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doi:10.1016/j.jelekin.2003.09.023
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003 Elsevier Ltd. All rights reserved.
Journal of Electromyography and Kinesiology 14 (2004) 135–152
www.elsevier.com/locate/jelekinInterventions to reduce work-related musculoskeletal disorders
Barbara Silverstein �, Randy Clark
Safety & Health Assessment and Research for Prevention (SHARP), Washington State Department of Labor and Industries, PO Box 44330,
Olympia, Washington 98504-4330, USA
Abstract
Work-related Musculoskeletal Disorders (WMSDs) continue to present a major challenge to workers and their employers invirtually every industry sector. Many disciplines have been involved in providing advice and working on interventions to preventWMSDs or reduce their consequences. Since the early 1990s, 15 systematic reviews (excluding specific treatment modalities) haveappeared in the peer-reviewed literature addressing musculoskeletal disorder reduction. The National Research Council–Instituteof Medicine summarized many of these efforts in 2001. Using a systematic literature search strategy, we identified 20 randomizedcontrolled studies, 17 quasi-experimental studies with control groups, and 36 paper reporting case studies with in the peer-reviewed literature between 1999–2003. Evidence is continuing to build that demonstrates combinations of measures appear tohave the greatest effect in reducing WMSDs, although individual engineering and administrative controls can also have positiveeffects.# 2003 Elsevier Ltd. All rights reserved.
Keywords: Musculoskeletal disorders; Interventions; Systematic review; Prevention
1. Introduction
The National Research Council–Institute of Medi-cine (NRC–IOM) [43] reviewed the evidence from awide range of disciplines on the work-relatedness ofmusculoskeletal disorders of the low back and upperextremities (WMSDs), finding the evidence convincingwith respect to multifactorial causality. Part of theirreview was based on a review of systematic reviews ofprimary and secondary prevention/intervention studiesprior to 2000 and more recent intervention studies. Asnoted by that review and by Zwerling et al. [64], thereare certain design considerations that will make inter-vention studies more effective. While randomized con-trolled trials (RCTs) present a strong study design,they are not always possible or ethical. They may bemore relevant to clinical treatments but even there, thestudy protocols used may not have widespread com-pliance outside of the trial. Quasi-experimental designswith comparison groups, followed by pre-post typeprospective studies can be effective designs if they
adequately measure exposure, health outcomes and
potential confounders or effect modifiers. Consider-
ation of adequate power to detect differences should be
determined before beginning any study. Sufficient fol-
low-up is required to adequately evaluate interventions
but this duration will vary based on the health out-
come of interest. Evidence of compliance with the
intervention as well as potential contamination between
groups needs to be considered. Appropriate statistical
methods need to be used to assess effects of the inter-
vention, with consideration for sample size and number
of variables. In some cases, detailed data collection
during ‘‘natural experiments’’ in a number of case stu-
dies may be aggragated to provide useful information,
recognizing a potential publication bias.In the last few years, there have been a number of
systematic reviews of the literature regarding preven-
tion of musculoskeletal disorders or their consequences
(disability), as well as a number of newly published
papers since the NRC–IOM review. The current review
aims to update the previous reviews in the hopes of
improving the knowedge base for reducing muscu-
loskeltal disorders and disability for working popula-
tions.
136 B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152
2. Methods
A systematic search of electronic databases was con-ducted to identify intervention studies that includedergonomics related primary prevention measures toreduce musculoskeletal symptoms and disorders atwork [5,48,52]. Selection criteria included a) peer-reviewed articles, b) published between 1990–2002, andc) in English. Databases and search words are includedin Table 1. Each electronic database was numbered inthe table in the order in which it was accessed.Abstracts were printed and reviewed. The most com-plete search was of OSH-ROM. However, there wereoverwhelming numbers of articles that had ‘‘inter-vention’’ or ‘‘prevention’’ in the keywords or abstract,but did not actually include an intervention study.Thus, for each additional database search, the searchwas more restricted. The tables of contents of five jour-nals for 2000–March 2003 were also reviewed toincrease the likelihood that no intervention studieswere missed in the databases for that period (Ergo-nomics, Scandinavian Journal Work Environment andHealth, American Journal of Industrial Medicine,American Journal of Industrial Hygiene and Inter-national Journal of Industrial Ergonomics). Oneadditional RCT was identified in May 2003.
Articles were then categorized into a) reviews, b)randomized controlled trials, c) prospective studieswith comparison group, d) case studies with pre-postmeasures but without comparison group, e) ergonomicsand other interventions used in secondary prevention,and f) other. The other category contained a number ofwell-conducted studies that evaluated the effect of anintervention on reduction in exposure or fatigue but
not musculoskeletal symptoms or disorders in workenvironments per se. Excluded from this review werearticles in conference proceedings and technical reportsthat have not yet been introduced into the peer-reviewed literature. Also excluded in the final selectionof studies were those pre-post study designs withoutcomparison populations. This was done more in theinterest of brevity than merit.
3. Results
We identified 17 review articles between 1990–2003related to ergonomic interventions or reduction/pre-vention of musculoskeletal disorders at work. Fifteenof these were systematic reviews (Table 2). An attemptwas made to categorize the studies as related to pri-mary prevention or secondary prevention. Nine of thereviews had some primary prevention interventionsincluded. The most extensive reviews of primary pre-vention studies were conducted by Westgaard andWinkel [62] who identified 92 peer-reviewed and non-peer reviewed studies between 1966–1996, and byKarsh et al. [26] covering the peer-reviewed literatureprior to January 1, 1999 (101 studies), Table 2.
The eight reviews focused on low back pain([13,20,28,36,38,46,50,56], ranged from those whodevelop back pain to returning to work after lumbarsurgery. The most common back pain interventionsreviewed were for back schools including training inlifting techniques and ‘‘ergonomics’’ and exercise.There was very little evidence presented that backschools have any lasting effect. There may be sometemporary effect in the first six months but it is not
Table 1
Databases and searches
P
ubMed 2 O SH-ROM 1 E MBASE 5 ErgonomicAbstracts on
Line 3
S
S
I
ocial
cience
ndex 4
Ergonomic� AND intervention� x
X x x xMusculoskeletal� (including MSD) AND prevention,
(including primary, secondary)
x
x xCarpal tunnel AND prevention x
xBack pain and (prevention OR control x
X x xIntervention studies AND (musculoskeletal disorders OR
ergonomics)
x
X xErgonomics AND program evaluation
XErgonomics AND program x
X x xWork-related upper extremity disorders and prevention
XNeck pain AND (prevention OR control)
XShoulder pain AND (prevention OR control)
XBack pain AND (prevention OR control)
x xRandomized control trials AND ergonomics
xRSI AND prevention x
xWork Organization AND ergonomics
xNote: OSH-ROM includes CISDOC from the ILO, HSELINE and MHIDAD from the UK, NIOSHTIC and NIOSHTIC-2 from the USA and
RILOSH from Canada, and Medline-OEM subset from the National Library of Medicine USA.
B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152 137
Table 2
Review of systematic reviews of prevention efforts to reduce musculoskeletal symptoms and disorders at work
Author R
eview topic Study Number & Type C onclusions[13]
S
S
R
ystematic database search.
eturn to work after
absence due to low back
disorders
n ¼ 12=130 met criteria: 9 RCTs, 3 prospective
Exercise & functional conditioning (11), Education (9)
Train in work methods (8)
Treatment guide (1)
Treatment+technical (1)
8
w
in
m
V
studies combined exercise, conditioning, training in
ork methods & lifting (Back school). 2 studies
cluded ergonomic interventions in integrated
odel.
arious levels of compliance observed not to be well
addressed. No effect of physician guidelines.
Effect greatest during subacute phase (60 days),
preventable fraction �11 to �80%.
[20]
P
S
T
ystematic database search.
raning effectiveness on
LBP prevention, among
employees,
quasi-experimental design.
Used in meta-analysis n ¼ 8: 5 studies of nurses,
1—hospital workers, 1—factory workers, 1 bus
drivers. Outcome: 5 ¼ back pain, 3 ¼ sick leave.
Ergonomic counseling ¼ 1
M
o
fo
D
eta-analysis showed small decrease in occurrence
r sick leave following training. Studies differed in
llow-up time.
ifficult to tell if intervention accounted for change.
No indication that working conditions changed.
[21]
P
N
in
IOSH review of
tervention studies showing
positive effect.
51 peer-reviewed and non-peer-reviewed, multiple
study designs Selection methods not described
5
e
1 studies reported some reduction in exposure via
ngineering controls 24/27 studies reported
decreases in pain, discomfort, or sick leave
[22]
P
R
e
eview of corporate
rgonomics programs
n ¼ 33. Programs reported in journals, conferences
& books that mainly address physical factors and
have ‘‘serious’’ company support
1
P
o
8/33 reported reduced MSD incidence or cost.
roductivity & quality assessed with different levels
f rigor. Selection bias—only those with positive
results report findings
[26]
P
S
b
ystematic search for papers
efore 1/1/99 examined,
non-agricultural, English
language. Evaluated subject
selection, intervention,
design, confounders,
dependent measures,
statistics and results
101 studies
8 back belt
21 ergo/lifting training
10 tools/technology
14 exercise (7randomized)
1 job redesign
47 multiple (2 randomized)
32% used experimental/quasi-experimental
8
w
B
(d
T
p
T
r
4% of studies found some positive results, majority
ere mixed
ack belts: 50% had at least some positive result.
id not have large prospective study, Wassell 2000)
raining (8 included exercise): 67% showed some
ositive results
ools/technologies: 90% showed some positive
esults
Exercise alone: 86% showed some positive results
Job design: 1 of 4 postures changed over time
Multiple: 97% showed some positive results
Overall results support engineering, administrative
and person-focused interventions can be effective,
most effective is the multiple component interven-
tions
[28]
P
S
o
ystematic search for papers
n low back problems in
nursing and intervention
studies.
10 prospective
11 interventions
T
e
raining/exercise: reduced sick days, increased
xtensor strength in 2/4 studies. Ergonomics
training, transfer technique: no effect
Ergonomic program controls: 2 decreased incidence
of LBP rates
Concludes studies with individual focus had mixed
results whereas those with organizational and indi-
vidual focus showed decrease.
[31]
P
S
in
ystematic review for
tervention at work to
prevent carpal tunnel
syndrome or UEMSD.
Required
comparison
n ¼ 24.
12 Engineering only
4 personal only
8 multiple
E
o
b
P
ngineering: lab studies without subsequent measure
f CT S, included keyboards types: mixed results;
ent hammer decrease ulnar dev, increase radial dev.
ersonal: wrist splints increase CTP; biofeedback: no
difference; exercise: no difference.
Multiple: programs with engineering and training: all
but 1 had at least positive short-term results. Some
controlled for confounding better than others
[34]
P
S
1
ystematic review 1985–9/
998 for back and neck pain
27 studies of primary interventions in randomized or
controlled trials using subjects not seeking treatment.
No ergonomic interventions or risk factor
modifications met the inclusion criteria. Interventions
graded on 4 levels of evidence. Notes issue of
compliance with intervention may affect results.
L
lu
p
B
e
E
umbar supports : Concludes strong evidence that
mbar supports are not effective in primary
revention.
ack schools and Education: Concludes strong
vidence back schools are not effective
xercises: Concludes strong evidence of effective-
ness.
Ergonomics: no RCTs. Concludes no good quality
evidence of effectiveness
Risk Factor Modification: No RCTs/CCTs.
Concludes no good quality evidence of effectiveness
(continued on next page)
138 B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152
Table 2 (continued )
Author R
eview topic Study Number & Type C onclusions[36]
S
S
d
ystematic electronic
atabase search: meta-
analysis of effects of back
schools
18 studies (1977–1993) met inclusion criteria. Used
meta-analytic approach. 1685 participants in meta-
analysis. All taught correct body posture and
movements, 78% fundamentals of spine, 67% physical
therapy, 61% ergonomics principles, 16–39% for other
aspects. Pain intensity recorded in 9 studies
P
fo
H
m
C
w
ain intensity: very small effect only in short term
llow-up.
ealth care utilization: significant effect first 6
onths only.
orrect back posture and movement: strongest effect
ithin six months.
Lost work time: no significant effect
Concludes: No substantial positive effect sizes could
be found for pain intensity, functional status and
intake of analgesics in any follow-up time period.
Suggestive evidence that back schools tied to the
workplace may lead to stronger effects.
[45]
S
S
4
ystematic Cochrane review
3 of published and
unpublished studies
attempting randomization
for non-
surgical treatment for carpal
tunnel syndrome (excluded
steroid injections)
.21 met study criteria.
Participants diagnosed with Carpal Tunnel
Syndrome, excluding those with CTR.
Outcome improved clinical symptoms at least
3 months after treatment, functional status,
physical examination, etc.
11 different interventions identified.
S
o
d
p
U
k
h
plinting (3): Limited evidence that nocturnal brace
ves improves symptoms, function or night splint is
ifferent than fulltime splint, no effect of wrist
osition in splint. All were short-term studies.
ltrasound (3): Limited evidence ‘‘Ergonomic’’
eyboards (2): Equivocal evidence on pain relief and
and function
Oral medication/vitamins (6): Diuretics-limited
negative evidence.
NSAIDs-limited negative evidence.
Oral steroids-moderate short-term improvement.
B6-limited negative evidenceTendon gliding exercises
(1): limited positive evidence
Yoga v. splints (1): limited positive short term
evidence
Passive range of motion (1): limited negative evi-
dence
Wear magnetic device (1): limited negative evidence
Chiropractic v. splints (1): limited evidence
Soft laser acupunctur (1):limited negative evidence
Insulin injection into CT(1): limited positive evi-
dence.
