus was reached by the review team

on the intervention domains and categories, evidence was

synthesized for each domain and category.

Results

Study Selection

The bibliographic searches identified 15,556 articles, of

which 3091 were duplicates. Of the 12,465 remaining arti-

cles, 12,113 were excluded in the abstract screening as they

did not meet our eligibility criteria. Of the 352 full-text arti-

cles retrieved, 221 met the overall inclusion criteria. Since

the aim of this review was to investigate the effectiveness of

interventions for workers with physically demanding work,

we only included the articles describing this population

(n = 78). The remaining articles (143) will be reported in a

separate paper, reporting the effectiveness of interventions

for workers with sedentary employment.

Table 3

Best evidence synthesis guidelines ([20] adapted from Kenney et al. 2010

Level of evidence Minimum quality

Strong

High (> 85%)

Minimum quantity

Three

Consistency

Terminology for messages

Moderate

Limited

Mixed

Insufficient

Recommendations

Three high quality studies

agree

If more than three studies,

3/4th of the medium and

high quality studies agree

Two high quality studies agree Practice considerations

Medium (50–85%)

Two high quality

Two medium quality and one Two medium quality studies

and one high quality study

high quality

agree. If more than three

studies, more than 2/3rd of

the medium and high quality

studies agree

If two studies (medium and/or

Medium (50–85%)

One high quality

high quality), agree

Two medium quality OR One If more than two studies, more

medium quality and one high then 1/2 of the medium and

high quality studies agree

quality

Medium and high

Two

Findings from medium and

high quality studies are

contradictory

No high quality studies, only one medium quality study, and/or any number of low quality stud-

ies

Journal of Occupational Rehabilitation

In addition to the 78 articles identified for this review, 4

articles were sent to the review team by colleagues, which

were published after the systematic search was carried out.

In, total 82 papers were included in the review. 19 of these

82 articles reported different outcome measures (i.e. pri-

mary or secondary outcome measures not related to MSD)

of a unique interventional study (see flow chart; Fig. 1) and

were therefore not included in the evidence synthesis. In

total, 54 studies were included in the evidence synthesis.

Table 4 summarizes the characteristics of the included stud-

ies: (1) author year and country, (2) study design, (3) study

population, (4) intervention and comparison, (5) number of

participants (n), (6) time-frames of outcome measurement

(follow-up), (7) results (interventional effect and region of

MSD), and (8) quality appraisal.

or stretching), aerobic training (including aerobic training/

exercise and soccer) and stretching (stretching alone or in

combination with warming-up or bodyweight exercises).

Four studies did not match any of the intervention domains

and are therefore discussed separately (see Table 4). Studies

that encompass more than one intervention arm could be

included more than one time under different intervention

domains. Outcomes varied across the 54 included studies,

but all studies included the outcome measures musculoskel-

etal pain, symptoms, prevalence or discomfort. The inter-

ventional effect from the included studies was classified as

positive if the study reported positive results on these MSD-

related outcome measures.

Evidence Synthesis

Level of evidence from the 54 high and medium quality

studies was synthesized on 5 broad intervention domains

and 3 sub-categories within these domains. Level of evi-

dence can be seen in Table 5. Importantly, no intervention

domains were associated with "negative effects".

Quality Appraisal

34 studies were classified as high quality (> 85% of crite-

ria met), 20 studies were medium quality (50–85% of cri-

teria met) and 9 studies were low quality (< 50% of criteria

met). Only high and medium quality studies were eligible

for the evidence synthesis whereas the summary table only

describes these studies (see Table 4).

Physical Exercise

20 studies reporting on 23 different interventions were

identified and grouped within the physical exercise domain

[24–43]. 8 interventions form high-quality studies and

8 interventions from medium quality studies presented

a positive effect of workplace exercise on MSD. Accord-

ingly, there was moderate evidence of a positive effect of

the domain of physical exercise. Thus, the present review

results in the following message for stakeholders: Practice

consideration: “Consider implementing physical exercise at

the workplace for reducing MSD, especially if it is applica-

ble to the work context”.

Within the domain of physical exercise, 9 studies report-

ing on 9 different interventions were identified and grouped

within the strength training category [24–32]. 5 interventions

form high-quality studies and 4 interventions from medium

quality studies presented a positive effect of strength training

at the workplace on MSD. There was strong evidence of a

positive effect of strength training. This resulted in the fol-

lowing message for stakeholders: Recommendation. “Imple-

menting strength training at the workplace can help reduce

MSD among workers with physically demanding work”.

Within the domain of physical exercise, 5 studies report-

ing on 5 different interventions were identified and grouped

within the aerobic training category [31,

33–36].

2 interven-

tions form high-quality studies and 1 intervention from a

medium quality study presented a positive effect of aerobic

training at the workplace on MSD. There was limited evi-

dence of a positive effect of aerobic training. This resulted

in the following message for stakeholders: “Not enough

Data Extraction

26 of the studies were published after 2012, 11 studies were

published from 2008 to 2012, 11 studies were published

from 2003 to 2007, and 6 studies were published from 1998

to 2002. 36 of the studies were RCTs and 18 studies were

non-RCTs. Study designs under the umbrella “non-RCTs”

included intervention studies, randomized intervention stud-

ies, cross-over intervention studies and clinical trials.

The majority of the 54 high and medium quality studies

were published in Denmark (n = 18), with a further 6 per-

formed in Norway, 5 in the Netherlands, 3 in the US, 3 in

Italy, 3 in Japan, 2 in Sweden, 2 in Canada, 2 in France, 1 in

Iran, 1 in Israel, 1 in Hungary, 1 in Belgium, 1 in Chile, 1 in

Finland, 1 in Hong-Kong (China), 1 in Korea, 1 in Switzer-

land, and 1 in Turkey.

Categorization into Intervention Domains

and Categories

The interventions across the 54 studies were grouped into 5

intervention domains: physical exercise (n = 20), ergonom-

ics (n = 13), participatory ergonomics (n = 5), multifac-

eted (n = 15) and stress management (n = 3). Within these

domains, 3 interventional categories were further estab-

lished, based on a practical and data-driven approach by the

review-team: strength training (including strength training/

resistance training alone or in combination with mobilization

Table 4

Characteristics of the included studies grouped within the 5 overall intervention domains: physical exercise, ergonomics, participatory ergonomics, multifaceted and stress management.

