Kamwendo 1991

Methods	The study claims to be a controlled trial with randomly assigned participants. The study had two intervention groups and one control group. The intervention period lasted four weeks and follow‐up was conducted after six months. The study took place in Sweden. The year the study was conducted is not stated, but it must have been before 1991 when the article was published.
Participants	Medical secretaries were invited to be part of the study. The setting was a hospital where both interventions and follow‐up took place. The secretaries' major tasks were typing patient journals, letters and reports, in addition to telephone, mail an appointment duties. Inclusion criteria were having experienced some pain in either the neck or shoulder region during the previous year, and having estimated their average time of sitting during working hours to be a minimum of five hours daily. In addition, the inclusion criteria were having worked at least 30 hours a week and not being under medical treatment for their neck and shoulder problems. From a study of 420 medical secretaries, 119 fulfilled the initial inclusion criteria. After further screening 40 secretaries were excluded for different reasons, hence 79 secretaries were included in this trial. The participants were all females and the mean age was 39.4. They had worked as secretaries for an average of 9.6 years and 73% of them worked full time. The number of participants was 25, 28 and 26 in the intervention group 1, intervention group 2 and control group respectively. Three secretaries went on maternity leave during the study period and thus 76 remained at six months follow‐up. There is no information about how pain was defined in the selection of participants.  During the previous year 63% of the 420 secretaries had experienced neck pain. Of the sample of 119 participants all had experienced some pain in the neck or the shoulder region during the previous year.
Interventions	Intervention group 1: Traditional neck school. Participants in this group attended a four‐hour traditional neck school conducted by a therapist. Lectures were given twice weekly during working hours and consisted of a series of slides which included anatomy, aetiology of musculoskeletal disorders, ergonomics and self‐care measures. Part of each lecture was used to pause‐gymnastics in form of exercises using the neck and shoulder followed by relaxation. In addition, ergonomics of the workplace was demonstrated. Intervention group 2: Reinforced neck school. In addition to the above described neck school, the participants in this group received a variety of measures to enhance compliance. The participants were visited by a therapist at the workplace. Ergonomic adjustments were discussed. They were also interviewed by a psychologist on psychosocial and organizational factors. The total additional time allotted to this group was two hours per individual. Other methods to enhance compliance in this group were: 1) Only measures that the participants agreed upon were included in their individual program. 2) The participants received written information for a pause‐gymnastics program. 3) A written list of all measures agreed upon was given to the participants. 4) Participants were contacted for a follow‐up after three months. Control group: The control group was not offered any intervention until after completion of all follow‐up assessments.
Outcomes	Measurements were made baseline, after the four‐week intervention period and at six months follow‐up. The outcomes were: Expectancy: Four questions were used to measure expected outcome. The questions asked were how relevant the program was, whether it could be recommended to others, and how successful it might be for neck and shoulder, as well as for back pain. Each question had a ten‐point scale ranging from 1 'not at all relevant' to 10 'very relevant'. Ergonomic knowledge: A multiple choice questionnaire was constructed with 13 questions (range 0‐49 points) covering the neck school material. This test was applied in both intervention groups before and after neck‐school. The control group did not receive the test. Fatigue and pain: Daily ratings of muscular neck and shoulder fatigue and pain was carried out at work for a five days period. Ratings were conducted three or four times a day. A ten cm Visual Analogue Scale anchored by 'no pain' to ' considerable pain' was used. Work load: Estimated workload was rated daily using ten cm Visual Analogue Scale anchored by 'usually little to do' to 'unusually mush to do'. Range of motion: Active range of motion was measured at pre‐, post‐, and follow‐up periods, according to American Academy of Orthopedic Surgeons recommendations by means of a Myrin goniometer. Headache and low back pain: This was rated at pre‐, post, and follow‐up periods using a. ten cm Visual Analogue Scale anchored by 'no pain' to ' considerable pain'. Sickness absence: Information about sick leaves was obtained from the Swedish Social Insurance Agency. Diagnoses, number of sick leave occasions, and number of days on sick leave were registered. Interview information at follow‐up: Number of ergonomic changes the participants had implemented at work, number of pieces of equipment acquired, and number of visits to a physician, therapist or chiropractor for neck and shoulder pain or headache after the four week programme were registered. Adherence to individual programs for intervention group B was also registered.
Notes	Additional information about the study was found in another publication (Kamwendo 1991B). First author was contacted for missing information, but could not respond our questions, since the study is rather old.
Risk of bias
Bias	Authors' judgement	Support for judgement
Adequate sequence generation?	Low risk	Quote:“The subjects were randomly assigned to a control group or one of two interventions groups.” No details are given on how the randomisation procedure was performed. First author was contacted for clarification, but could not respond, since the study is rather old. We think that the method of randomisation most likely was adequate, but the information available is limited.
Allocation concealment?	Unclear risk	No information is given on allocation concealment in the article or provided by author on request.
Blinding? All outcomes ‐ participants?	High risk	No detailed information is given, but it is not likely that the participants could be blinded to the intervention.
Blinding? All outcomes ‐ providers?	High risk	No detailed information is given, but it is not likely that the care providers could be blinded to the intervention.
Blinding? All outcomes ‐ outcome assessors?	Unclear risk	The outcome assessor may have been blinded, but it is not clear in the text if the research team and the intervention team were separate.
Incomplete outcome data addressed? All outcomes ‐ drop‐outs?	Unclear risk	Even though 76 out of 79 participants remained in the study at the end, it is quite uncertain that there is data for all the 76 individuals regarding the main outcome variable.
Incomplete outcome data addressed? All outcomes ‐ ITT analysis?	Unclear risk	Intention‐to‐treat analyses are not reported. Author could not clarify this matter.
Free of selective reporting?	Low risk	No selective reporting is suspected in this article.
Similarity of baseline characteristics?	Unclear risk	No information comparing the three groups at baseline is given.
Co‐interventions avoided or similar?	Low risk	No information is given on co‐interventions, but it seems unlikely.
Compliance acceptable?	Low risk	Quote: “Consequently, the failure of this study to demonstrate a decrease in neck or shoulder discomfort did not occur as a result of poor compliance, rather despite good compliance”. Attendance to neck school was 100% in intervention group 1 and 98% in intervention group 2, which is very acceptable.
Timing outcome assessments similar?	Low risk	The timing of the outcomes was the same for all three groups.