[46]
S
T
S
o
tr
ystematic Cochrane review
f randomized controlled
ials through April 2000,
Cochrane 2001 for
rehabilitation following first
time lumbar disc surgery
Identified 6/13 studies that were high quality I
mmediately post surgery: no strong evidence for anytreatment (no good studies)
4–6 weeks post-op: strong evidence for intensive
exercise programs on functional status and faster
return to work. No difference on long-term follow-
up. No strong evidence that supervised training is
better than home exercises.
Multidisciplinary rehabilitation program: limited
evidence of equal effectiveness as usual care.
Intensive exercise + horseback riding. No significant
difference
Aerobics + usual treatment: No significant difference
Starts more than 12 months post-op: no difference in
outcomes for those with intensive or mild exercises.
Concludes: evidence for intensive rehabilitation
programs is not overwhelming
[38]
P
S
q
ystematic qualitative and
uantitative review of
low back pain intervention
in reducing employee
absenteeism
35/185 identified articles were usable for meta-analysis
(Hunter & Schmidt, 1990). Unusable articles were
clinical reviews or commentary
R
a
E
educed Bed rest (5): significantly less frequent
bsence but low effect sizes
xercise (9 ) significantly less frequent absence
Spinal (chiropractic) manipulations (6): significantly
less frequent absence but low effect sizes
Back school or education (6): non-significant effect
on absence
(NOTE nonindependence due to overlapping samples,
significant heterogeneity of effect sizes suggests
modifiers unaccounted for in the analysis)
B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152 139
sustained over time. There was little evidence to sug-gest following treatment guidelines had an effect. Therewas strong evidence that lumbar supports are not effec-tive. Intensive physical exercise compared to none iseffective in reducing back pain and disability, especially4–6 weeks after surgery. There was limited evidencethat individual risk factor modification had any effect.There was some evidence that reducing bed rest timereduces work absence time. There were no RCTs ident-ified in these reviews of ergonomics program elements.However, in prospective studies, there was some evi-dence of positive effect. Cognitive-behavioral therapy(CBT) models that included problem solving and cop-ing strategies had some success in return to work forchronic LBP patients. Ergonomic job modification aspart of a return-to-work rehabilitation program hadgenerally positive effects with workers having lost timeback pain.
There were two systematic reviews for carpal tunnelsyndrome (CTS) ([31,45]. For those with CTS, there is
limited evidence that nocturnal bracing, or full-timebracing, ultrasound, tendon-gliding exercises, yoga,insulin injected into the carpal tunnel, oral steroidsmay have positive short term effect. There is limitedevidence of a negative effect for diuretics, NSAIDS, vit-amin B6, passive range of motion, wearing a magneticdevice, and soft laser acupuncture. ‘‘Ergonomic key-boards’’ had mixed results in two studies. The reviewof studies to prevention CTS or upper extremity dis-orders included 12 engineering laboratory studies withmixed results, 4 personal interventions (exercise, bio-feedback, splints) with no difference, and 8 studies withmultiple interventions, 7 of which had some short-termpositive results.
Hagg [22] reviewed 33 corporate ergonomics pro-grams where 18 of 33 reported reduced WMSD inci-dence or cost. Grant and Habes [21] reported on 51ergonomic intervention studies from both peer-reviewed and non-peer-reviewed literature that showedsome reduction in exposure via engineering controls.
Table 2 (continued )
Author R
eview topic Study Number & Type C onclusions[50]
S
S
in
ystematic review of RCTs
English between 1975–
1993. RTW with industrial
low back pain
35/4000 citations met criteria.12/35 used nonsurgical
interventions. Return to work after chronic back pain
outcome studies had methodological limitations
E
C
w
xercise(4): mixed results.
ognitive-behavioral (5): no differences in return to
ork in 4 studies, one of which included ‘‘ergonom-
ics’’. Study that also had ‘‘ergonomics’’, had signifi-
cant improvement in treatment vs. controls at 3–12
m0.
[56]
S
S
2
ystematic review (1966–3/
001) of return to work for
low back pain patients off
work or on modified work.
Outcome: work absenteeism
identified 14 RCTs evaluating the
effects of 19 return to work (RTW)
interventions
S
c
lo
tandard inpatient rehab program + psychological
omponent: no significant difference due to psycho-
gical addition.
Most studies had multiple interventions.
Physical exercises: (17): mixed results, largely posi-
tive
Education (15): mixed results
Ergonomics (3) job modifications in combination
with other measures: 2/3 positive RTW
Behavioral (7): mixed results
[62]
P, S
S
r
ystematic review of peer-
eviewed and non-peer-
reviewed literature:
improvement of
musculoskeletal health in
working populations
92 accepted field studies, laboratory studies,
case studies
M
(
echanical exposure studies (20)Workstation design
10) 8 positive effects, 1 negative
Repetition (3) 3 positive effects
Program (7) 7 positive effects
NOTE-most small studies of short durationProduction
system studies (32) Rationalization (7): 3 positive, 4
negative
Organizational Culture (25): 19+, 5mixed, 1 negative
NOTE-most small studies of short
duration, publication bias of positive week studiesMo-
difier Intervention (39)Physical therapy (3): 2 posi-
tive, 1 negative
Health education ((5): 5 negative
Exercise (16): 13 positive, 2 negative, 1 mixed
Relaxation: 1 positive
Work technique: 3 positive, 1 mixed
Multiple (9): 8 positive, 1 mixed. Conclusion: while
there is evidence of improved effect, authors make
strong plea for more rigorous study designs.
Note: P¼ primary, S¼ secondary, T¼ tertiary, CBT ¼ cognitive behavioral therapy:
140 B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152
Of the 27 reports where pain, discomfort or sick leavewere used as outcomes, 24 reported decreases. Thesetwo reviews suffer from publication bias where selec-tion criteria were unlikely to identify negative studies.The review by Karsh [26] was extensive and includedpeer-reviewed articles, conference proceedings and casestudies. Ninety percent of the 10 studies with tool/tech-nology change and 97% of the 47 multiple interventionstudies had some positive results. Fewer studies showedpositive results for exercise (86%), training (67%), andback belts (50%). The extensive review by Westgaardand Winkel [62] of the peer-reviewed and non-peerreviewed literature divided studies into mechanicalexposures that were primarily small studies with shortdurations, production system studies (also small and ofshort duration), and modifier interventions. The mech-anical studies largely had short-term positive effects,the production system studies of rationalization weremixed and largely positive for changes in organiza-tional culture. The modifier studies showed largelypositive effects for exercise, work technique andmultiple interventions, negative effects for healtheducation, and mixed effects for physical therapy.
We identified 20 RCTs published in the peer-reviewed literature between 1999–2003, Table 3. Ofthese, 10 included some primary prevention measuresand were primarily involving computer users ornursing personnel.
Among nursing personnel, Alexandre et al. [3] repor-ted improvement in back pain intensity and medicationuse 4 months after receiving exercise and ergonomicstraining, compared to those who had 45 min trainingon the spine and lifting techniques. Dahl and Nilsson[9] reported no differences in pain severity for thoseinvolved in a worksite CBT intervention but reducedanalgesic use and expectations of pain with certainmovements. Both of these studies had small groupswith volatile estimates. Horneij et al. [24] found no sig-nificant difference in back pain among home healthworkers who were in individually designed exerciseprograms, work-place stress management, or controlgroup after 18 months. High turnover and dropouthampered this study. Helewa et al. [23] found no differ-ence in development of back pain over 24 months forhospital and university staff who performed abdominalmuscle strengthening exercises 5 min per day. Yassi[63] et al. and Aaras [10] et al. evaluated nursing per-sonnel in rehabilitation, medical and surgical units)who 1) had usual practice, 2) safe lifting programemphasis, and 3) no strenuous lifting and new patienthandling equipment. Biomechanical analyses generallyshowed reduced loads when equipment was used (butnot always). Frequency of manual handling tasksdecreased significantly in the 3rd group and bothintervention groups reported less fatigue. There wereno significant changes in injury rates although the
distribution of injuries changed with a smaller percentof back disorders in the 3rd group. Short staffing, andhigher workloads hampered compliance with the inter-ventions over the study period. Power to detect signifi-cant differences was low.
Among the four computer user studies, interventionsincluded a participatory approach to ergonomics, withsymptoms and physical findings of WMSDs, as well asexposure reduction as outcomes [6], intensive ergonom-ics training and adjustments with participatory redesignand musculoskeletal discomfort and exposure reductionas outcomes [27], simple workstation adjustments withdiscomfort as outcome [40] and software-stimulatedbreaks with pain intensity and sick leave as outcomes[58]. Brisson et al. found age differences in effect withWMSD improvements greater for those less than 40years; postural stresses were significantly decreased inthe intervention group. Ketola et al. reported signifi-cant improvement in the intervention group at twomonths but no significant differences at 10 months. Theauthors believe this non-effect was related to contami-nation. Mekhora et al. found wide variation in dis-comfort over time with no significant differencesbetween groups that could be attributed to the inter-vention. There was a three month lag between whenthe first and second groups received the intervention.Van den Heuvel found no difference between breakgroups with and without exercise component and noindifferent difference between groups in pain intensity,frequency or sick leave based on short follow-up time.
Faucett [16] evaluated the effect of biofeedback andof adult learning with CBT in a 6-week interventionwith electronics workers with the aim of decreasingmuscle tension and symptoms. Reinforcement occurredat 18 and 32 weeks. Although the biofeedback groupwas able to decrease trapezius muscle tension and par-tially forearm extensor tension, without reinforcementthey returned to previous levels at 72 weeks. Neither ofthe interventions appears to have long-term effects onsymptoms.
Three studies with multi-pronged interventions wereconducted by Loisel [35] among workers with morethan 3 months work absence due to low back pain,Arnetz [4] among Swedish workers with 4+ weekswork absence, and Morken et al. [42] among Norwe-gian aluminum workers at 8 different plants focusingon WMSD symptoms, coping and psychosocial factors.
Loisel followed the groups (normal care, clinicalrehabilitation, participatory ergonomics and Sher-brooke combined) for six years looking at lost work-days, cost-benefit and cost-effectiveness. The Sherbrookemodel returned subjects to work more frequently, costmore initially but saved more at six years than theother models compared to normal care. The occu-pational (ergonomics) intervention cost less than the
Tab
le3
Ran
do
miz
edco
ntr
olled
tria
lsin
pri
mary
pre
ven
tio
no
fw
ork
-rel
ate
dm
usc
ulo
skel
etal
dis
ord
ers,
1999–200
3
Au
tho
rsP
op
ula
tio
nIn
terv
enti
on
Res
ult
s
[3]
S
670
Bra
zilian
fem
ale
nu
rsin
gaid
esin
au
niv
ersi
tyh
osp
ital
wit
hat
least
1
yea
rsex
per
ien
cean
dat
least
6
mo
nth
so
fb
ack
pain
Ou
tco
me:
pain
inte
nsi
ty
Par
am
etri
can
dn
on
-para
met
ric
stati
stic
s.
Co
ntr
ol
gro
up
(n¼
27):
45
min
class
on
spin
ae
an
ato
my
an
dlift
ing
tech
niq
ues
Inte
rven
tio
ngro
up
(n¼
27)
rece
ived
exer
cise
san
d
edu
cati
on
stre
ssin
ger
go
no
mic
s2/w
eek
for
4m
on
ths
+45
min
exer
cise
2/w
eek
Gro
up
ssi
milar
inage,
exp
erie
nce
,ch
ild
ren
at
ho
me.
Fo
llo
w-u
p:
4m
on
ths
Cer
vic
al
pain
inte
nsi
tysi
gn
ifica
ntl
yd
ecre
ase
din
the
inte
rven
tio
ngro
up
bu
tn
ot
the
con
tro
lgro
up
for
bo
thth
ela
st7
days
an
dla
st2
mo
nth
s.,
lum
bar
sign
ifica
nt
dec
rease
in
last
7d
ays
.
Inte
rven
tio
ngro
up
had
sign
ifica
nt
dec
rease
inm
edic
ati
on
,in
terf
eren
cew
ith
ho
me/
lei-
sure
.B
oth
gro
up
sh
ad
sign
ifica
nt
dec
rease
inp
hysi
cian
vis
its.
No
te:
sho
rtfo
llo
w-u
p,
smal
ln
um
ber
s,p
oss
ible
‘‘in
terv
enti
on
effec
t.’’
[4]
Sw
edis
hL
BP
claim
an
ts(6
5
inte
rven
tio
n,
72
refe
ren
ts)
wit
h4+
wee
ks
sick
leave.
12-m
on
th
follo
w-u
p.
Earl
yact
ive
case
man
age
men
tw
ith
vis
itto
claim
s
man
age
r/er
go
no
mis
tin
1st
wee
kan
dall
3vis
itw
ork
pla
ceb
y2n
dw
eek
toid
enti
fyp
hysi
cal
an
dp
sych
oso
cial
risk
san
dfi
xth
emso
wo
rker
can
retu
rnto
wo
rk
Inte
rven
tio
ngro
up
had
144.9
(11.8
)lo
std
ays
vs.
197.9
(14.0
)fo
rre
fere
nts
,
reim
bu
rsem
ent
fro
min
sura
nce
syst
em$9,6
00(7
54)
vs.
$12,1
96.
Incl
ud
ing
cost
sfo
r
ergo
no
mis
t,in
terv
enti
on
s,et
c.,
Ben
efit
toco
stra
tio
was
6.8
.at
on
eyea
r.
[6]
P
626
Can
adia
nu
niv
ersi
tyV
DU
wo
rker
s>
5h
rs/w
eek
.P
re-p
ost
test
wit
hre
fere
nts
.R
an
do
m
allo
cati
on
of
un
its.