Three interventional categories were further established within the domain of physical exercise: strength training, aerobic training, stretching. Four studies did not match any of the overall inter-

vention domains and are presented as “Other” interventions. The characteristics include (1) author year and country, (2) study design, (3) study population, (4) intervention and comparison, (5)

number of participants (n), (6) time-frames of outcome measurement (follow-up), (7) results (interventional effect and region of MSD), and (8) quality appraisal (H = high quality, M = medium

quality)

Author, year, country

Physical exercise

Strength training

Jakobsen (2015)

Denmark [24]

Rasotto (2015)

Italy [25]

Sundstrup (2014)

Denmark [26]

Study design Study population

Intervention and comparison

Follow-up

Results (effect and region of MSD)

RCT

Healthcare workers

RCT

Manufacturing workers

I = High-intensity strength training

111

and coaching

C = Control (home-based exercises)

I = Mobilization and strength training 30

C = Control (no intervention)

I = High-intensity strength training

C = Control (individualized ergo-

nomic training and education)

I = High-intensity strength training

282

10 weeks

Yes (p ≤ 0.0003) Low back and neck/

shoulder

Yes (p = 0.039) Shoulder

6 months

RCT

Slaughterhouse workers

10 weeks

Yes (p < 0.0001) Shoulder, arm and

hand

Zebis (2011)

Denmark [27]

RCT

Laboratory technicians

20 weeks

Yes (p < 0.001, p = 0.07) Neck and

shoulder

Munoz-poblete (2019)

Chile [28]

RCT

Manufacturing workers

C = Control (received advice to stay

255

physically active)

I = Strength training with progressive 52

resistance

16 weeks

Yes (p = 0.007, p = 0.045, p = 0.259

p = 0.481, p = 0.016, p = 0.182,

p = 0.034, p = 0.013) Upper limb,

neck, right and left shoulders, right

and left elbows, right and left

wrists

Yes (p = 0.02, p = 0.05) Neck/shoul-

der, low back

Jay (2011)

Denmark [30]

RCT

Laboratory technicians

C = Control (stretching exercise)

I = High-intensity strength training

8 weeks

Rasotto (2015)

Italy [32]

RCT

Metal workers

C = Control (received recommenda-

tion to continue their usual physical

activities)

I = Mobilization and strength training 34

Journal of Occupational Rehabilitation

5 months

10 months

Yes (p = 0.0043, p = 0.1037,

p = 0.2053, p = 0.0080) Neck, shoul-

der, elbow and wrist

Yes (p = 0.0164, p = 0.0224,

p = 0.3429, p = 0.0007) Neck, shoul-

der, elbow and wrist

C = Control (continue in performing

their normal daily activities)

Table 4

(continued)

Author, year, country

Balaguier (2017)

France [29]

Study design Study population

Non-RCT

Vineyard workers

Intervention and comparison

I = Morning: warm-up. After work:

trunk flexor, extensor strengthening

or/and trunk stretching

Follow-up

4 weeks

Results (effect and region of MSD)

No (p > 0.05) Low back

Journal of Occupational Rehabilitation

8 weeks

12 weeks

Oldervoll (2001)

Norway [31]

Non-RCT

Hospital employees

C = Control (not further described)

I:2 = Strength training

C = Control (continue their normal

daily activities)

Aerobic training

Korshoj (2018)

Denmark [33]

RCT

Cleaners

I = Aerobic exercise

C = Control (lectures on healthy liv-

ing only)

I:2 = Soccer

15 weeks

Yes (p < 0.01) Low back

Yes (p < 0.05) Low back

Yes (p = 0.031) Neck, shoulder, and

lower back

4 months

12 months

12 weeks

40 weeks

No (p = 0.80) Low back

No (p = 0.72) Low back

Yes (p = 0.001) Neck and shoulder

No (p > 0.05) Lower back region

Yes (p = 0.002) Neck and shoulder

No (p > 0.05) Lower back region

No (p = 0.517) Head, neck, upper

back and low back, arm, shoulder,

and leg

Yes (p = 0.02) Low back

Barene (2014)

Norway [34]

RCT

Hospital employees

Eriksen (2002)

Norway [35]

RCT

Postal workers

C = Control (not further described)

I:3 = Physical aerobic exercise

189

12 weeks

Horneij (2001)

Sweden [36]

Oldervoll (2001)

Norway [31]

RCT

Homecare workers

Non-RCT

Hospital employees

C = Control (not further described)

I:2 = Physical exercise (aerobic and

stretching)

C = Control (usual care)

I:1 = Aerobic exercise

C = Control (continue their normal

daily activities)

344

12 months

15 weeks

Yes (p = 0.031) Neck, shoulder, and

low back

Stretching

Bertozzi (2015)

Italy [37]

Non-RCT

Holmstrom (2005)

Sweden [38]

Non-RCT

Poultry slaughterhouse workers I = Bodyweight and postural exer-

cises, relaxation, stretching, and

extension

C = Home exercise

Construction workers

I = Morning warm-up including

stretching exercises

C = Control (not further described)

5 weeks

No (p = 0.7, p = 0.1) Cervical and

lumber

3 months

No (p > 0.05) Back

Table 4

(continued)

Author, year, country

Han (2016)

Korea [39]

Study design Study population

Non-RCT

Automotive (assembly line)

Intervention and comparison

I:1 = Pelvic control hamstring stretch

I:2 = General hamstring stretch

C = Control (home stretching)

General physical exercise

Andersen (2015)

Denmark [40]

RCT

Healthcare workers

Follow-up

6 weeks

Results (effect and region of MSD)

Yes (p < 0.05) Low back

Barene (2014)

Norway [34]

RCT

Hospital employees

I = Aerobic fitness and strength

training

C = Control (received health guidance 27

only)

I:1 = Zumba

3 months

Yes (p ≤ 0.01) All body parts/regions

12 weeks

40 weeks

Yes (p = 0.01) Neck and shoulder

No (p = 0.13) Neck and shoulder

Gram (2012)

Denmark [41]

RCT

Constructions workers

C = Control (not further described)

I = Aerobic exercise and strength

training

12 weeks

No (p = 0.96, p = 0.11, p = 0.37,

p = 0.31, p = 0.92, p = 0.73, p = 0.74,

p = 0.70) Neck, shoulder: right,

left and dominant, upper back, low

back, hip, knee

Jorgensen (2011)

Denmark [42]

RCT

Cleaners

C = Control (given 1-hour lecture on

general health promotion)

I:1 = Physical coordination training

12 months

No (p > 0.05) Neck, shoulder and low H

back

Burger (2012)

Switzerland [43]

Ergonomics

Jensen (2006)

Denmark [45]

Non-RCT

Manufacturing workers

100

C = Control (healthcare check,

pulmonary test and aerobic capacity

test)

I = Whole-body vibration training

C = Control (no treatment)

4 weeks

Yes (p < 0.01) All body parts/regions

RCT

Healthcare workers

I:1 = Ergonomics; practical class

room education/instruction

3 months

12 months

No (p = 0.16) Low back

No (p = 0.10) Low back

Journal of Occupational Rehabilitation

Oleske (2007)