Ob
serv
ew
ork
,
Qu
esti
on
nai
rean
dp
hysi
cal
exam
for
sym
pto
mat
ic.
Mea
sure
men
ts2
wee
ks
pre
6w
eek
sp
ost
inte
rven
tio
n.
McN
emar’
ste
st
40
gro
up
sra
nd
om
lyass
ign
ed(8
1%
part
icip
ati
on
rate
),80%
fem
ale
,75%
cler
ical,
mea
no
f8
yea
rso
njo
b,
43
yo
.
Inte
rven
tio
n:
(n=
284)
:P
RE
CE
DE
part
icip
ato
ry
ap
pro
ach
toer
go
no
mic
str
ain
ing,
2se
ssio
ns
of
3h
ou
rsin
2w
eek
s.
Co
ntr
ol
gro
up
(343)
Ob
serv
ati
on
so
fw
ork
stati
on
s
for
po
stu
ral
stre
sso
rs.
All
3p
ost
ura
lst
ress
essi
gn
ifica
ntl
yd
ecre
ase
din
inte
rven
tio
ngro
up
,le
ssfo
rco
ntr
ol
gro
up
(age
effec
tw
ith
vis
ual
targ
et)
Wo
rkst
ati
on
com
po
nen
tsim
pro
ved
sign
ifica
ntl
yfo
r<
40
yea
ro
lds
bu
tle
ssso
for
tho
se
over
40
yea
rs.
Sym
pto
ms
an
dp
hysi
cal
exam
fin
din
gs
dec
rease
dsi
gn
ifica
ntl
yfo
rin
terv
enti
on
yo
un
ger
an
dm
arg
inally
for
old
ersu
bje
cts.
No
sign
ifica
nt
chan
ges
for
the
exp
erim
enta
lgro
up
bu
tth
esa
me
patt
ern
sw
ere
pre
sen
t.
Po
ten
tial
effec
tm
od
ifier
sw
ere
no
tsi
gn
ifica
ntl
yd
iffer
ent
bet
wee
ngro
up
s.
Po
ten
tial
con
tam
inati
on
may
un
der
esti
mate
effec
t.Y
ou
nger
wo
rker
sh
ad
mo
reV
DU
tim
eth
an
old
erw
ork
ers
[9]
P/S
75%
of
90
pra
ctic
al
nu
rses
had
daily
pain
am
on
gS
wed
ish
pu
blic
hea
lth
wo
rker
sp
rovid
ing
eld
er
serv
ices
29
at
risk
of
dev
elo
pin
g
chro
nic
pain
(no
lon
gte
rmsi
ckle
ave
yet
).F
ollo
w-u
p4-2
4m
on
ths.
Ou
tco
mes
:p
ain
rela
ted
dysf
un
ctio
n,
fear,
an
dw
ork
an
dlife
sati
sfact
ion
.
Use
dA
NO
VA
an
dM
AN
OV
A
Co
ntr
ol:
regu
lar
sym
pto
mallev
iati
on
Inte
rven
tio
n:
CB
T30
min
ute
so
nce
per
wee
k�
4at
the
wo
rksi
te.
Mu
ltid
imen
sio
nal
Pai
nIn
stru
men
t(M
PI)
:N
osi
gn
ifica
nt
diff
eren
ceb
etw
een
gro
up
sat
base
lin
e,th
rou
gh12
mo
nth
sfo
rp
ain
sever
ity,
inte
rfer
ence
,life
con
tro
l,aff
ecti
ved
istr
ess
an
dso
cial
sup
po
rt.
No
oth
ervari
able
sw
ere
sign
ifica
ntl
yd
iffer
ent
at
on
eyea
rso
no
t
rep
eate
dat
2yea
rs.
Wo
rkan
dlife
qu
ality
vari
able
s:T
he
con
tro
lgro
up
incr
ease
du
seo
fan
alg
esic
san
dfe
lt
them
selv
essi
cker
du
rin
gth
efi
rst
few
follo
w-u
ps.
Exp
ecta
tio
ns
of
pain
wit
hce
rtain
mo
vem
ents
wer
esi
gn
ifica
ntl
yd
iffer
ent
bet
wee
nth
e
two
gro
up
sat
base
lin
ean
db
etw
een
base
lin
eth
rou
ghfo
llo
w-u
p4
for
the
inte
rven
tio
n
gro
up
.
Ver
ysm
all
sam
ple
size
8/29
dro
po
uts
by
24
mo
nth
s.L
arg
en
um
ber
of
vari
ab
les
for
such
smal
lgro
up
incr
ease
svo
lati
lity
of
esti
mate
s.
[16]
P
139/155
US
elec
tro
nic
sw
ork
ers.
Ran
do
mass
ign
men
tto
con
tro
l
or
trea
tmen
tgro
up
Ou
tco
mes
:sy
mp
tom
sd
iari
es
an
dE
MG
trap
eziu
sre
cord
ings.
108
com
ple
ted
sym
pto
ms
data
at
32
wee
ks.
AN
OV
A
Co
ntr
ol
gro
up
Inte
rven
tio
nfo
r6
wee
ks
wit
hre
info
rcem
ent
at
18,
32
wee
ks
1:
bio
feed
back
typ
eo
per
ant
train
ing
tod
ecre
ase
mu
scle
ten
sio
n
2.
ad
ult
learn
ing
an
dC
BT
insm
all
gro
up
s
Sym
pto
ms
dec
rease
dm
od
estl
yat
6w
eek
sfo
rth
eC
BT
gro
up
an
dre
turn
edto
base
lin
e
at
32
wee
ks;
un
chan
ged
for
the
bio
feed
back
gro
up
at
6w
eek
sb
ut
then
wo
rsen
edat
32
wee
ks;
incr
ease
dst
ead
ily
for
the
con
tro
lgro
up
.
Bet
wee
n6–32
wee
ks,
the
bio
feed
back
gro
up
was
con
sist
entl
yeff
ecti
ve
inre
du
cin
gm
us-
cle
ten
sio
nin
the
trap
eziu
sare
aan
dp
art
ially
succ
essf
ul
inth
efo
rearm
s,h
ow
ever
wit
h-
ou
tre
info
rcem
ent,
retu
rned
tob
ase
lin
ele
vel
sat
72
wee
ks.
Ret
enti
on
was
83%
for
con
tro
ls,
80%
for
CB
Tan
d70%
for
bio
feed
back
.
[19]
S
700
US
acu
teL
BP
pati
ents
at
risk
of
bec
om
ing
chro
nic
.F
ollo
wed
at
3-m
on
thin
terv
als
for
12
mo
nth
s.
Ou
tco
mes
:p
ain
dis
ab
ilit
y,
RT
W,
hea
lth
care
use
)
Hig
hri
skp
ati
ents
ass
ign
edto
2gro
up
s
Inte
rven
tio
n:
fun
ctio
nal
rest
ora
tio
nea
rly
inte
rven
tio
n
over
3w
eek
per
iod
(n¼
22)
No
nin
terv
enti
on
(n¼
48)
Lo
wri
skn
on
inte
rven
tio
n(n
¼54)
Hig
h-r
isk
inte
rven
tio
ngro
up
had
few
erin
dic
eso
fch
ron
icp
ain
dis
ab
ilit
yw
her
eas
the
hig
h-r
isk
no
n-i
nte
rven
tio
nh
ad
an
incr
ease
inall
ind
ices
.
Gre
ate
rco
stsa
vin
gs
for
earl
yin
terv
enti
on
NO
TE
:W
hile
RT
Ww
as
an
ou
tco
me
mea
sure
,th
ere
was
no
con
tro
lfo
rty
pe
of
wo
rko
r
wo
rkacc
om
mo
dati
on
by
the
emp
loyer
(co
ntinued
on
nex
tpage)
B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152 141
Tab
le3
(cont
inued
)
Au
tho
rsP
op
ula
tio
nIn
terv
enti
on
Res
ult
s
[23]
P
Un
iver
sity
staff
,P
hD
stu
den
ts,
ho
spit
al
staff
,are
are
sid
ents
.
Pre
vio
us
LB
Pex
clu
ded
.
509/189
0su
bje
cts
elig
ible
,402
ran
do
mly
allo
cate
d.
52
excl
ud
ed
for
pro
toco
ld
evia
tio
ns.
101
did
no
tco
mp
lete
24
mo
nth
s,
2x
as
man
yin
test
gro
up
.
Ab
do
min
al
mu
scle
stre
ngth
enin
gex
erci
ses-
setu
ps
5m
in/d
ay.
Co
ntr
ol
gro
up
rece
ived
regu
lar
back
edu
cati
on
incl
ud
ing
lift
ing
tech
niq
ue.
Ass
ign
men
t
stra
tifi
edb
yage
gro
up
,gen
der
,re
gu
lar
exer
cise
statu
s.
24-m
on
thfo
llo
w-u
p.
Ou
tco
me:
at
least
1b
ack
pain
epi-
sod
ein
pre
vio
us
24
mo
nth
s,ab
do
min
al
stre
ngth
,gri
p
stre
ngth
.
At
base
lin
e,te
stgro
up
had
12.7
%h
igh
erp
revale
nce
of
back
pain
inla
st5
yea
rs.
No
diff
eren
ceat
6,
12,
24
mo
nth
s.N
od
iffer
ence
inab
do
min
al
mu
scle
or
gri
pst
ren
gth
.
Yo
un
gm
ale
sin
exp
erim
enta
lgro
up
wh
oex
erci
sere
gu
larl
yw
ere
less
lik
ely
toex
per
ien
ce
LB
P,
old
erm
enm
ore
lik
ely
toex
per
ien
ceL
BP
.
[24]
S
282
Sw
edis
hfe
male
nu
rsin
gass
ista
nts
wo
rkin
gin
ho
me
hea
lth
care
follo
wed
for
18
mo
nth
svia
qu
esti
on
nair
e
Go
al:
Imp
rovem
ent
inn
eck
,sh
ou
lder
&lo
w
back
pain
,an
dp
erce
ived
ph
ysi
cal
exer
tio
nan
d
psy
cho
soci
alfa
cto
rs.
2le
vel
ran
do
miz
ati
on
Inte
rven
tio
n:
1)
ph
ysi
cal
train
ing
pro
gra
mfo
r
4se
ssio
ns
(IT
),2)
stre
ssm
an
age
men
tfo
r7
sess
ion
s
(SM
),3)
con
tro
lgro
up
No
sign
ifica
nt
diff
eren
ces
inn
eck
/sh
ou
lder
pain
bet
wee
ngro
up
sb
ut
all
imp
roved
at
12
mo
nth
s.IT
less
inte
rfer
ence
wit
hw
ork
du
eto
LB
Pat
12
mo
nth
s,m
arg
inal
effec
tin
SM
.
No
diff
eren
cein
per
ceiv
edex
erti
on
.S
Mm
ore
dis
sati
sfied
wit
hsu
per
vis
ory
clim
ate
at
18
mo
nth
s.L
arge
dro
po
ut
rate
.A
llh
ad
learn
edtr
an
sfer
tech
niq
ues
at
beg
inn
ing
of
pro
ject
.M
ore
ITw
ork
ing
part
tim
e,fe
wer
yea
rs.
[27]
P
Ou
to
f412
offi
ceem
plo
yee
s,124
sym
pto
mati
c(n
eck
an
du
pp
erlim
b)
Fin
nis
hV
DU
wo
rker
sra
nd
om
ized
into
thre
egro
up
s.Q
ues
tio
nn
air
es,
dia
ry,
wo
rklo
ad
mea
sure
men
tsan
d
ergo
no
mic
sra
tin
go
fw
ork
stati
on
s.
Ou
tco
me:
chan
ge
inM
Sd
isco
mfo
rt.
Ass
essm
ents
2w
eek
sb
efo
re,
2
an
d10
mo
nth
saft
erin
terv
enti
on
Gro
up
1re
ceiv
edin
ten
sive
ergo
no
mic
s:in
div
idu
al
chec
klist
ass
essm
ent
on
layo
ut,
ad
just
men
ts,
bre
ak
s;
part
icip
ate
inre
des
ign
.
Gro
up
2re
ceiv
edo
ne
ho
ur
ergo
no
mic
sed
uca
tio
n
Gro
up
3w
as
refe
ren
cean
dre
ceiv
edo
ne-
page
leafl
eto
nM
Sh
ealt
h&
VD
Uw
ork
as
did
the
oth
ergro
up
s.
Inte
nsi
ve
ergo
no
mic
sgro
up
ob
tain
edm
ore
acc
esso
ries
,er
go
no
mic
sim
pro
vem
ents
wer
e
sign
ifica
ntl
ygre
ater
.
Sig
nifi
can
td
ecre
ase
ind
isco
mfo
rtfo
ra
nu
mb
ero
fare
as
at
2m
on
ths
bu
tn
ot
sign
ifica
nt
at
10
mo
nth
s.F
or
the
edu
cati
on
gro
up
,se
ver
al
bo
dy
are
ash
ad
sign
ifica
ntl
yle
ssd
is-
com
fort
at
2m
on
ths
bu
tn
ot
at
10
mo
nth
s.
Diffi
cult
top
reven
tp
erso
nal
inte
ract
ion
bet
wee
ngro
up
s.W
ork
load
data
lost
for
1/3
of
each
gro
up
.B
asel
ine
dis
com
fort
level
slo
w.
No
wo
rko
rgan
izati
on
chan
ges
imp
lem
ente
d.
[32]
S
Th
ree
ran
do
miz
edtr
ials
of
tho
sew
ith
mu
scu
losk
elet
al
dis
ord
ers
wit
hth
e
aim
of
pre
ven
tin
glo
ng-t
erm
dis
ab
ilit
y
3ra
nd
om
ized
con
tro
lled
stu
die
sin
hig
h,
med
ium
,
an
dlo
wri
skM
SD
po
pu
lati
on
sth
at
had
psy
cho
logic
al
scre
enin
gte
st.
Inte
rven
tio
n:
6gro
up
cogn
itiv
e-
beh
avio
ral
ther
ap
y(C
BT
)se
ssio
ns
by
train
edth
erap
ists
+m
edic
al
care
of
the
pati
ent’
sch
oic
e:G
oal
top
rom
ote
cop
ing.
Ou
tco
me
lon
gte
rmsi
ckle
ave
an
dh
ealt
hca
re
uti
liza
tio
n
Ass
essm
ent
at
pre
test
an
d12
mo
nth
sp
ost
inte
rven
tio
n.‘‘Low
risk
gro
up’’:pain
butnot
patien
ts
No
diff
eren
ceb
etw
een
gro
up
s.‘‘M
edium
risk
gro
up’’
Ris
ko
fd
evel
op
ing
>14
sick
days
3
tim
esgre
ater
inu
sual
gro
up
.N
od
iffer
ence
inh
ealt
hca
reu
tiliza
tio
no
rp
ain
Hig
hrisk
:C
BT
gro
up
had
sign
ifica
ntl
yfe
wer
sick
days
,le
ssh
ealt
hca
reu
tiliza
tio
nb
y9-
fold
.P
ain
inte
nsi
tyd
idn
ot
diff
er.
NO
TE
:u
ncl
ear
ifp
op
ula
tio
ns
wer
ew
ork
ing
an
dw
he-
ther
ther
ew
ere
an
yd
iffer
ence
sin
typ
eso
fem
plo
ym
ent.
[30]
P
249/314
male
milit
ary
con
scri
pts
(65
dro
pp
edo
ut)
.B
ase
lin
e&
10
mo
nth
follo
w-u
p
Ou
tco
me:
self
-rep
ort
edb
ack
pain
du
rin
gp
ast
3w
eek
s,p
ast
yea
r,so
ugh
ttr
eatm
ent
Inte
rven
tio
n(1
01/150
at
10
mo
nth
s):
on
e40-m
inu
te
less
on
on
back
pro
ble
ms
an
der
go
no
mic
s,p
ass
ive
pro
ne
exte
nsi
on
sev
ery
day,
back
sch
oo
lap
pro
ach
).
Co
ntr
ol
gro
up
(113/164
):n
oth
ing
An
alysi
s,
Pea
rso
nv
2,
Fis
her
Exa
ct.
An
alysi
sex
clu
ded
dro
p-o
uts
an
dth
entr
eate
das
back
pain
On
lysi
gn
ifica
nt
base
lin
ed
iffer
ence
was
con
tro
lgro
up
was
hea
vie
r.
Inte
ntio
nto
trea
tanalysis.
No
sign
ifica
nt
diff
eren
cein
3p
ast
3w
eek
sw
ith
back
pain
epis
od
es.
Inte
rven
tio
ngro
up
had
sign
ifica
ntl
ylo
wer
on
e-yea
rp
revale
nce
(33%
inte
r-
ven
tio
n,
51%
con
tro
ls),
an
dsi
gn
ifica
ntl
yfe
wer
med
ical
vis
its,
pri
mari
lyam
on
gth
ose
wit
hp
revio
us
back
pain
.N
od
iffer
ence
sw
ere
fou
nd
for
tho
sew
ho
had
no
pre
vio
us
back
pain
.89%
of
inte
rven
tio
ngro
up
rep
ort
edd
ifficu
lty
do
ing
the
exer
cise
sd
uri
ng
mili-
tary
serv
ice.
Wo
rst
case
an
aly
sis:
sim
ilar
resu
lts.
142 B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152
[33]
S
Pre
ven
tio
no
flo
ng
term
dis
abilit
y
rela
ted
tosp
inal
pain
inacu
tean
d
sub
acu
tep
ati
ents
Ran
do
miz
edgro
up
s
1.
No
rmal
care
+6
sess
ion
so
f
cogn
itiv
e-b
ehavio
ral
gro
up
inte
rven
tio
nto
imp
rove
cop
ing
(n¼
107)
2.
No
rmal
care
+in
form
ati
on
pam
ph
let
on
trea
tmen
tan
dca
re
(n¼
70)
3.
No
rmal
care
+in
form
ati
on
in6
sess
ion
so
ntr
eatm
ent
an
dca
re(n
¼66)
Ou
tco
me:
aft
ero
ne
yea
r,si
ckle
ave,
hea
lth
care
use
,ri
skp
erce
pti
on
88%
com
ple
ted
12m
on
thfo
llo
w-u
pass
essm
ent.
CB
Tgro
up
53%
att
end
ed5+
sess
ion
s.S
elf
rep
ort
s:P
am
ph
let
gro
up
83%
read
it,
72%
read
info
pack
ets
CB
Tgro
up
fou
nd
inte
rven
tio
nm
ost
hel
pfu
l.
Su
bje
cts
had
mild
sym
pto
ms
at
base
lin
e.W
ith
ingro
up
imp
rovem
ent
for
CB
Tan
dp
am
-
ph
let
gro
up
s,n
osi
gn
ifica
nt
diff
eren
ces
bet
wee
ngro
up
s.
Act
ivit
yle
vel
:n
osi
gn
ifica
nt
diff
eren
ces.
Fea
r:n
osi
gn
ifica
nt
bet
wee
ngro
up
diff
eren
ces.
Wit
hin
gro
up
imp
rovem
ent
sign
ifica
nt
for
info
rmati
on
gro
up
s
Hea
lth
care
use
:si
gn
ifica
ntl
yle
ssfo
rC
BT
gro
up
Sic
kn
ess
ab
sen
ce:
CB
Tsi
gn
ifica
ntl
y
bet
ter
than
pam
ph
let
bu
tn
ot
info
pack
etgro
up
Sic
kle
ave
mo
reth
an
30
days:
risk
9ti
mes
less
for
CB
Tth
an
com
bin
edo
ther
gro
up
s
NO
TE
:n
oco
ntr
ol
for
job
rela
ted
fact
ors
[35]
S
6.4
-yea
rfo
llo
w-u
po
fw
ork
ers
wit
hlo
wb
ack
pain
dis
ab
ilit
y.
Wo
rkp
lace
sin
30
km
rad
ius,
wo
rker
sra
nd
om
ized
into
gro
up
sb
yin
du
stry
sect
or)
Inte
rven
tio
ns
1.
No
rmal
care
(26)
2.
Clin
ical
reh
ab
care
wit
hb
ack
sch
oo
l
(31)
3.
Occ
up
ati
on
al—
part
icip
ato
ry
ergo
no
mic
s(2
2)
4.
Sh
erb
roo
ke
(co
mb
ined
2&
3)
(25)
Ou
tco
me:
lost
wo
rkd
ays
Co
stb
enefi
t,co
st
effec
tiven
ess
an
alysi
s
Gro
up
sd
iffer
edb
yage
an
dgen
der
.
Mea
nC
on
seq
uen
ces
of
Dis
ease
Co
st
1yea
r6
yea
rto
tal
6yea
rC
-B
No
rmal
$7133
$23517
$0
Clin
ical
$6458
$10045
$16176
Occ
up
ati
on
al
$3040
$12820
$16827
Sh
erb
roo
ke
$5622
$7060
$18585
No
te:
no
rmal
gro
up
had
4ver
yex
pen
sive
case
s,o
ccu
pat
ion
al
had
1.
Job
mo
ds
sugges
ted
in37/47
elig
ible
case
s,h
alf
imp
lem
ente
d
[42]
P
2181
No
rweg
ian
alu
min
um
wo
rker
s
fro
m8
pla
nts
,721
pro
du
ctio
nw
ork
er
con
tro
lsan
d3699
con
tro
lsfr
om
oth
erse
ctio
ns.
Bas
elin
eq
ues
tio
nn
air
e
tom
easu
rem
usc
ulo
skel
etal
sym
pto
ms,
cop
ing,
an
djo
bd
eman
ds,
con
tro
l,so
cial
sup
po
rt.
Fo
llo
w-u
p
surv
eyat
16
mo
nth
s.In
clu
ded
stan
dard
No
rdic
Qu
esti
on
nair
e-5
po
int
freq
uen
cysc
ale
.
3-y
ear
ob
serv
ati
on
per
iod
toex
amin
eeff
ect
of
train
ing
pro
gra
mw
ith
part
icip
ato
ryap
pro
ach
on
mu
scu
losk
elet
al
sym
pto
ms
an
deff
ect
of
sup
ervis
ory
part
icip
ati
on
.41
gro
up
str
ain
edb
y
ph
ysi
oth
erap
ists
:10
sess
ion
so
ver
1yea
r:er
go
no
mic
s,
wo
rko
rgan
izati
on
,W
MS
Ds,
cop
ing,
solu
tio
n
dev
elo
pm
ent
Base
lin
eq
ues
tio
nn
air
eco
mp
lete
db
y
5654
(92%
),14%
fem
ale
.G
rou
pra
nd
om
izati
on
of
pro
du
ctio
nw
ork
ers
(hea
vy
ph
ysi
cal
wo
rk).
At
follo
w-u
p5143
com
ple
ted
qu
esti
on
nair
e
1.
132
op
erat
ors
+su
per
vis
ors
2.
135
op
erat
ors
on
lytr
ain
ed
3.
2su
per
vis
or
gro
up
san
dm
an
age
rs
train
ed,
147
op
erat
ors
no
ttr
ain
ed
4.
Co
ntr
ols
A=
423
op
erat
ors
5.
Co
ntr
ols
B=
134
4o
per
ato
rs
94%
had
som
eM
Sp
ain
in12
mo
nth
sb
efo
reb
ase
lin
e.(N
od
iffer
ence
bet
wee
ngro
up
so
n
an
yo
fth
ep
ara
met
ers
of
inte
rest
exce
pt
no
n-r
and
om
ized
Bco
ntr
ols
wit
hm
ore
con
tro
l
an
dco
pin
g).
Ch
an
ges
imp
lem
ente
d:
red
esig
nw
ork
pla
ce,
aid
so
rto
ols
,re
du
cere
pet
itiv
em
oti
on
,
incr
ease
djo
bvari
atio
n.
Inte
rven
tio
ngro
up
sin
crea
sed
cop
ing
skills
wit
hgro
up
2
incr
easi
ng
the
mo
st.
Psy
cho
soci
al
para
met
ers
did
no
tsi
gn
ifica
ntl
ych
an
ge.
Co
ntr
ol
gro
up
Bin
crea
sed
pre
vale
nce
of
som
eM
Ssy
mp
tom
s.N
osi
gn
ifica
nt
sym
pto
mre
du
c-
tio
ns
ino
ther
gro
up
so
rsi
gn
ifica
nt
diff
eren
ceb
etw
een
gro
up
s.(N
ote
s:co
de
matc
hin
g
pro
ble
ms
resu
lted
inlo
ssto
follo
w-u
po
f700,
bu
tn
ot
sign
ifica
ntl
yd
iffer
ent
at
base
lin
e.)
Po
ten
tial
un
der
esti
mate
du
eto
con
tro
lgro
up
Are
ceiv
ing
effec
tso
fin
terv
enti
on
bec
au
se
they
wo
rked
inth
esa
me
envir
on
men
tas
inte
rven
tio
ngro
up
s.F
ollo
w-u
psu
rvey
righ
t
aft
erin
terv
enti
on
an
dso
luti
on
sn
ot
yet
fully
imp
lem
ente
d.
Res
tru
ctu
rin
gd
uri
ng
stu
dy
per
iod
.P
hysi
cal
stre
sso
rsn
ot
mea
sure
d.
(co
ntinued
on
nex
tpage)
B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152 143
Tab
le3
(cont
inued
)
Au
tho
rsP
op
ula
tio
nIn
terv
enti
on
Res
ult
s
[40]
P
80/470
Th
ai
com
pu
ter
use
rsw
ith
ten
sio
nn
eck
syn
dro
me
Su
bje
ct
dis
com
fort
bef
ore
an
daft
er
inte
rven
tio
nfo
rtw
ogro
up
s
ran
do
miz
ed,
SN
Q.
AN
OV
A
Gro
up
1re
ceiv
edin
terv
enti
on
3m
on
ths
bef
ore
gro
up
2.
Inte
rven
tio
n:
wo
rkst
ati
on
ad
just
men
tu
sin
gsi
mp
le
mate
rials
by
the
ind
ivid
ual
.D
isco
mfo
rtm
easu
red
8ti
mes
wit
hin
6m
on
ths
for
bo
thgro
up
s.
Su
bje
ctiv
ees
tim
ate
so
fw
ork
load
an
dw
ork
ho
urs
at
com
pu
ter
Dis
com
fort
valu
esd
ecre
ase
din
bo
thgro
up
sfo
rall
bo
dy
are
as.
Larg
evari
ati
on
in
dis
com
fort
over
tim
e.In
terv
enti
on
effec
tin
imm
edia
tere
du
ctio
nin
dis
com
fort
aft
er
inte
rven
tio
n,
seco
nd
gro
up
dis
com
fort
dec
rease
dw
ell
bef
ore
inte
rven
tio
nan
dre
main
ed
at
that
level
po
stin
terv
enti
on
.U
sed
com
bin
edb
od
yp
art
dis
com
fort
sco
res
wh
en
sele
ctio
no
fsu
bje
cts
was
on
nec
k/sh
ou
lder
sym
pto
ms.