USA [46]

RCT

C = Control (lessons on skincare,

proper treatment of persons with

diabetes, and asthma and safety

procedures in chemicals handling)

Industrial workers (automotive) I:1 = Back support + education

C = Control (education)

222

211

12 months

No (p = 0.091) Low back

Table 4

(continued)

Author, year, country

Roelofs (2007)

Netherlands [47]

Warming (2008)

Denmark [49]

Study design Study population

RCT

Healthcare workers

Intervention and comparison

I = Lumbar support

C = Control (not further described)

I:1 = Ergonomics; transfer technique

instruction, physical exercise

I:2 = Transfer technique instruction

C = Control (usual care)

I = Lumbar support

C = Control (no intervention)

I:1 = Safe lifting program

183

177

116

Follow-up

12 months

Results (effect and region of MSD)

Yes (p = 0.020) Low back

Journal of Occupational Rehabilitation

RCT

Nurses

12 months

3 months

No (p > 0.05) Low back

Hagiwara (2017)

Japan [50]

Yassi (2001)

Canada [56]

RCT

Healthcare workers

Yes (p = 0.036) Knee, shoulder, neck, M

back

No (p > 0.05) Low back and shoulder

Yes (p = 0.009, p = 0.041) Low back

and shoulder

Yes (p = 0.015, p = 0.037) Low back

and shoulder

No (p > 0.05) Low back and shoulder

Yes (p < 0.001) Low back

RCT

Healthcare workers

6 months

12 months

I:2 = No strenuous lifting program

127

6 months

12 months

Shojaei (2017)

Iran [48]

Hartvigsen (2005)

Denmark [44]

Non-RCT

Nurses

Non-RCT

Nurses

Iwakiri (2018)

Japan [51]

Non-RCT

Care workers

C = Control (usual practice)

I = Educational program and ergo-

nomic posture training

C = Control (no intervention)

I = Educated in body mechan-

ics, patient transfer, and lifting

techniques, and use of low-tech

ergonomic aids

C = Control (instruction in lifting

technique)

I = Ergonomic education program

103

171

6 months

24 months

No (p < 0.88) Low back

145

12 months

18 months

No (p = 0.69) Low back

No (p = 0.09) Low back

No (p = 0.65, p = 0.46, p = 0.95, p =

0.68, p = 0.68, p = 0.40) Low back,

shoulder, hand-wrist

No (p > 0.05) Low-back, neck, shoul-

ders, knees, and wrists

Luijsterburg (2005)

Netherlands [52]

Non-RCT

Construction workers (brick-

layer)

C = Control (not further described)

I = Devices for raised bricklaying

10 months

Risor (2017)

Denmark [53]

Non-RCT

Nurses

C = Control (not further described)

I = Patient handling equipment, buy-

ing relevant equipment, training in

its use

C = Control (not further described)

130

293

12 months

201

Table 4

(continued)

Author, year, country

Sezgin (2018)

Turkey [54]

Study design Study population

Non-RCT

ICU nurses

Intervention and comparison

I = An ergonomic risk management

program based on the PRECEDE-

PROCEED model

C = Control (not further described)

I = Insoles

Follow-up

26 weeks

Results (effect and region of MSD)

No (p = 0.633) All body parts/regions M

Shabat (2005)

Israel [55]

Non-RCT

Postal workers

5 weeks

10 weeks

Yes (p < 0.05) Low back

C = Control (placebo insoles)

Participatory ergonomics

Brandt (2018)

Denmark [57]

RCT

Construction workers

I = Participatory ergonomics:

Reduce the number of events

with excessive physical workload

3 months

No (p = 0.53) Arms, hands, knees,

shoulder and back

No (p = 0.59) Arms, hands, knees,

shoulder and back

6 months

C = Control (handouts about MSD

and lifting guidelines)

I = Participatory ergonomics: Identify

strenuous work tasks and seek solu-

tions for decreasing physical and

mental workload

C = Control (no visits and no train-

ings by researchers at these group)

I = Participatory ergonomics: Improve

the use of assistive devices in

patient transfer

263

Haukka (2008)

Finland [58]

RCT

Kitchen workers

9–12 months No (p > 0.05) 6 out of 7 body regions. H

Yes (p = 0.026) forearms/ hands

241

316

6 months

No (p = 0.868, p = 0.205, p = 0.117)

Low back, shoulder, neck

No (p > 0.05) Low back, shoulder,

neck

Jakobsen (2019)

Denmark [59]

RCT

Healthcare workers

12 months

C = Control (encouraged to con-

tinue with their normal working

procedures including living up to

standard OSH guidelines)

I:1 = Participatory ergonomics train-

ing program with the operators and

their supervisor

I:2 = Participatory ergonomics train-

ing program with operators only

I:3 = Participatory ergonomics train-

ing program with managers and

supervisors only

309

Journal of Occupational Rehabilitation

Morken (2002)

Norway [61]

RCT

Industry workers

132

12 months

No (p > 0.05) All body parts/regions

135

147

12 months

No (p > 0.05) All body parts/regions

Table 4

(continued)

Author, year, country

Study design Study population

Intervention and comparison

C1 = Control (not receive any special

attention or information)

C2 = Control (not receive any special

attention or information)

I = Participatory ergonomics: Ergo-

nomics change team implementing

physical changes at the factory

C = Control (not further described)

Multifaceted

Chaleat-Valayer (2016)

France [62]

RCT

Healthcare workers

423

1344

10 months

No (p = 0.33, p = 0.52, p = 0.33,

p = 0.96, p = 0.26, p = 0.50, p = 0.62,

p = 0.05) Back, shoulder/upper arm

forearm/hand and leg/lower limb

Follow-up

Results (effect and region of MSD)

Journal of Occupational Rehabilitation

Laing (2005)

Canada [60]

Non-RCT

Manufacturing workers

18 months

No (p = 0.1417, p = 0.7002) Lumbar

and radicular

Christensen (2011)

Denmark [63]

RCT

Healthcare workers

I = Pain management education, exer- 171

cise at workplace, exercise at home;

booklet for self-management

C = Control (usual care)

171

I = Exercise; strength training, CBT, 54

dietary

C = Control (a monthly two-hour oral

lecture)

I:2 = Exercise, information on stress,

coping and practical examination

(IHP)

I:4 = Organizational intervention

165

12 months

No (p = 0.452, p = 0.427, p = 0.476,

p = 0.552) Neck, shoulder, upper

back, lower back

Eriksen (2002)

Norway [35]

RCT

Postal workers

12 weeks

199

12 weeks

No (p = 0.517) Head, neck, upper

back and low back, arm, shoulder,

and leg

No (p = 0.517) Head, neck, upper

back and low back, arm, shoulder,

and leg

No (p > 0.05) Low back, upper

extremity

Ijzelenberg (2007)