[54]
S
60
chro
nic
,n
on
-sp
ecifi
clo
wb
ack
pain
suff
erer
s(m
ean
du
rati
on
of
16.8
yea
rs)
wh
ow
ent
thro
ugh
18-m
on
th
inte
rven
tio
ntr
ial.
3yea
rsp
ost
inte
rven
tio
n,
qu
esti
on
nair
eo
n
LB
Pan
dm
ain
tain
inte
rven
tio
n
18
mo
nth
tria
lw
her
eb
ase
lin
ed
ata
collec
ted
for
6
mo
nth
san
dth
enra
nd
om
izati
on
into
gro
up
s
Tre
atm
ent:
rest
rict
ben
din
gact
ivit
ies
inea
rly
mo
rnin
gfo
r2
haft
erri
sin
g,
aft
er4
hsl
igh
tb
end
ing,
aft
er6
hn
orm
al
act
ivit
y.
Co
ntr
ols
:sh
am
stre
tch
ing
exer
cise
sF
inal
6m
on
ths
incl
ud
edcr
oss
over
by
con
tro
lgro
up
to
inte
rven
tio
n.
3yea
rp
ost
qu
esti
on
nair
e:u
sefu
lnes
s
of
flex
man
age
men
t,ad
her
ence
,p
ain
-fre
ed
ays
in
past
mo
nth
50/60
resp
on
ses
toq
ues
tio
nn
air
e
66%
tho
ugh
tfl
exm
an
age
men
tu
sefu
lin
con
tro
llin
gL
BP
,
62%
con
tin
ue
tou
seit
,74%
rep
ort
edfu
rth
erre
du
ctio
nin
pain
days,
22
%in
crea
se
No
nco
mp
lian
tre
spo
nd
ents
had
mo
rep
ain
days
than
com
plian
tre
spo
nd
ents
(no
tsi
g-
nifi
can
t)b
ut
ther
ew
as
no
diff
eren
cein
pain
inte
nsi
tyb
etw
een
the
two
gro
up
s.
[57]
S
176/260
Fin
nis
hn
ewsp
ap
erca
rrie
rs
wh
oh
ad
low
erlim
bsy
mp
tom
s
pre
vio
us
3m
on
ths
wer
ed
iagn
ose
d
wit
h‘‘o
ver
use
inju
ries
.’’
Ou
tco
me:
VA
Sp
ain
inte
nsi
ty
du
rin
gw
alk
ing,
nu
mb
ero
fp
ain
ful
days
,glo
bal
ass
essm
ent,
fati
gu
e,
hyp
erk
erato
tic
skin
lesi
on
san
d
over
use
dia
gn
ose
s,co
sto
fca
re.
Su
bje
cts
mu
stw
alk
at
least
3k
mo
rcl
imb
100
flig
hts
of
stair
sp
erd
ay
on
thei
rro
ute
s.33
excl
ud
edd
ue
ton
ew
sho
es,
no
inju
ries
,et
c.
Tre
atm
ent:
ind
ivid
ually
ad
just
edfo
otw
ear
wit
h
go
od
sho
ckab
sorb
ers
(n¼
86)
Co
ntr
ol:
wea
ro
wn
foo
twea
rF
ollo
w-u
p
qu
esti
on
nair
eat
3,
6m
on
ths:
com
plian
ce,
care
seek
ing,
exp
osu
re,
pain
inte
nsi
ty,
sick
leave
an
d
falls
inju
rin
glo
wer
lim
bs.
At
1yea
r,re
-exam
ined
an
dco
mp
lete
dan
oth
erq
ues
tio
nn
air
e.
95%
of
test
rep
ort
edco
mp
lian
ceat
1yea
r,
27%
go
tn
ewte
stsh
oes
du
eto
wea
r.44%
of
con
tro
lgro
up
go
tn
ewsh
oes
wit
hin
12
mo
nth
s
On
eyea
rfo
llo
w-u
p
No
sign
ifica
nt
diff
eren
ces
bet
wee
ngro
up
sin
pain
inte
nsi
ty,
nu
mb
ero
fp
ain
days,
ab
ilit
y
tow
ork
,le
isu
reti
me
walk
ing
act
ivit
ies,
nu
mb
ero
fo
ver
use
inju
ries
,re
late
dsi
ckle
ave
or
fall
rela
ted
inju
ries
.
Tes
tgro
up
had
hig
her
glo
bal
ass
essm
ent
incl
ud
ing
com
fort
of
sho
es,
few
erh
yp
erk
er-
ato
tic
skin
lesi
on
so
np
lan
ter
asp
ect.
Co
ntr
ol
gro
up
had
hig
her
foo
tfa
tigu
era
tin
gan
dsp
ent
twic
eas
mu
cho
nm
edic
al
foo
t
care
[58]
P
268/1000
Du
tch
com
pu
ter
wo
rker
s
(4+
days
for
5+
ho
urs
)w
ith
nec
k/
up
per
lim
bsy
mp
tom
sin
22
offi
ces
fro
msa
me
com
pan
yex
am
ined
by
ph
ysi
cian
for
RS
Ib
ut
no
tn
eed
ing
trea
tmen
t.
Des
ign
:C
lust
erra
nd
om
izati
on
.
Ou
tco
me:
pain
inte
nsi
ty/fr
equ
ency
,
sick
leave.
Co
mp
ute
ru
sage
reco
rded
on
lin
e
Pri
or
toin
terv
enti
on
,w
ork
stati
on
ad
just
men
ts
mad
e.8
wee
kfo
llo
w-u
p
Co
ntr
ol
gro
up
(6lo
cati
on
s,n¼
90)
Inte
rven
tio
n
1:
soft
ware
stim
ula
ted
tak
ing
extr
ab
reak
s(8
loca
tio
ns,
n¼
97)
of
4m
inev
ery
35
min
,
7s
mic
rob
reak
ever
y5
min
of
use
.
Inte
rven
tio
n2:
soft
ware
stim
ula
ted
bre
ak
s
+4
exer
cise
sd
uri
ng
extr
ab
reak
s(8
loca
tio
ns,
n¼
81).
Sel
fre
po
rts
of
com
plian
ce:
74%
gro
up
2d
id
exer
cise
sm
ost
of
the
tim
e
Gro
up
svari
edw
ith
gen
der
an
dage,
ad
just
edfo
rin
AN
OV
As.
55%
inte
rven
tio
ngro
up
sre
po
rted
reco
ver
yfr
om
sym
pto
ms
com
pare
dto
34%
for
con
tro
lgro
up
.
Inte
rven
tio
ngro
up
wit
ho
ut
exer
cise
had
hig
her
pro
du
ctiv
ity
an
db
oth
inte
rven
tio
n
gro
up
sh
ad
low
erer
ror
rate
s.
No
sign
ifica
nt
diff
eren
ceb
etw
een
gro
up
sin
pain
inte
nsi
ty,
freq
uen
cyo
rsi
ckle
ave.
Co
nfl
icti
ng
resu
lts
on
inte
ract
ion
bet
wee
np
erce
ived
job
dem
and
san
dre
cove
ry.
Po
ten
tial
‘‘in
terv
enti
on
bia
s’’,
sho
rtin
terv
enti
on
tim
e.R
edu
ctio
nin
com
pla
ins
by
all
gro
up
s.L
ow
init
ial
resp
on
sera
te(1
700/
12000
retu
rned
init
ial
qu
esti
on
nair
e)
[59]
S
Du
tch
pati
ents
on
sick
leave
for
no
nsp
ecifi
cL
BP
refe
rred
to
reh
ab
ilit
atio
nce
nte
rO
utc
om
e:
days
of
sick
leave,
wo
rkst
atu
s
Gro
up
1:
beh
avio
ral
gra
ded
act
ivit
y(C
BT
)+
pro
ble
m-s
olv
ing
ther
ap
y(n
¼45)
Gro
up
1:
beh
avio
ral
gra
ded
act
ivit
y+
gro
up
edu
cati
on
(n¼
39)
Fo
llo
w-u
pat
6m
on
ths,
Act
ivit
y+
ther
ap
ygro
up
had
sign
ifica
ntl
yfe
wer
sick
days
,m
ore
favo
rab
lew
ork
statu
s(8
5%
vs.
63%
RT
W)
an
dfe
wer
rece
ived
dis
abilit
yp
ensi
on
at
on
eyea
r
NO
TE
:D
idn
ot
eval
uate
wo
rkin
gco
nd
itio
ns
that
may
aff
ect
ab
ilit
yto
be
acc
om
mo
date
do
rre
turn
tow
ork
.
Do
n’t
kn
ow
ifim
pro
vem
ent
wo
uld
hap
pen
wit
ho
ut
eith
ertr
eatm
ent.
Pro
ble
mso
lvin
g
skills
can
hel
pim
pro
ve
ph
ysi
cal
load
fact
ors
144 B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152
[10,6
3]
P
346
Can
ad
ian
gen
eral
ho
spit
al
nu
rses
an
dass
ista
nts
at
risk
for
low
back
dis
ord
ers
Ou
tco
mes
:n
um
ber
of
stre
nu
ou
slift
s,w
ork
-fati
gu
e,b
ack
an
dsh
ou
lder
pain
,in
jury
rate
s.
Inte
rvie
wed
at
base
lin
e,6
an
d12
mo
nth
s:#
of
tran
sfer
san
dlift
ing
equ
ipm
ent
use
d,
dis
com
fort
,fa
tigu
e,
SF
36,
DA
SH
an
dL
ow
back
Dis
abilit
yQ
ues
tio
nn
aire
,H
osp
ital
inju
ryd
ata
invo
lvin
gp
ati
ent
tran
sfer
s,w
ork
ers
com
pen
sati
on
rep
ort
s.A
nal
ysi
s:2
an
d3-w
ay
rep
eate
dm
easu
res
AN
OV
Aan
d
pro
po
rtio
nal
haza
rds
mo
del
for
inju
ryra
tes
over
tim
e.
3ty
pes
of
serv
ice
are
as
(med
ical,
surg
ical
,
reh
ab
ilit
ati
on
)ra
nd
om
ized
into
3in
terv
enti
on
gro
up
s
A:
(n¼
103
at
base
,82
at
1yea
r)u
sual
pra
ctic
e
incl
ud
ing
train
ing
inlift
ing
tech
niq
ues
on
req
ues
t
an
do
nex
isti
ng
equ
ipm
ent
(1to
tal
mec
han
ical
lift
an
dsl
ide
bo
ard
s)
B:
‘‘sa
felift
ing’’
pro
gra
m(n
¼116
at
base
,85
at
1yea
r),
(1to
tal
lift
,tr
an
sfer
bel
ts,
4sl
idin
gb
oard
s)
C:
‘‘n
ost
ren
uo
us
lift
ing’’
(n¼
127
at
base
,94
at
1yea
r),
new
mec
han
ical
tota
llift
s,si
t-to
-sta
nd
lift
s,sl
idin
gd
evic
esfo
rea
chro
om
,n
um
ber
s
base
do
np
ati
ent
nee
ds
B&
Ch
ad
train
ing
inn
eweq
uip
men
tu
se.
Gre
ate
rco
mp
lian
cein
usi
ng
equ
ipm
ent
ingro
up
C(7
0%
)th
an
ingro
up
B(5
0%
).
Bio
mec
han
ical
an
aly
sis
(n¼
36
ass
ista
nts
)o
fp
eak
an
dcu
mu
lati
ve
load
(WA
TB
AK
)
du
rin
gsi
mu
late
dtr
an
sfer
sin
dic
ated
gen
erally
red
uce
dsp
inal
load
sw
ith
new
equ
ipm
ent.
So
me
situ
ati
on
sin
wh
ich
the
equ
ipm
ent
use
resu
lted
inh
igh
erlo
ad
sw
hen
use
rsw
ere
un
train
edo
rn
on
com
plian
t.
Inso
me
pati
ent
han
dlin
gta
sks
wit
heq
uip
men
tto
ok
lon
ger
than
usi
ng
no
equ
ipm
ent.
Wit
hh
eavy
pati
ents
,all
un
its
use
deq
uip
men
t.R
easo
ns
for
no
n-c
om
plian
ce:
sho
rtst
aff
-
ing,
incr
ease
dti
me,
acc
essi
bilit
yo
feq
uip
men
t,m
an
age
men
tsu
pp
ort
,p
eer
pre
ssu
re
Fre
qu
ency
of
man
ual
han
dlin
gta
sks
sign
ifica
ntl
yd
ecre
ase
do
nC
.
Bo
thin
terv
enti
on
gro
up
sre
po
rted
dec
rease
dfa
tigu
e,b
ack
an
dsh
ou
lder
pain
inte
nsi
ty
an
dfr
equ
ency
dec
rease
d,
bu
tgro
up
Ch
ad
gre
ate
rim
pro
vem
ent.
No
sign
ifica
nt
chan
ge
inin
jury
rate
s..
35%
of
inju
ries
on
Cw
ere
back
com
pare
dto
75%
inA
an
d62%
inB
.
No
te:
40-6
0%
po
wer
tod
etec
tsi
gn
ifica
nt
dec
rease
inin
jury
rate
sto
half
on
an
yarm
.
Pre
vio
us
stu
dy
at
this
faci
lity
ind
icat
edst
affi
ng
level
s,w
ork
load
,in
crea
sed
pati
ent
han
dlin
gass
oci
ate
dw
ith
sho
rtage
san
dh
igh
eracu
ity
con
trib
ute
toin
jury
.
Note
:P¼
pri
mary
,S¼
seco
nd
ary
,T¼
tert
iary
,C
BT¼
cogn
itiv
eb
ehavio
ral
ther
ap
y.
B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152 145
clinical intervention at one year but at six years wasabout the same.
In a randomized design, Arnetz [4] used active casemanagement by the Swedish insurance agency withergonomic assessment and intervention within 2 weeksof notice of sick leave (n ¼ 65), compared to those withusual management (n ¼ 72) for those with MSDs(primarily of the back and neck/shoulder). The earlyintervention approach reduced average sick leave sig-nificantly more than the comparison group (144.9(11.8) versus 197.9 (14.0) p< 0:01) at 12 months.
Morken [42] followed a large number of Norwegianaluminum industry workers over three years to exam-ine the effect of training programs with a participatoryergonomics approach or WMSD symptoms, psychoso-cial factors and coping. Geographic and administrativerandomization was used. Training groups includedonly supervisors, only production workers, and both,with two comparison groups. Within 12 months beforebaseline, 94% had symptoms. Changes implementedincluded redesign, aids and tools, reduced repetitivemotion and increased job variation. Psychosocial para-meters did not change, coping skills increased for theoperator only group the most. No significant symp-toms reductions were seen in any of the interventiongroups. The authors noted a potential underestimationof effect due to the control group A received the bene-fits of the workplace changes and the follow-up surveywas done almost immediately after the interventionwas implemented. Restructuring took place during thestudy period, making assessment of impact more difficult.
We identified 17 quasi-experimental studies between1999–2003 that had comparison populations but with-out random allocation, all used primary preventioninterventions (Table 4), two involving computer work-ers and 6 involving health care workers.
Among computer users, Aaras [2] reported on anongoing study in which the control group received thesame interventions as the intervention groups but 3.5–4.5 years later. Interventions included workstationadjustments, lighting and optometric corrections. Theinitial intervention groups continued to have reduceddiscomfort. The third group had significantly lower vis-ual complaints but continued to have head, back andforearm pain. Shoulder pain decreased significantly.Demure [11,12] found a significant reduction in unsat-isfactory workstation parameters. There was decreasedprevalence of pain severity for the hand/wrist but nosignificant decrease for those reporting discomfort atbaseline.
Among health care workers, Carrivick [7] reportedsignificant improvements in workers compensationrates, lost time and costs for cleaners where manualhandling risks were addressed. In the orderlies controlgroup there was an increase in these three indicators.Evanoff [14] noted a similar reduction two years after
Tab
le4
Qu
asi-
exp
erim
enta
lst
ud
ies
bet
wee
n1999–
2003
Au
tho
rP
op
ula
tio
nIn
terv
enti
on
Res
ult
s
[1]
P
No
rweg
ian
VD
Uo
per
ato
rs
wit
h6
yea
rso
ffo
llo
w-u
pfo
r
mu
scu
losk
elet
al,
vis
ual
an
d
psy
cho
soci
al
stre
ssb
efo
rean
d
aft
erin
terv
enti
on
.
Ou
tco
mes
:q
ues
tio
nn
air
e
rati
ng
of
pain
,o
rgan
izati
on
al
an
dp
sych
oso
cial
mea
sure
s.U
sed
rep
eate
d
mea
sure
sA
NO
VA
S
Pre
vio
us
rep
ort
so
f3
gro
up
so
f50
male
sea
chw
ith
gro
up
Cse
rvin
gas
the
con
tro
l(A
ara
s,1998).
Inth
is
stu
dy,
gro
up
Cre
ceiv
edth
esa
me
inte
rven
tio
ns
3.5
yea
rs
late
r.U
sin
gp
art
icip
ato
ryer
go
no
mic
s,th
ein
terv
enti
on
s
incl
ud
edim
pro
ved
ligh
tin
gan
do
pto
met
ric
corr
ecti
on
s,
sup
po
rtfo
rth
efo
rearm
so
nth
eta
ble
top
.
Ori
gin
al
inte
rven
tio
ngro
up
sS
(so
ftw
are
)an
dT
(tec
hn
ical)
con
tin
ued
toh
ave
red
uce
d
mu
scu
losk
elet
al
dis
com
fort
.
Gro
up
Ch
ad
ligh
tin
gin
stal
led
at
3.5
yea
rsan
do
pto
met
ric
corr
ecti
on
sat
4.5
yea
rs:
At
6yea
rssi
gn
ifica
nt
imp
rovem
ent
inligh
tin
gan
dgla
rew
ith
Cgro
up
sim
ilar
toea
rly
inte
rven
tio
ngro
up
s.A
lth
ou
gh
Ch
ad
sign
ifica
ntl
ylo
wer
vis
ual
com
pla
ints
at
6yea
rs,
they
wer
est
ill
gre
ate
rth
an
for
the
ori
gin
al
inte
rven
tio
ngro
up
s.
Hea
dach
e,b
ack
ach
ean
dfo
rearm
pain
did
no
tsi
gn
ifica
ntl
ych
an
ge.
Sh
ou
lder
pain
sign
ifica
ntl
yd
ecre
ase
d
Red
uct
ion
inn
eck
pain
was
bo
rder
lin
esi
gn
ifica
nt
Att
emp
ted
toad
dre
sslo
ssto
follo
w-u
pw
ith
stati
stic
al
com
pari
son
s(2
3/50
inT
,6/50
inS
an
d14/50
inC
).R
edu
ctio
nin
emp
loym
ent
acc
ou
nte
dfo
rm
ost
of
the
dro
po
uts
.
[8]
P
Cle
an
ing
an
do
rder
lyse
rvic
es
wo
rker
sin
an
Au
stra
lian
600-b
edh
osp
ital.
4-y
ear
pre
-
inte
rven
tio
n,
3-y
ear
po
st
inte
rven
tio
nfo
llo
w-u
p.
Ou
tco
me:
Wo
rker
s
com
pen
sati
on
claim
sco
sts
an
dlo
stti
me.
Inte
rven
tio
ngro
up
:cl
ean
ers
wh
ere
part
icip
ato
ryri
sk
iden
tifi
cati
on
,ass
essm
ent
an
dco
ntr
ol
pro
cess
focu
sed
on
man
ual
han
dlin
gin
juri
es.
Co
ntr
ols
incl
ud
edch
an
ge
infl
oo
rco
ver
ings
soea
sier
tocl
ean
,sa
fer
equ
ipm
ent,
incr
ease
ind
aily
rota
tio
n.
Co
ntr
ol
gro
up
:o
rder
lies
du
rin
gsa
me
tim
ep
erio
d.
Mo
rep
art
-tim
ean
dfe
male
clea
ner
sth
an
ord
erlies
Inte
rven
tio
ngro
up
:si
gn
ifica
nt
66%
dec
rease
inin
jury
rate
,73%
dec
rease
inco
stra
te,
43%
dec
rease
ind
ura
tio
nra
te.
Co
mp
ari
son
gro
up
:p
ost
inte
rven
tio
nin
crea
sein
all
thre
era
tes
Co
var
iate
sn
ot
ass
oci
ated
wit
hre
spo
nse
vari
able
s
[11,1
2]
P
272
VD
Tu
sers
inla
rge
US
ad
min
istr
ati
ve
dep
artm
ent.
152/249
com
ple
ted
init
ial
stu
dy,3
3lo
stto
follo
w-u
p
Base
lin
eass
oci
atio
ns
wit
hh
an
d/w
rist
,n
eck
/sh
ou
lder
,
an
db
ack
dis
com
fort
wer
ew
ith
du
rati
on
of
VT
Dw
ork
,
wo
rkst
ati
on
layo
ut,
psy
cho
soci
al
fact
ors
an
dso
me
per
son
alfa
cto
rs.
118
VD
Tu
sers
1yea
raft
erw
ork
stati
on
mo
difi
cati
on
s
imp
lem
ente
d
Sig
nifi
can
tre
du
ctio
nin
per
cen
to
fu
nsa
tisf
act
ory
wo
rkst
ati
on
para
met
ers
base
do
n
AN
SI
100.
Mu
scu
losk
elet
al
dis
com
fort
imp
roved
mo
st(5
7%
)fo
rh
an
d/w
rist
pain
sever
ity
an
d
less
sow
ith
freq
uen
cy.
Ho
wev
er,
for
tho
sere
po
rtin
gd
isco
mfo
rtat
base
lin
e,th
ere
wer
en
osi
gn
ifica
nt
diff
er-
ence
sat
follo
w-u
p.
[14]
P
Ord
erlies
in1200-
bed
US
ho
spit
al.
Ou
tco
mes
:w
ork
inju
ry,
lost
tim
ein
jury
,w
ork
ers
com
pen
sati
on
cost
s.
Pre
-po
stsy
mp
tom
s,
sati
sfact
ion
,p
sych
oso
cial
stre
sso
rs
Inte
rven
tio
n:
man
age
men
t/o
rder
lyp
art
icip
ato
ry
ergo
no
mic
ste
am
des
ign
edan
dim
ple
men
ted
chan
ges
in
train
ing,
wo
rkp
ract
ices
.
Co
mp
aris
on
:o
ver
all
ho
spit
alra
tes
2yea
rp
ost
inte
rven
tio
np
erio
d:
sign
ifica
nt
dec
rease
dri
sks
of
inju
ry,
tim
elo
ssin
jury
,
an
din
jury
wit
h3+
lost
days
am
on
go
rder
lies
com
pare
dto
enti
reh
osp
ital
.T
ota
llo
st
days
dec
lin
edfr
om
136.2
to23.0
per
100
FT
Es.
An
nu
al
wo
rker
sco
mp
ensa
tio
nco
sts
dec
rease
db
yh
alf
.S
ign
ifica
nt
imp
rovem
ent
insa
tisf
act
ion
,p
sych
oso
cial
dis
tres
san
d
soci
al
sup
po
rt
[15]
P
136
Fre
nch
no
n-c
leri
cal
ho
spit
al
wo
rker
sw
ith
age-
sex
matc
hed
con
tro
ls.
Pre
ven
tio
n
of
low
-back
pain
.
Ou
tco
mes
:M
usc
ulo
skel
etal
com
pla
ints
an
dch
an
ges
in
hab
its
du
rin
gw
ork
an
dle
isu
re
eval
uate
db
efo
rein
terv
enti
on
an
dtw
oyea
rla
ter
Inte
rven
tio
n:
hea
dn
urs
esan
dp
hysi
cal
ther
ap
ists
wit
h
ergo
no
mic
str
ain
ing
pro
vid
eded
uca
tio
no
nlo
wb
ack
pain
pre
ven
tio
nfo
rgro
up
so
f12
emp
loyee
sin
pati
ent
han
dlin
g.3
an
d6
mo
nth
sla
ter,
wo
rker
so
bse
rved
in
pra
ctic
eIn
terv
enti
on
an
dco
ntr
ol
gro
up
sh
ad
50
nu
rses
,
72
nu
rsin
gass
ista
nts
,14
clea
ner
s.
At
base
lin
e,co
ntr
ols
rep
ort
edm
ore
dis
com
fort
inp
ati
ent
han
dlin
gan
dw
ork
ing
po
stu
res.
No
majo
rch
an
ges
inp
erso
nal
life
bet
wee
ngro
up
s.
Inte
rven
tio
ngro
up
rep
ort
edch
an
ge
inw
ork
ing
con
dit
ion
sd
uri
ng
2yea
rsaft
er
train
ing.
Pat
ien
tn
eed
ssi
milar
at
base
lin
ean
dfo
llo
w-u
p.
No
diff
eren
cein
per
cep
tio
no
fw
ork
envir
on
men
to
rh
ealt
hat
follo
w-u
pN
od
iffer
ence
insy
mp
tom
so
rh
ealt
hca
reu
tiliza
tio
n.
Inte
rven
tio
ngro
up
mo
reab
leto
iden
tify
ing
pre
cip
itati
ng
fact
or
than
con
tro
ls.
75%
of
inte
rven
tio
ngro
up
rate
din
terv
enti
on
as
po
or
or
acc
epta
ble
.
146 B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152
[18]
P
Sw
edis
hC
ar
bo
dy
sealin
g
dep
art
men
tw
ork
ers.
Ou
tco
mes
:m
edic
al
dep
art
men
tre
po
rts
of
WM
SD
s,p
hysi
cal
wo
rklo
ad
by
qu
esti
on
nair
ean
dd
irec
t
mea
sure
men
ts;
psy
cho
soci
al
by
gro
up
dis
cuss
ion
an
d
qu
esti
on
nair
e.
Inte
rven
tio
n:
pro
du
ctio
nsy
stem
chan
ge
inb
od
ysh
op
.
Pri
or
toin
terv
enti
on
,w
ork
ers
had
mo
red
iscr
etio
nin
ho
wth
eyd
idth
ejo
b.
New
syst
emw
as
ad
just
ab
leh
eigh
t
lin
esy
stem
.L
ess
wo
rker
dis
cret
ion
n¼
78=90
Co
mp
ari
son
gro
up
:23/45
sim
ilar
wo
rkas
pre
-in
terv
enti
on
bo
dy
sealin
ggro
up
Am
ou
nt
of
tim
ein
stre
nu
ou
sp
osi
tio
ns
dec
rease
db
ut
cycl
eti
me
als
od
ecre
ase
d.
Wo
rker
sfe
ltlik
ero
bo
ts.
WM
SD
sin
crea
sed
slig
htl
yin
stu
dy
gro
up
bu
tn
ot
in
refe
ren
cegro
up
fro
msa
me
pla
nt.
Aver
age
sick
leave
days
incr
ease
dfo
rb
oth
gro
up
s.
Sym
pto
ms
inla
st7
days
incr
ease
dsi
gn
ifica
ntl
yin
the
stu
dy
gro
up
for
nec
k,
sho
uld
er
an
dh
an
dw
rist
.