Netherlands [64]

RCT

Physical demanding workers

(not specified)

Jaromi (2018)

Hungary [65]

RCT

Nurses

Jay (2015)

Denmark [66]

RCT

Laboratory technicians

C = Control (not further described)

I = Individually tailored education

and training, immediate treatment

of sub-acute LBP, ergonomic

adjustment

C = Control (usual care)

I = Back school program: Didactic

education, spine-strengthening

exercises and education in patient

handling techniques

C = control (written lifestyle guid-

ance)

I = Physical, cognitive, and mindful-

ness group-based training

344

258

12 months

231

12 weeks

Yes (p < 0.001) Low back

10 weeks

Yes (p < 0.0001) Neck, back, shoul-

der, elbow and hand

Table 4

(continued)

Author, year, country

Study design Study population

Intervention and comparison

Follow-up

Results (effect and region of MSD)

Oude Hengel (2013)

Netherlands [68]

RCT

Construction workers

C = Control (encouragement to par-

ticipate in the company’s on-going

health initiatives)

I = Ergonomics, rest break, empower- 171

ment

3 months

6 months

12 months

No (p-value NA) Back, neck,

shoulder, upper extremities, lower

extremities

No (p-value NA) Back, neck,

shoulder, upper extremities, lower

extremities

No (p-value NA) Back, neck,

shoulder, upper extremities, lower

extremities

Peters (2018)

USA [69]

RCT

Construction workers

C = Control (not further described)

I = Ergonomics + worksite health

promotion

C = Control (no intervention)

I = Participatory ergonomics, physical

training, CBT

(cross-over design)

I = Exercise, nutritional and psycho-

logical intervention, ergonomics

C = Control (not further described)

I = Intervention mapping and coach-

ing program

122

324

1 month

6 months

No (p = 0.252) All body parts/regions H

No (p = 0.683) All body parts/regions

Yes (p = < 0.0001) Low back

Rasmussen (2015)

Denmark [70]

Roussel (2015)

Belgium [71]

Viester (2015)

Netherlands [72]

RCT

Nurses

283

594

12 weeks

RCT

Hospital employees

162

6 months

No (p > 0.05) Low back

RCT

Construction workers

6 months

12 months

No (p > 0.05) Back, neck/shoul-

ders, upper extremities, and lower

extremities

No (p > 0.05) Back, neck/shoul-

ders, upper extremities and lower

extremities

No (p > 0.05) Low back

Warming (2008)

Denmark [49]

Tveito (2009)

Norway [74]

Kamioka (2011)

Japan [67]

RCT

Nurses

RCT

Nurses

C = Control (usual care)

I1 = Ergonomic; transfer technique

instruction, physical exercise

C = Control (usual care)

I = Exercise, ergonomic

C = Control (no intervention)

I = Stretching exercise + ergonomic:

learning

C = Control (not further described)

152

12 months

Journal of Occupational Rehabilitation

9 months

No (p = 0.283, p = 0.220) Neck, back

Non-RCT

Caregivers

12 weeks

No (p = 0.653) Low back

Table 4

(continued)

Author, year, country

Szeto (2010)

Hong Kong [73]

Study design Study population

Non-RCT

Nurses

Intervention and comparison

I = Ergonomics training, exercise,

education/theory (back school

program)

C = Control (no intervention)

I:1 = Stress management training

C = Control (not further described)

I:1 = Stress management

Follow-up

8 weeks

Results (effect and region of MSD)

No (p = 0.067) Shoulder, low back,

neck, knee, elbow

Journal of Occupational Rehabilitation

162

344

12 weeks

No (p = 0.517) Head, neck, upper and H

lower back, arm, shoulder, and leg

No (p = 0.057) Low back

No (p = 0.063) Low back

No (p = 0.64) Low back

No (p = 0.85) Low back

Stress management

Eriksen (2002)

Norway [35]

Horneij (2001)

Sweden [36]

RCT

Postal workers

RCT

Homecare workers

12 months

18 months

Jensen (2006)

Denmark [45]

RCT

Healthcare workers

C = Control (usual care)

I:2 = Stress management

3 months

12 months

C = Control (lessons on skincare,

proper treatment of persons with

diabetes, and asthma and safety

procedures in chemicals handling)

Others

Jorgensen (2011)

Denmark [42]

RCT

Cleaners

I:2 = CBT

12 months

No (p > 0.05) Neck, shoulder and low H

back

Sundstrup (2014)

Denmark [77]

Faucett (2007)

USA [75]

RCT

Slaughterhouses workers

100

C = Control (health care check,

pulmonary test and aerobic capacity

test)

I = Topical menthol

C = Control (placebo gel)

I:1 = Rest breaks trial 1

I:2 = Rest breaks trial 2

C = Control (only legally breaks)

I = Reduced working hours

C = Control (not further described)

147

286

48 hours

Yes (p = 0.016, p = 0.027) Hand,

forearm, elbow, wrist, arm

Yes (p = 0.01) Mid/lower back and

lower extremities

Yes (p = 0.01) Mid/lower back and

lower extremities

Yes (p = 0.034) Neck/shoulder.

No (p = 0.320) Back

Non-RCT

Agriculture workers

3 days

Wergeland (2003)

Norway [76]

Non-RCT

Care institution workers

12 months

quality appraisal,

high quality study (> 85% of criteria met) and

medium quality study (50–85% of criteria met),

CBT

cognitive-behavioural therapy,

RCT

randomized controlled trial,

non-RCT

non-randomized controlled trial,

intervention group (if multiple intervention arms are present,

2 refers to intervention arm number 2 etc.),

control/comparison group

Journal of Occupational Rehabilitation

Table 5

Level of evidence and accompanying messages for stakeholders

Intervention category

Studies Interventions Consistency

Level of evidence

Message for stakehold-

ers based on the scientific

literature

Practice consideration: Con-

sider implementing physical

exercise at the workplace for

reducing MSD, especially if

it is applicable to the work

context

Recommendation: Implement-

ing strength training at the

workplace can help reduce

MSD among workers with

physically demanding work

Not enough evidence from the

scientific literature to guide

current policies/practices

Not enough evidence from the

scientific literature to guide

current policies/practices

Not enough evidence from the

scientific literature to guide

current policies/practices

Not possible to make specific

recommendations since the

components of the participa-

tory ergonomics interven-

tions are so different

Not possible to make spe-

cific recommendations

since the components of the

multifaceted interventions

are so different

Recommendation: Implement-

ing a stress management

intervention at the workplace

seem to have no effect on

reducing MSD among work-

ers with physically demand-

ing work

Not enough evidence from the

scientific literature to guide

current policies/practices

Physical exercise

16 Effect (H = 8, M = 8);

7 No benefit (H = 6 M = 1)

Moderate (of a positive

effect)

Strength training

9 Effect (H = 5, M = 4);

0 No benefit

Strong (of a positive effect)

Aerobic training

3 Effect (H = 2, M = 1);

2 No benefit (H = 2, M = 0)

2 Effect (H = 0, M = 2);

2 No benefit (H = 1, M = 1)

5 Effect (H = 2, M = 3);

10 No benefit (H = 5, M = 5)

7 No benefit (H = 3, M = 4)

Limited

Stretching

Mixed

Ergonomics

Limited

Participatory ergonomics 5

Strong (for no benefit)

Multifaceted

3 Effect (H = 3, M = 0)

13 No benefit (H = 11,

M = 2)

Strong (for no benefit)

Stress management

0 Effect;

3 No benefit (H = 3, M = 0)

Strong (for no benefit)

Others

Rest breaks

Reduced working hours

CBT

Topical analgesics

2 Effect (M = 2)

1 Effect (M = 1)

1 No benefit (H = 1)

1 Effect (H = 1)

Limited

Insufficient

Limited

evidence from the scientific literature to guide current

policies/practices”.

Within the domain of physical exercise, 3 studies report-

ing on 4 different interventions were identified and grouped

within the stretching category [37–39]. 0 interventions

form high-quality studies and 2 interventions from medium

quality studies presented a positive effect of stretching at

the workplace on MSD. There was mixed evidence of the

effect of stretching. This resulted in the following message

for stakeholders: “Not enough evidence from the scientific

literature to guide current policies/practices”.

Ergonomics

13 studies reporting on 15 different interventions were iden-

tified and grouped within the ergonomics domain [44–56].

5 interventions from high-quality studies and 5 interven-

tions from medium quality studies presented no effect of

Journal of Occupational Rehabilitation

workplace ergonomics on MSD. There was limited evidence

for no benefit for the domain of ergonomics. This resulted

in the following message for stakeholders: “Not enough evi-

dence from the scientific literature to guide current policies/

practices”.

Other Interventions

4 studies did not match any of the 5 intervention domains.

Only one study for each of the following interventions was

identified: rest breaks (medium quality study showing a pos-

itive effect) [75], reduced working hours (medium quality

study showing a positive effect) [76], cognitive behavioral

therapy (high-quality study showing no benefit) [42], topi-

cal analgesics (high-quality study showing a positive effect)

[77]. This resulted in limited or insufficient evidence for

each intervention type and the following messages for stake-

holders: “Not enough evidence from the scientific literature

to guide current policies/practices.”

Participatory Ergonomics

5 studies reporting on 7 different interventions were iden-

tified and grouped within the participatory ergonomics

domain [57–61]. 3 interventions from high-quality studies

and 4 interventions from medium quality studies presented

no benefit of participatory ergonomics on MSD. There was

strong evidence for no benefit for the domain of participa-

tory ergonomics. Within this domain, the interventional

components were so different, and our data-driven approach

did not allow to further divide them into meaningful catego-

ries. This resulted in the following message for stakeholders:

“Not possible to make specific recommendations since the

components of the participatory ergonomics interventions

are so different”.

Discussion

54 suitable high or moderate quality studies were found

reporting on the effect of 69 unique workplace interven-

tions, serving as a solid foundation for the evidence syn-

thesis and the subsequent recommendations for practition-

ers. There was moderate evidence of a positive effect of the

domain of physical exercise at the workplace to reduce MSD

among workers with physically demanding work. Within

this domain, there was strong evidence of a positive effect

of workplace strength training, where all 9 studies pointed

in the same direction. There was limited evidence for the

domain of ergonomics and thereby not enough evidence to

guide current practices. There was strong evidence for no

benefit for the domain of participatory ergonomics, multifac-

eted interventions, and stress management. The remaining

single-domain intervention categories (rest breaks, reduced

working hours, CBT, topical analgesics) only had one study

each, and thereby not enough evidence to guide current prac-

tices. Importantly, no intervention domains were associated

with "negative effects".

Multifaceted

15 studies reporting on 16 different interventions were iden-

tified and grouped within the multifaceted domain [35,

49,

62–74].

11 interventions from high-quality studies and 2

interventions from medium quality studies presented no

benefit of multifaceted workplace-interventions on MSD.

There was strong evidence for no benefit for the domain of

multifaceted interventions. Within this domain, the inter-

ventional components were so different, and our data-driven

approach did not allow to further divide them into meaning-

ful categories. This resulted in the following message for

stakeholders: “Not possible to make specific recommenda-

tions since the components of the multifaceted interventions

are so different”.

Physical Exercise

Stress Management

3 studies reporting on 3 different interventions were iden-

tified and grouped within the stress management domain

[35,

36, 45].

3 interventions from high-quality studies pre-

sented no benefit of workplace stress management on MSD.

There was strong evidence for no benefit for the domain

of stress management. This resulted in the following mes-

sage for stakeholders: Recommendation. “Implementing a

stress–management intervention at the workplace seem to

have no effect on reducing MSD among workers with physi-

cally demanding work.”

16 of 23 interventions supported the domain of workplace

physical exercise, resulting in a moderate level of evidence.

Previous reviews have found evidence for the use of work-

place exercise (not specified) for workers with upper limb,

neck or back conditions/pain [17,

78]

whereas others have

not [14,

20, 79].

Kennedy et al. [20] found mixed evidence

for exercise as an occupational health and safety intervention

in the prevention of upper extremity MSDs among workers

in general. This was however only based on four studies

that all evaluated a somewhat similar exercise program that

included a variety of activities such as strengthening, stretch-

ing, coordination, relaxation and/or stabilization exercises.

The many studies within the domain of physical exercise

allowed for a further categorization into strength training,

Journal of Occupational Rehabilitation

aerobic training, and stretching. All of the studies within

the category of strength training showed an effect on MSD

and therefore led to a strong level of evidence for a posi-

tive effect. These findings seemed to be consistent for both

care/hospital workers and industry/manufacturing workers.

A limited level of evidence was also found for aerobic train-

ing, whereas the studies on stretching showed mixed results.

This is somewhat in line with previous reviews performed

on the general working population or office workers. Van

Eerd et al. [13] found strong evidence of resistance train-

ing, moderate evidence of stretching exercise programs, and

limited evidence for a positive effect of aerobic training as

workplace-based interventions in the prevention of upper

extremity MSDs and symptoms. Further, Sihawong et al.