Per
ceiv
edch
an
ges
inR
PE
an
dp
reci
sio
nw
ork
incr
ease
d,
oth
erlo
ad
sd
ecre
ase
d
slig
htl
y.
Over
hea
dw
ork
rem
ain
edat
mo
reth
an
45
min
ute
s/d
ay.
Pla
nn
edte
am
mee
tin
gs
rare
lyh
eld
.Im
ple
men
tati
on
pla
nn
ing
was
vie
wed
as
po
or.
[25]
P
350
pro
du
ctio
nw
ork
ers
chan
gin
gfr
om
8h
ou
rto
12
ho
ur
rota
tin
gsc
hed
ule
at
on
e
div
isio
no
fm
an
ufa
ctu
rin
gsi
te
Ou
tco
mes
:A
ge,
gen
der
ad
just
edO
SH
Are
cord
ab
le
inju
ryra
tes,
sati
sfact
ion
Hig
hly
au
tom
ate
dw
ork
envir
on
men
t.
Inte
rven
tio
ngro
up
:ch
an
ged
to12
hro
tati
ng
shif
ts
at
thei
rre
qu
est
Co
mp
ari
son
gro
up
wo
rked
at
the
site
ino
ther
org
an
izati
on
s.
Inju
ryra
tes
pre
:1986–87
Po
st:1
988–19
95
Wo
rker
so
n12-h
shif
tst
ron
gly
favo
red
it.
Lo
stw
ork
day
ad
just
edca
sein
jury
rate
sfo
r
inte
rven
tio
ngro
up
was
2.0
/100
bef
ore
an
d2.0
2/10
0aft
erin
terv
enti
on
.
Co
ntr
ol
gro
up
was
1.9
6an
d2.3
7re
spec
tivel
y.
[29]
P
Sw
edis
hcl
ean
ing
wo
rker
s
Ou
tco
me:
sick
nes
sab
sen
ce
over
8m
on
thp
erio
d,
cost
Inte
rven
tio
n:
97
clea
ner
s(8
9fe
male
)
Ref
eren
ts:
30
clea
ner
s(2
9fe
male
)
Gro
up
sco
mp
ara
ble
on
mo
stm
easu
res
of
inte
rest
Inte
rven
tio
n:
part
icip
ato
ryap
pro
ach
,m
ass
age,
lead
ersh
ip,
bet
ter
clea
nin
gm
eth
od
s,tr
ain
ing,
fitn
ess
Lab
or
cost
sin
crea
sed
13.6
%an
dfe
ll3.6
%in
refe
ren
tgro
up
.P
rod
uct
ive
ho
urs
dec
rease
daft
erin
terv
enti
on
.S
ick
nes
sab
sen
cein
crea
sed
inth
ein
terv
enti
on
gro
up
.
Sic
kn
ess
ab
sen
ceco
stin
crea
sed
10.2
%p
erem
plo
yee
inth
ein
terv
enti
on
gro
up
bu
t
62.5
%in
the
con
tro
lgro
up
.
Wh
enage,
dep
end
ents
,yea
rso
fw
ork
incl
ud
edin
mo
del
,ad
just
edch
an
ge
into
tal
sick
nes
sab
sen
ceco
sts
dec
rease
db
ord
erlin
esi
gn
ifica
ntl
yw
ith
the
inte
rven
tio
nfo
rth
e
yo
un
ger
age
gro
up
bu
tn
ot
the
old
erage
gro
up
.P
ayb
ack
per
iod
was
esti
mate
dto
be
4
yea
rs(1
.8yea
rsfo
rth
eyo
un
ger
gro
up
)
[37]
P
Wo
rker
sin
36
man
ual
han
dlin
gjo
bs,
34
un
der
wen
t
ergo
no
mic
sim
pro
vem
ent,
4
did
no
t.
Ou
tco
me:
OS
HA
reco
rdab
le
inju
ryra
te
Tru
nk
mo
tio
nan
dw
ork
pla
cefe
atu
res
mea
sure
dfo
r142
emp
loyee
sp
erfo
rmin
gjo
bs
pre
an
dp
ost
inte
rven
tio
n.
Inte
rven
tio
ns
incl
ud
edad
din
glift
tab
les,
rais
e/lo
wer
pro
du
ct,
lift
aid
s,re
des
ign
wo
rkare
as.
10%
emp
loyee
s
incl
ud
edin
bo
thp
rean
dp
ost
ass
essm
ent.
LB
Dri
skd
iffer
ence
was
corr
elate
dw
ith
inci
den
cera
ted
iffer
ence
ðr¼
047,
p<
0:0
4).
Sig
nifi
can
td
ecre
ase
inO
SH
Ain
cid
ence
rate
wit
hre
du
ced
risk
inex
po
sure
.L
ift
tab
les
an
dlift
aid
esh
ad
the
mo
stim
po
rtan
teff
ects
inin
jury
an
dri
skre
du
ctio
n,
imp
rovem
ent
injo
bsa
tisf
act
ion
.
No
te:
Ris
kvalu
esan
dra
tes
are
for
diff
eren
tp
op
ula
tio
ns
pre
-po
st.
On
ly10%
of
emp
loyee
so
njo
ban
aly
zed
at
bo
thti
mes
.D
irec
tio
no
fp
ote
nti
al
mis
class
ifica
tio
n
un
kn
ow
n.
[39]
P
New
Ham
psh
ire
emp
loyer
s.
Ou
tco
me:
wo
rker
s
com
pen
sati
on
inci
den
cera
tes
for
carp
al
tun
nel
syn
dro
me
Inte
rven
tio
n:
14
emp
loyer
sw
ith
his
tory
of
hig
hra
tes
wh
ow
ere
part
of
OS
HA
loca
lem
ph
asi
sp
rogra
min
ergo
no
mic
sw
ith
insp
ecti
on
sb
etw
een
1992–
1995.
Co
mp
ari
son
:all
oth
erem
plo
yer
s
Insp
ecte
dem
plo
yer
sh
ad
agre
ater
dec
lin
ein
CT
Sra
te(3
8p
er10,0
00
FT
Es
in1992—
3.8
per
10,0
00in
1997)
than
oth
erem
plo
yer
sn
ot
insp
ecte
d(6
.6ver
sus
3.4
resp
ecti
vel
y).
Do
esn
ot
ad
dre
ssre
gre
ssio
nto
the
mea
n.
[41]
P
US
Air
craft
man
ufa
ctu
rin
g
wo
rker
s
Ou
tco
me:
wo
rker
s
com
pen
sati
on
dir
ect
an
d
ind
irec
tco
sts.
Ris
km
an
agem
ent
inte
rven
tio
np
rogra
mgro
up
an
d
matc
hed
con
tro
ls.
Pro
gram
imp
lem
ente
din
1995
for
new
emp
loyee
s.
1998,
sub
gro
up
(n¼
199)
pro
spec
tivel
yst
ud
ied
for
med
ical
man
agem
ent
base
do
nin
div
idu
al
risk
sco
res
com
pare
dw
ith
age-
gen
der
-jo
b
matc
hed
con
tro
ls(n
¼240),
an
dco
mp
an
y.
Inte
rven
tio
n:
med
ical,
ergo
no
mic
,ed
uca
tio
nal,
base
d
on
ind
ivid
ual
risk
sco
res
OS
HA
reco
rdab
lein
jury
rate
ssi
milar
Lo
stti
me
OS
HA
rate
san
dlo
stw
ork
day
rate
incr
ease
dw
ith
ind
ivid
ual
risk
sco
res,
no
over
all
diff
eren
ceb
etw
een
tho
sew
ho
wen
tth
rou
gh
the
pro
gra
man
dth
ose
wh
od
id
no
t.
To
tal
cost
sfo
rW
Cw
ere
ass
oci
ated
wit
hin
div
idu
al
risk
sco
re.
Est
imate
dsa
vin
gs
$1333
per
case
[44]
P
VD
Uw
ork
ers
at
new
spap
ers
Ou
tco
me:
Nec
k,
sho
uld
er
an
darm
sym
pto
ms
Inte
rven
tio
ns
(n¼
10
inea
chgro
up
)E
envir
on
men
tal
red
esig
nm
easu
res
ET
:en
vir
on
men
tal
an
dw
ork
tech
niq
ue
mea
sure
s
Mea
sure
dp
ost
ure
,m
on
ito
rvie
win
g,
mu
scle
act
ivit
yan
dp
ain
7m
on
thfo
llo
w-u
p
Red
uct
ion
inn
eck
,sh
ou
lder
an
del
bo
wp
ain
sign
ifica
ntl
ygre
ate
rin
ET
gro
up
alt
ho
ugh
bo
thgro
up
sh
ad
red
uct
ion
s.
Sig
nifi
can
tch
an
ge
insh
ou
lder
flex
ion
an
dri
gh
ttr
ap
eziu
san
dex
ten
sor
carp
ira
dia
lis
mu
scle
act
ivit
y.
No
te:
small
sam
ple
size
,sh
ort
-ter
mfo
llo
w-u
p.
(co
ntinued
on
nex
tpage)
B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152 147
[47]
P
Bac
kan
dsh
ou
lder
stre
ssin
ho
spit
al
nu
rsin
gp
erso
nn
el:
5-y
ear
follo
w-u
p.
Ou
tco
me:
Bac
kan
dsh
ou
lder
inju
ries
,lo
std
ays,
rest
rict
ed
days
RP
Efo
rst
aff
Lik
ert
scale
of
com
fort
for
pati
ents
Erg
on
om
ics
pro
gra
mu
sin
gass
isti
ve
dev
ices
in
inte
rven
tio
nh
osp
ital
Co
ntr
ol
ho
spit
al
use
du
sual
care
RP
Ein
resi
den
th
an
dlin
gta
sks
sign
ifica
ntl
ylo
wer
inin
terv
enti
on
ho
spit
al,
for
bo
th
sho
uld
eran
db
ack
252
pati
ent
resp
on
ses:
pati
ent
com
fort
an
dse
curi
tysi
gn
ifica
ntl
yb
ette
rat
inte
rven
tio
n
ho
spit
al
18
mo
nth
sp
ost
inte
rven
tio
n:
sign
ifica
nt
dec
rease
inlo
stw
ork
days
,3
yea
rsin
crea
sein
inju
ries
an
dth
enlo
wer
again
inyea
rs4
an
d5.
Inju
ries
still
occ
urr
ing
wh
enh
an
dlin
g
hea
vy
pati
ents
(>100
kg).
NO
TE
:p
rovid
esd
ata
on
lost
days
an
dn
um
ber
of
inju
ries
bu
tn
ot
as
rate
san
dn
ot
for
com
pari
son
ho
spit
al
at
5-y
ear
follo
w-u
p.
[51]
P
27
male
Jap
an
ese
fork
lift
dri
vers
,260
oth
erb
lue
collar
wo
rker
s,55
man
age
rsat
cop
per
smel
ter.
Pre
ven
tio
no
flo
wb
ack
pain
3su
rvey
sb
efo
rean
daft
er.
Case
of
LB
P:
seek
ing
trea
tmen
t
for
pain
fro
mp
hysi
cian
.
Ch
an
ge
1:
lum
bar
sup
po
rts,
jack
ets,
exer
cise
Ch
an
ge
2in
tro
du
ced
9m
on
ths
late
r:fa
cility
chan
ge
tore
du
cew
ho
leb
od
yvib
rati
on
(su
spen
ded
seats
,p
neu
mati
cti
res)
an
dh
eavy
pla
stic
curt
ain
sat
do
ors
tore
du
ceco
ld.
Co
mp
aris
on
:1)
oth
erb
lue-
collar
wo
rker
sin
the
pla
nt,
2)
wh
ite
collar
wo
rker
s.P
ote
nti
al
per
son
al
con
fou
nd
ers
incl
ud
ed
Bas
elin
ep
revale
nce
of
LB
Pw
as
63%
for
fork
lift
dri
ver
s,32%
oth
erb
lue
collar
wo
rker
s,22%
man
age
rsF
or
fork
tru
ckd
river
s,p
revale
nce
fell
to56%
wit
hp
erso
nal
inte
rven
tio
nan
d33%
wit
hre
du
ctio
nin
wh
ole
bo
dy
vib
rati
on
thro
ugh
ou
tth
efa
cility
.
LB
Pp
revale
nce
rem
ain
edre
lati
vely
con
stan
tin
the
oth
ergro
up
s.
No
diff
eren
cein
use
of
per
son
al
dev
ices
bet
wee
nth
ose
wh
od
idan
dd
idn
ot
have
LB
P
at
21
mo
nth
s.
[53]
P
1239
fem
ale
nu
rses
fro
m2
En
glish
ho
spit
als
.
Po
stal
qu
esti
on
nair
eat
base
lin
e,18-2
8m
on
ths
late
r,in
terv
enti
on
ad
min
iste
red
at
on
eh
osp
ital.
At
32
mo
nth
s,an
oth
erp
ost
al
surv
ey
Ou
tco
me:
LB
Pin
pre
vio
us
mo
nth
.A
naly
sis:
pre
vale
nce
rati
os
usi
ng
GL
M
Inte
rven
tio
nh
osp
ital
:h
osp
ital
-wid
em
an
ual
han
dlin
g
po
licy
,m
an
age
rsu
rged
tob
rin
gab
ou
tcu
ltu
ral
chan
ge,
team
bri
efin
gs,
700
new
slid
esh
eets
,ad
dit
ion
al
lift
ing
equ
ipm
ent
inm
edic
al,
surg
ical,
ort
ho
ped
ican
din
ten
sive
care
ward
s.L
ink
nu
rses
on
each
un
itto
tak
eo
wn
ersh
ip
of
inte
rven
tio
n.