[80] found strong evidence for the effectiveness of muscle

strengthening and endurance exercises in treating neck pain

among office workers. Skamagki et al. [16] found some con-

sistency in their included studies, suggesting that high‐inten-

sity strength training at the workplace can decrease pain and

symptoms for employees who experience long‐term muscu-

loskeletal disorders. However, at the time of that review, they

also concluded that current research was limited. The pre-

sent review underscores the importance of strength training

as an effective intervention to reduce MSD among workers

with physically demanding work.

In spite of this strong evidence, recent numbers from the

Working Environment and Health study in Denmark shows

that less than a third of Danish workers are offered physical

exercise at the workplace [81]. Thus, future studies should

investigate barriers to implementing physical exercise at the

workplace rather than testing its effectiveness.

neck, or shoulder. In line with this, Van Eerd et al. [13]

found mixed evidence for ergonomics training + worksta-

tion adjustment based on 8 studies and concluded that

there is not enough evidence from the scientific literature

to guide current policies/practices. They also reported

moderate evidence of no benefit from workstation adjust-

ment alone. As the ergonomic interventions were very

heterogeneous, it should also be recognized that general

conclusions about the effectiveness of workplace ergonom-

ics should be done with care.

Participatory Ergonomics

Participatory ergonomics means actively involving workers

in developing and implementing workplace changes which

will improve productivity and reduce risks to safety and

health [82]. This is based on the assumption that workers are

the experts,and, given appropriate knowledge, skills, tools,

facilitation, resources, and encouragement, they are best

placed to identify and analyze problems, and to develop and

implement solutions which will be both effective in reducing

injury risks and improving productivity and be acceptable to

those affected [82,

83].

Despite these assumptions, we found

that participatory ergonomics at the workplace had no effect

on reducing MSD among workers with physically demand-

ing work. Thus, all 7 interventions from high or medium

quality studies showed no effect of participatory ergonomics,

leading to a strong level of evidence for no benefit for this

interventional domain. This is somewhat in disagreement

with previous studies on the general working population.

As an example, Rivilis et al. [84] found moderate evidence

that participatory ergonomic interventions have a positive

impact on MSD related symptoms. However, 3 of their 6

included studies were on sedentary workers (i.e. 2 studies

on office workers and 1 study on garment workers) and their

database search was performed until 2004. Further, Van Eerd

et al. [13] found mixed evidence for low-intensity participa-

tory ergonomics based on 4 studies on the general working

population. Thus, sedentary workers of the general working

population may have driven these positive effects reported

in previous reviews. It has previously been suggested, that

it may be more challenging to implement and study inter-

ventions among non-office workers [13]. Compared with

office-work, the nature of work in workplaces with predom-

inantly physically demanding work is obviously different

and includes a great variety in work schedules, workstation

design and work organization which could make it difficult

to implement and conduct an evaluation. The present results

on the effect of participatory ergonomics could therefore

also reflect challenges in implementing such interventions at

workplaces with physically demanding work. As the partici-

patory ergonomics interventions were very heterogeneous,

Ergonomics

10 of 15 interventions showed no positive effect of work-

place ergonomics on MSD leading to a limited level of

evidence for no benefit for the domain of ergonomics: not

enough evidence from the scientific literature to guide cur-

rent policies/practices. Previous reviews on the general

working population have both reported an effect, no effect

and conflicting results of workplace ergonomics on MSD.

Hoosain et al. [17] found positive effects for the use of

ergonomic controls, ergonomic training and workstation

adjustments, although these intervention categories had

few high-quality studies. In opposition, Verbeek et al. [15]

found no evidence available from RCTs for the effective-

ness of manual material handling advice and training or

manual material handling assistive devices for treating

back pain. They concluded that more high-quality studies

could further reduce the remaining uncertainty. Further,

Verhagen et al. [79] found conflicting evidence concerning

the effectiveness of ergonomic programs over no treatment

in the treatment of work-related complaints of the arm,

Journal of Occupational Rehabilitation

it should also be recognized that general conclusions about

the effectiveness of participatory ergonomics should be done

with care. A discussion on this can be seen in the “Methodo-

logical Considerations” below.

not effective in nurses with and without low back pain and

Van Eerd et al. [13] found moderate evidence for no effect

of job stress management training for the prevention of

upper extremity MSDs and symptoms.

Multifaceted Interventions

13 of 16 interventions from high or medium quality stud-

ies showed no effect of multifaceted workplace-interven-

tions on MSD among workers with physically demanding

employment. This resulted in a strong evidence level for

no benefit for the domain of multifaceted interventions.

In line with this, Van Hoof et al. [14] found very few low

risk of bias RCTs and therefore concluded that there is

no strong evidence for any intervention (including multi-

dimensional interventions) in treating or preventing low

back pain in nurses. Further, Dick et al. [85] found limited,

but high quality, evidence that multidisciplinary rehabilita-

tion for non-specific musculoskeletal arm pain, including

both physical and psychosocial approaches, was beneficial

for those workers absent from work for at least 4 weeks.

In the present study, it was not possible to make recom-

mendations to stakeholders since the components of the

multifaceted interventions were so different. Lack of suc-

cessful implementation could have contributed to the lack

of effectiveness seen in some of the studies within this

domain, which have been thought to be highly effective

for reducing multifactorial outcomes such as MSD (fur-

ther discussed below). Thus, it can not be ruled out, that

there could have been more than 3 effective multifaceted

interventions if implemented successfully. The 3 multi-

factorial interventions that were found to be effective in

reducing MSD consisted of the following interventional

components: (1) Spine Care for Nurses program consisting

of didactic education, spine-strengthening exercises and

education on safe patient handling techniques [65], (2)

physical, cognitive, and mindfulness group-based training

[66], and (3) participatory ergonomics, physical training,

and cognitive-behavioural training [70]. Table 4 further

describes the components of the multifactorial interven-

tions that were found effective and not effective in the

present review.

Practical Relevance

The prevention of MSDs at workplaces is a challenge

and practitioners have therefore specifically asked for an

evidence-based approach to better identify and imple-

ment effective interventions for employees with physically

demanding work. In addition, implementing evidence-based

initiatives at workplaces is a well-known challenge that may

be due to the fact that existing knowledge is not conveyed

clearly enough to the users, including the workplaces. Like-

wise, it is nearly an impossible task for OSH practitioners

to find, read and synthesize relevant scientific literature on

effective workplace solutions to reduce MSD. Employing

the IWH review guidelines for the review provided us with

the opportunity to develop relevant recommendations for

practitioners. The involvement of relevant stakeholders in

some of the review-steps has also maximized the practical

relevance of the review and increased the opportunity for the

evidence-based knowledge to reach relevant users [86–89].

By providing a solid and up-to-date evidence base with

clear and understandable messages for practice, we hope

that practitioners can be better suited to choosing the best

solution to reduce MSD among employees with physically

demanding work. Importantly, such messages and recom-

mendations must not only be carefully crafted but also care-

fully delivered. The stakeholders will, therefore, be involved

in both the development of practical tools—based on this

review—and the delivery of both tools and messages to rel-

evant workplaces. Notably, practitioners should also base

the decision on what is relevant and applicable to their spe-

cific workplace context and take into consideration, that the

results are based on the scientific literature, and not on the

knowledge and know-how of practitioners and workplaces.

Methodological Considerations

The perception of musculoskeletal pain and symptoms con-

stitutes a complex interaction of both biological, psycho-

logical and social factors [4,

90].

MSD-related outcomes

are therefore also complex measures that potentially can be

affected by a multitude of factors. Further, the time-frame

necessary before changes in MSD becomes apparent likely

varies with the workplace intervention being delivered (i.e.

intervention type) along with the population studied (e.g.

intensity of MSD, functional consequence of MSD, dura-

tion of MSD). In the present study, the MSD-related out-

comes included pain, symptoms, discomfort, or prevalence

of MSD/pain. However, information was lacking in regard

Stress Management

3 of 3 interventions from high or medium quality studies

showed no effect of stress management leading to a strong

level of evidence for no benefit for this interventional

domain. This is in line with previous reviews on upper

limb and back pain among the general working population

and among nurses [13,

14, 17].

For instance, Van Hoof

et al. [14] found that stress management in isolation was

Journal of Occupational Rehabilitation

to the duration of MSD in the included studies. Even though

duration is closely related to preventing MSD, which was not

in focus for this review, it could have had an effect on the

present results. In addition, some industries have itinerant

workforces e.g. construction workers. Thus, seeing effects

at longer time points is often complicated by not having the

same workers that were exposed to the intervention. Thus,

time-frames of outcome measurement could be an important

factor for the effectiveness of workplace studies. For the pre-

sent review, in case of several follow-up periods reported in

the same study, data on MSD from the longest time-frame

of outcome measurements were employed for the evidence

synthesis (unless specifically stated in the study aim that a

given follow-up time was the primary focus of the study).

This definition could have introduced a certain amount of

bias in the present reporting, especially if results on MSD

appeared to vary between different time-frames. However,

after inspecting the time-frames of outcome measurement,

illustrated in Table 4, this was not an important factor that

would change the overall evidence synthesis in the present

review. Of all the included studies forming the evidence syn-

thesis (Table 4), 15 studies (evaluating 17 different work-

place interventions) had more than one follow-up meas-

urement. Of these, only 3 studies (evaluating a total of 4

interventions) showed different results on MSD between the

time-frames of outcome measurement: one study within the

domain of ergonomics, and two studies within the domain

of physical exercise, of which one was within the category

of strength training. Deciding to use only the interventional

effects of the shortest time-frames of outcome measurement

would therefore not change the overall level of evidence for

any of the interventional domains or categories.

Importantly, length to the latest time-frame of outcome

measurement (i.e. study duration) varied between stud-

ies included in the different interventional domains. For

instance, the average time to the latest outcome measure-

ment was 19.6 weeks for interventions within the domain of

physical exercise, whereas it was 42 weeks for ergonomics

interventions, 41 weeks for participatory ergonomics inter-

ventions, and 31 weeks for multifaceted interventions. This

could have influenced the present results and it also seems

to highlight the need for investigating long-term effects of

physical exercise at the workplace. Whether the present find-

ings reflect a ceiling effect of the intervention effects after a

short time-frame or a gradually diminishing adherence to the

intervention occurs with time—and thereby limits further

improvements—cannot be elucidated based on the informa-

tion available in the included studies.

The interventional effect from the included studies was

classified as positive if the study reported positive results

on MSD-related outcomes such as pain, the prevalence of

MSD/pain, symptoms, or discomfort. It should, however,

be noted, that the effect was not necessarily based on the

primary outcome results, but could also reflect secondary or

tertiary outcome measures. As an example, in the included

study by Brandt et al. [57] the primary outcome of the par-

ticipatory ergonomics intervention was the number of events

with excessive physical workload during a working day,

while pain intensity in the last week (0–10 VAS-scale) was

regarded as a secondary outcome measure. Thus, other study

outcomes than those related to MSD could also be relevant

and may have shown other results. Still, the review team

and stakeholders decided that this was the best approach

to answer the study’s aim of investigating the effectiveness

of workplace interventions to rehabilitate musculoskel-

etal disorders among workers with physically demanding

employment. However, by focusing on these MSD related

outcomes, the results do not necessarily say anything about

the impact of MSD on disability level, activity limitations,

and participation restrictions. The use of the International

Classification of Functioning, Disability and Health model

(ICF) [91] could, therefore, be a helpful tool in directing our

attention to different aspects of functioning relevant to the

workplace context rather than solely focusing on symptoms

of MSD. Previous results from workplace interventions have

also focused on other types of outcomes than pain, such

as work ability and sick leave, which are more related to

the employees functioning during daily work. Thus, future

reviews could be inspired by the ICF framework and employ

these specific aspects of functioning at a workplace level as

effective measures of workplace interventions.

We found strong evidence for no benefit of participatory

ergonomics and multifaceted interventions at the workplace.

Importantly, within these domains (along with the domain

of ergonomics), the interventional components were so dif-

ferent and our data-driven approach did not allow to further

divide them into meaningful categories. There may have

been many factors that could have contributed to the lack of

effectiveness seen in some of these studies. Workplace inter-

ventions are complex and many factors can influence how

the intervention was implemented, which in turn contributes

to how effective they are. As mentioned above, the time-

frame for outcome measurements could be an important fac-

tor because working conditions—although modifiable—can

take a long time to modify due to the length of time required

to implement new policies, practices or programs. Further,

MSD is a complex outcome measure and it can take time

to see any meaningful change. Importantly, every organiza-

tion is different and interventions need to fit the company/

workplace [92], which can be complicated by the fissured,

multi-employer structure of some workplaces e.g. construc-

tion. Further, different industries are likely to have different

working conditions and different interventions may, there-

fore, be more effective to MSD than others. For instance,

multifaceted and participatory ergonomic intervention seem

to be appropriate approaches for reducing the symptoms of

Journal of Occupational Rehabilitation

MSD, even though we did not find evidence for this in the

scientific literature [93]. Importantly, the results of such

interventions do not only depend on the effectiveness of the

effort itself, but also on the implementation strategy involv-

ing the planning and processing of the intervention so that

it is integrated into the work organization and culture [93].

It can be very difficult to transfer a highly controlled and

carefully planned intervention to practice since, in real life,

management and not the researcher controls the implemen-

tation of workplace interventions and production systems

and workflows are changeable [94,

95].

Lack of successful

implementation could, therefore, have contributed to the lack

of effectiveness seen in some of the studies in the present

review. Thus, the conclusion of the present review regard-

ing multifactorial and participatory interventions should be

interpreted with caution.