2d
ay
train
ing
Co
mp
aris
on
ho
spit
al:
aft
erH
SE
vis
it,
beg
an
imp
lem
enti
ng
less
exte
nsi
ve
equ
ipm
ent
pu
rch
ase
s&
train
ing
Co
vari
ate
s:p
erso
nal,
psy
cho
soci
al
fact
ors
Bas
elin
ere
spo
nse
56%
,fo
llo
w-u
p55%
Base
lin
ep
revale
nce
at
bo
thh
osp
itals
27%
,
hig
her
wit
hB
MI>
30
kg=
m2,
stre
ssed
or
dep
ress
ed,
per
ceiv
edh
igh
erjo
bd
eman
ds,
low
erin
tere
st,
con
tro
lo
rjo
bsa
tisf
act
ion
.Jo
bsa
tisf
act
ion
was
mo
stsi
gn
ifica
nt
psy
cho
soci
al
fact
or.
Ris
kin
crea
sed
wit
hin
crea
sein
man
ual
han
dlin
g(e
spec
ially
wit
h
flo
or
tob
ed1+
/d
ay).
Psy
cho
soci
al
fact
ors
imp
roved
inb
oth
ho
spit
als
at
follo
w-u
p.
So
me
dec
rease
inm
an
-
ual
han
dlin
gat
inte
rven
tio
nh
osp
ital
bu
tm
ay
have
bee
ngre
ate
rat
com
pari
son
.N
o
chan
ge
inL
BP
pre
vale
nce
bet
wee
nth
etw
osu
rvey
sfo
rth
eco
mp
ari
son
ho
spit
al,
incr
ease
d3%
inin
terv
enti
on
ho
spit
al.
Issu
es:
sign
ifica
nt
loss
tofo
llo
w-u
pb
y2
yea
rsso
rep
eat
cro
ss-s
ecti
on
al
an
aly
sis
use
d.
Hea
lth
care
ass
ista
nts
excl
ud
edat
follo
w-u
pin
com
pari
son
ho
spit
al(n
ot
by
des
ign
),
low
resp
on
sera
te,
hei
gh
ten
edaw
are
nes
sm
ay
have
incr
ease
dre
po
rtin
g,
inad
equ
ate
follo
w-u
pti
me
(4–14
mo
nth
s)
[61]
P
Po
ole
dan
aly
sis
of
4
inte
rven
tio
ns
am
on
gw
ork
ers
inn
urs
ing
ho
mes
an
dh
om
e
care
inO
slo
,H
elsi
nk
i,an
d
Sto
ckh
olm
Ou
tco
me:
Pre
-po
st
qu
esti
on
nair
eso
nn
eck
sho
uld
eran
db
ack
,p
ain
in
pre
vio
us
3-1
2m
on
ths,
exh
au
stio
naft
erw
ork
,
per
son
al
an
dw
ork
fact
ors
.
An
alysi
s:co
mb
ined
data
,
mu
ltiw
ay
freq
uen
cyan
alysi
s
wit
hh
iera
rch
ical
log-l
inea
r
mo
del
Inte
rven
tio
n:
red
uct
ion
inw
ork
ing
ho
urs
fro
m
7+
ho
urs
to6
hp
erd
ay
wit
hre
ten
tio
no
ffu
ll-t
ime
sala
ry
Osl
o:
46
inte
rven
tio
n,
158
refe
ren
ts(2
2m
on
ths)
Hel
sin
ki:
60
inte
rven
tio
n,
89
refe
ren
ts(2
2m
on
ths)
Sto
ckh
olm
:41
inte
rven
tio
n,
22
refe
ren
ts(3
2m
on
ths)
Wo
rkfa
cto
rsan
dp
erso
nal
fact
ors
incl
ud
edin
qu
esti
on
nair
e.R
epla
cem
ent
per
son
nel
inall
3
loca
tio
ns
tom
ak
eu
pfo
rre
du
ced
ho
urs
Nec
k–sh
ou
lder
pain
inin
terv
enti
on
gro
up
dec
rease
d33%
inO
slo
an
dH
elsi
nk
ian
d
slig
htl
yle
ssin
Sto
ckh
olm
.N
od
ecre
ase
inre
fere
nce
gro
up
s.
Bac
kp
ain
dec
rease
inin
terv
enti
on
sin
Osl
oan
dH
elsi
nk
iaft
er1.5
yea
rsb
ut
incr
ease
at
1yea
r.S
tock
ho
lmn
od
iffer
ence
inre
du
ctio
nb
etw
een
gro
up
s.
Ph
ysi
cal
exh
au
stio
nle
ssaft
erin
terv
enti
on
,n
ore
du
ctio
nin
refe
ren
ts
Mu
ltiw
ay
freq
uen
cyan
aly
sis
of
com
bin
edd
ata
:si
gn
ifica
nt
inte
ract
ion
for
nec
k-
sho
uld
erp
ain
an
dfo
rex
hau
stio
nsh
ow
edre
du
ctio
ns
wer
esi
gn
ifica
nt,
no
tso
for
back
pain
.In
terv
enti
on
gro
up
sh
ad
incr
ease
djo
bsa
tisf
act
ion
,sp
ent
mo
reti
me
wit
hch
il-
dre
nan
dso
cial
act
ivit
ies
NO
TE
:in
crea
sein
over
tim
ed
uri
ng
stu
dy
per
iod
for
sever
al
inte
rven
tio
np
erso
ns.
Incr
ease
dw
age
cost
sm
ay
be
mit
igat
edb
yle
sstu
rno
ver
148 B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152
[60]
P
US
mate
rial
han
dlin
gw
ork
ers
in160
new
reta
ilst
ore
sin
30
state
s,6.5
mo
nth
sfo
llo
w-u
p
Ou
tco
me:
wo
rker
s
com
pen
sati
on
rate
sfo
r
mate
rial
han
dlin
gb
ack
inju
ries
,se
lf-r
epo
rted
back
pain
inp
revio
us
6m
on
ths
4+
tim
es.
An
aly
sis:
mu
ltiv
ari
ab
le
Po
isso
nre
gre
ssio
n,
logis
tic
regre
ssio
n
Inte
rven
tio
n(8
9st
ore
s)m
an
dato
ryb
ack
bel
tu
se
(n¼
7500)
Co
mp
ari
son
(71
sto
res)
vo
lun
tary
back
bel
tu
sage
4741
excl
ud
edp
rio
rto
base
lin
ein
terv
iew
.
6311
com
ple
ted
follo
w-u
pin
terv
iew
3418
at
bel
t
req
uir
edst
ore
s2893
vo
lun
tary
bel
tst
ore
s
Co
llec
ted
life
style
,p
sych
oso
cial,
bel
tw
eari
ng,
dem
ogra
ph
icd
ata
.Jo
bs
cate
go
rize
din
tolift
ing
level
s
Nei
ther
back
rela
ted
wo
rker
sco
mp
ensa
tio
ncl
aim
sra
tes
or
self
-rep
ort
edb
ack
pain
wer
eass
oci
ate
dw
ith
freq
uen
tb
ack
bel
tu
seo
ra
bel
t-re
qu
irem
ent
sto
rep
olicy
.
Wo
rker
sco
mp
ensa
tio
nra
tera
tio
for
tho
sefr
equ
entl
yw
eari
ng
ver
sus
infr
equ
ent
wea
rers
was
1.2
an
dto
nev
erw
eare
rs0.9
5(n
ot
sign
ifica
nt)
,fo
rse
lf-r
epo
rts,
rate
rati
os
wer
e0.9
7an
d0.9
2re
spec
tivel
y(n
ot
sign
ifica
nt)
.N
osi
gn
ifica
nt
diff
eren
ces
inL
BP
by
bel
tu
sefo
rth
ose
inm
ost
stre
nu
ou
sjo
bca
tego
ries
(po
ssib
leex
po
sure
mis
class
ifica
tio
n).
Evalu
ated
po
ten
tial
sele
ctio
nb
ias.
Th
ose
no
tco
mp
leti
ng
follo
w-u
pin
terv
iew
2ti
mes
as
lik
ely
toh
ave
back
pain
bu
tn
od
iffer
ence
inb
elt
wea
rin
g.
Note:P¼
pri
mary
,S¼
seco
nd
ary
,T¼
tert
iary
,C
BT¼
cogn
itiv
eb
ehav
iora
lth
erap
y.
B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152 149
an orderlies’ intervention team implemented trainingand work practices changes when compared to the restof the hospital, noting a significant concomitantimprovement in psychosocial measures. Fanello [15]found no positive effect of ergonomics training onreducing LBP among non-clerical hospital workers.Smedley [53] found no change in low back pain preva-lence between nursing staff at an intervention hospital(policy, equipment, participatory link nurses) than at acontrol hospital (which had received a governmentinspection and implemented equipment and policychanges). Psychosocial factors improved at both hospi-tals. Both hospitals had decreases in manual handling.As the authors note, there was a significant loss to fol-low-up due to turnover. Health care assistants (higherexposure) were inadvertently omitted at follow-up inthe comparison hospital. The partial intervention at thecomparison hospital may have minimized differencesbetween hospitals. Wergeland [61] combined data onelder care workers from studies in Oslo, Helsinki andStockholm that evaluated the impact of a shorter workday/week on neck, shoulder and back pain. Neck–shoulder pain decreased in two of the interventiongroups and none of the referents, whereas back painremained. Fewer work hours had a positive effect onexhaustion, job satisfaction and social life butincreased labor costs. This may be partially mitigatedby fewer turnovers.
The prospective back belt study of Wassell et al. [60]should impress the most skeptical that back belt usagedoes not reduce back injuries in manual handlingpopulations. Marras et al. [37], in a less conventionalstudy design, provide more compelling evidence thatjob changes that actually reduce loads on the spinereduce reported LBP case reporting rates.
4. Discussion
As noted by Frank [17] and Zwerling [64], it isextremely difficult to randomize engineering controls inmultiple workplaces. It is much easier to randomizepersonal behavior (exercise, education, treatment).Nonetheless, there has been considerable progress inattempting randomized trials that involve more thaneducation and exercise [4,6,32,35,42,48,63]. Both ran-domized trials in the workplace and quasi-experimentalstudies were confronted with changes in workplacesthat were unplanned by the researchers and beyondtheir control. Stable worksites with large numbers ofworkers doing the same thing are largely a thing of thepast. It is crucial to record the strengths, limitationsand unforeseen circumstances that occur during thestudy in order that scientific inquiry may progress.
Although not shown in this review, there is much tobe learned from prospective studies that do not have
150 B. Silverstein, R. Clark / Journal of Electromyography and Kinesiology 14 (2004) 135–152
control groups. This is a weaker design but not withoutinformation. These studies are particularly vulnerableto the unforeseen bigger changes outside the control ofthe researcher. Wherever possible, control groups assimilar to the intervention group as possible should befound [55]. Zwerling [64] suggests a hierarchicalapproach, using the pre-post and case study designsfirst and then with the most promising interventions,devote more resources to stronger designed studies
This review of more recent studies updates and con-firms the overall impression of Karsh [26] that multi-component interventions have a greater chance of suc-cess than single interventions but can be overwhelmedby external forces. Individual modifying factors do notappear to be particularly useful in preventing WMSDsbut exercise appears to be effective in mitigating someof the consequences. More complete accounting ofpotential confounders and effect modifiers canstrengthen a number of these studies. It is important tomeasure compliance with intervention in terms of effecton exposure as well as health outcomes. In the work-place studies, participatory approaches were often butnot always successful (e.g. Smedley [53]). None of thesestudies, with the exception of Marras [37], attempted tomeasure exposure in a way that can be used to setthresholds. Prospective studies of working populationswithout intervention in which there are detailedexposure estimates would serve that purpose better,given the difficulty in implementing intervention stu-dies.
5. Conclusions
Intervention studies can be coupled with other epide-miological studies where there are different levels ofexposure with confounder adjustments to estimate thereduction in morbidity if the risk factors were notpresent. Laboratory studies also increase the precisionin estimates of exposure-load relationships that can beused to complete the picture for developing healthymusculoskeletal work environments. There is sufficientinformation to act now without the perfect being theenemy of the good [49].
Acknowledgements
We wish to thank Hieu Pham of SHARP for enter-ing studies into a bibliographic database.
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Dr. Barbara Silverstein is the Research
Director of the Washington State Depart-
ment of Labor & Industries Safety and
Health Assessment and Research for Preven-
tion (SHARP) Program. She received her
raphy and Kinesiology 14 (2004) 135–152
Master of Science degree from the University
of California San Francisco, her Master of
Public Health in Epidemiology and Environ-
mental and Industrial Health from the Uni-
versity of Michigan, and her PhD in
Epidemiologic Science from the University
of Michigan. She has worked on ergonomics-related issues at OSHA,
the University of Michigan Center for Ergonomics, the Finnish Insti-
tute of Occupational Health, and the California Department of
Health Services. Her major areas of research have been identification
and control of work-related musculoskeletal disorders, comparison of
surveillance methods and intervention studies to control these dis-
orders. She has conducted field research in a number of industries,
including electronics, meat, poultry and fish processing, newspaper
publishing, appliance manufacturing, medical equipment manufactur-
ing, office work environment, pulp and paper mills, aluminum mills,
saw mills, construction, automotive manufacturing, and nursing
homes. She serves on a number of national and international com-
missions and editorial boards regarding occupational safety and
health.
Randy Clark is a research analyst for the
Washington State Department of Labor and
Industries’ SHARP Program. His research
interests include the prevention of work-
related musculoskeletal disorders and work-
related fatal injuries.