As expected, substantial heterogeneity in the interven-

tional outcome measures, study designs, and workplace con-

texts did not allow for the conduction of a meta-analysis.

Specifically, outcome characteristics such as pain intensity,

the prevalence of pain, symptoms, and discomfort were

too broad to be matched or pooled and therefore lacked the

comparability for a meaningful meta-analysis. This is also

coherent with other reviews within the field of work-related

interventions to reduce MSDs [13,

16, 17, 23].

Instead, we

employed the pre-planned best evidence synthesis approach

developed by IWH, with the opportunity to provide practi-

tioners with the requested evidence-based approach to better

identify and implement more relevant and effective work-

place solutions. However, this approach does not consider

sample size since small study populations count as much in

the evidence synthesis as studies including a larger study

sample.

Strengths and Limitations

Including both RCTs and non-RCTs in the systematic review

can both be considered a limitation and a strength. Including

non-RCTs may downgrade the validity and strength of our

systematic review and the risk of bias will become higher in

the blinding and sequence generation domains. Therefore,

we employ the IWH approach for the quality assessment

and subsequent best evidence synthesis that are developed

to handle other study designs than RCTs. Even though RCTs

are considered the most powerful experimental design in

clinical trials [96], solely including these may be too restric-

tive to understand effective workplace-based interventions

where randomized and carefully controlled trials (RCTs)

are not always possible. Hence, only including RCTs may

exclude valuable information on workplace interventions to

reduce MSDs among employees with physically demand-

ing work. This is in line with various reviews within the

field that have solely included RCTs and concluded that the

current research is limited. Thus, the focus of the current

review was to deliver the best evidence available for the

practitioners and the employed best evidence synthesis was

a transparent way of presenting this to our stakeholders.

To maximize practical relevance we therefore correspond-

ingly included non-RCTs and of the 54 high and moderate-

quality studies included in the evidence synthesis, one third

(i.e. 18 studies) were non-RCTs. We were, therefore, able

to include valuable information that otherwise would have

been excluded from the review if only RCTs were included.

Even though the IWH approach for the quality assess-

ment and subsequent best evidence synthesis are developed

to handle other study designs than RCTs, RCTs will, in gen-

eral, have the possibility to obtain a higher quality score

and have a higher impact on the level of evidence than non-

RCTs. This is especially because some of the questions in

the quality assessment form (Table 2) relates to the inter-

vention allocation and the randomization process (the two

questions within question number 3). Thus, information on

RCT versus non-RCT was somewhat accounted for in the

quality assessment using the IWH approach and therefore

also in the subsequent evidence synthesis. In relation to this,

we found that 88% of the included RCTs obtained a “high”

quality score (i.e. > 85% of the maximum score) whereas

this was the case for 22% of the non-RCTs. Further, within

all the domains in the evidence synthesis, the results from

the RCTs were in accordance with the results from the non-

RCTs. However, within the intervention category of stretch-

ing, only non-RCTs existed, whereas only RCTs existed

within the interventional domain of stress management.

A strength of the study is the involvement of relevant

stakeholders in the review process, which ensured a high

level of practical relevance. Stakeholder involvement in the

design and search strategy phases introduced a more practi-

cal approach that allowed practitioners to share their knowl-

edge and experience from practice along with their needs in

regard to developing suitable workplace solutions.

Another strength is that authors were contacted to clarify

whether potentially included studies were workplace-based

if doubt about the location of the intervention existed based

on the full-text reading. This led to the inclusion of sev-

eral studies that otherwise would have been excluded for

the review. Hence, this strengthens the foundation for the

evidence synthesis.

Even though the included studies were from 19 different

countries, differences in regard to the geographical distribu-

tion of studies clearly existed. Of the 54 studies included

in the review, 27 studies were from Scandinavian countries

(Denmark, Norway, Sweden, Finland) and only 13 studies

were performed outside Europe. The present study results

therefore mainly reflect the effectiveness of interventions in

workplaces with physically demanding work in Europe and

especially in the Scandinavian countries.

Journal of Occupational Rehabilitation

Publication bias cannot be ruled out from the present

review. We attempted to be as inclusive as possible, as we

expected that there weren’t that many eligible studies on work-

place interventions to reduce MSD among employees with

physically demanding work. Thus, studies with positive results

were possibly more likely to be eligible for the present review.

Even though the English language is generally perceived to be

the universal language of science—also in regard to research

within the field of work environment and health—only includ-

ing these studies could have biased the present results by not

representing all of the evidence available. Thus, the presence

of a language restriction bias in the present study cannot be

ruled out.

Ethical Approval/Informed Consent

Ethical assessment and informed

consent are not required since primary data collection will not be

undertaken.

Open Access

This article is licensed under a Creative Commons Attri-

bution 4.0 International License, which permits use, sharing, adapta-

tion, distribution and reproduction in any medium or format, as long

as you give appropriate credit to the original author(s) and the source,

provide a link to the Creative Commons licence, and indicate if changes

were made. The images or other third party material in this article are

included in the article’s Creative Commons licence, unless indicated

otherwise in a credit line to the material. If material is not included in

the article’s Creative Commons licence and your intended use is not

permitted by statutory regulation or exceeds the permitted use, you will

need to obtain permission directly from the copyright holder. To view a

copy of this licence, visit

http://creativecommons.org/licenses/by/4.0/.

Conclusions

The systematic search revealed 54 suitable high or moderate

quality workplace-studies (36 RCTs and 18 non-RCTs) that

focused on MSD among workers with physically demanding

employment, which served as a solid foundation for the evi-

dence synthesis and the subsequent recommendations for prac-

titioners. The evidence synthesis recommends that implement-

ing strength training at the workplace can reduce MSD among

workers with physically demanding employment. In regard to

workplace ergonomics, there was not enough evidence from

the scientific literature to guide current practices. Based on the

scientific literature, participatory ergonomics and multifaceted

workplace interventions seem to have no beneficial effect on

reducing MSD among this group of workers. As these inter-

ventional domains were very heterogeneous, it should also be

recognized that general conclusions about their effectiveness

should be done with care.

Authors Contributions

ES and LLA conceived the study and its design.

KGVS and EB conducted the search in the bibliographic databases. ES,

KGVS, and LLA participated in the selection of the studies. KGVS and

ES extracted the data. ES, KGVS, and LLA analysed and interpreted

the results. ES drafted the manuscript. All authors approved the final

version of the manuscript.

Funding

Author ES obtained a grant from the Danish Working

Environment Research Fund for this study (Grant Number: J.nr.

20185100188).

Availability of Data and Materials

The data that support the findings

of this review will be available from the corresponding author upon

reasonable request.

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