Workplace interventions for increasing standing or walking for decreasing musculoskeletal symptoms in sedentary workers

Sharon P Parry; Pieter Coenen; Nipun Shrestha; Peter B O'Sullivan; Christopher G Maher; Leon M Straker

doi:10.1002/14651858.CD012487.pub2

. 2019 Nov 19;2019(11):CD012487. doi: 10.1002/14651858.CD012487.pub2

Workplace interventions for increasing standing or walking for decreasing musculoskeletal symptoms in sedentary workers

Sharon P Parry ^1,^✉, Pieter Coenen ^1,², Nipun Shrestha ³, Peter B O'Sullivan ¹, Christopher G Maher ⁴, Leon M Straker ¹

Editor: Cochrane Work Group

PMCID: PMC6953379 PMID: 31742666

Abstract

Background

The prevalence of musculoskeletal symptoms among sedentary workers is high. Interventions that promote occupational standing or walking have been found to reduce occupational sedentary time, but it is unclear whether these interventions ameliorate musculoskeletal symptoms in sedentary workers.

Objectives

To investigate the effectiveness of workplace interventions to increase standing or walking for decreasing musculoskeletal symptoms in sedentary workers.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, OSH UPDATE, PEDro, ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal up to January 2019. We also screened reference lists of primary studies and contacted experts to identify additional studies.

Selection criteria

We included randomised controlled trials (RCTs), cluster‐randomised controlled trials (cluster‐RCTs), quasi RCTs, and controlled before‐and‐after (CBA) studies of interventions to reduce or break up workplace sitting by encouraging standing or walking in the workplace among workers with musculoskeletal symptoms. The primary outcome was self‐reported intensity or presence of musculoskeletal symptoms by body region and the impact of musculoskeletal symptoms such as pain‐related disability. We considered work performance and productivity, sickness absenteeism, and adverse events such as venous disorders or perinatal complications as secondary outcomes.

Data collection and analysis

Two review authors independently screened titles, abstracts, and full‐text articles for study eligibility. These review authors independently extracted data and assessed risk of bias. We contacted study authors to request additional data when required. We used GRADE considerations to assess the quality of evidence provided by studies that contributed to the meta‐analyses.

Main results

We found ten studies including three RCTs, five cluster RCTs, and two CBA studies with a total of 955 participants, all from high‐income countries. Interventions targeted changes to the physical work environment such as provision of sit‐stand or treadmill workstations (four studies), an activity tracker (two studies) for use in individual approaches, and multi‐component interventions (five studies). We did not find any studies that specifically targeted only the organisational level components. Two studies assessed pain‐related disability.

Physical work environment

There was no significant difference in the intensity of low back symptoms (standardised mean difference (SMD) ‐0.35, 95% confidence interval (CI) ‐0.80 to 0.10; 2 RCTs; low‐quality evidence) nor in the intensity of upper back symptoms (SMD ‐0.48, 95% CI ‐.96 to 0.00; 2 RCTs; low‐quality evidence) in the short term (less than six months) for interventions using sit‐stand workstations compared to no intervention. No studies examined discomfort outcomes at medium (six to less than 12 months) or long term (12 months and more). No significant reduction in pain‐related disability was noted when a sit‐stand workstation was used compared to when no intervention was provided in the medium term (mean difference (MD) ‐0.4, 95% CI ‐2.70 to 1.90; 1 RCT; low‐quality evidence).

Individual approach

There was no significant difference in the intensity or presence of low back symptoms (SMD ‐0.05, 95% CI ‐0.87 to 0.77; 2 RCTs; low‐quality evidence), upper back symptoms (SMD ‐0.04, 95% CI ‐0.92 to 0.84; 2 RCTs; low‐quality evidence), neck symptoms (SMD ‐0.05, 95% CI ‐0.68 to 0.78; 2 RCTs; low‐quality evidence), shoulder symptoms (SMD ‐0.14, 95% CI ‐0.63 to 0.90; 2 RCTs; low‐quality evidence), or elbow/wrist and hand symptoms (SMD ‐0.30, 95% CI ‐0.63 to 0.90; 2 RCTs; low‐quality evidence) for interventions involving an activity tracker compared to an alternative intervention or no intervention in the short term. No studies provided outcomes at medium term, and only one study examined outcomes at long term.

Organisational level

No studies evaluated the effects of interventions solely targeted at the organisational level.

Multi‐component approach

There was no significant difference in the proportion of participants reporting low back symptoms (risk ratio (RR) 0.93, 95% CI 0.69 to 1.27; 3 RCTs; low‐quality evidence), neck symptoms (RR 1.00, 95% CI 0.76 to 1.32; 3 RCTs; low‐quality evidence), shoulder symptoms (RR 0.83, 95% CI 0.12 to 5.80; 2 RCTs; very low‐quality evidence), and upper back symptoms (RR 0.88, 95% CI 0.76 to 1.32; 3 RCTs; low‐quality evidence) for interventions using a multi‐component approach compared to no intervention in the short term. Only one RCT examined outcomes at medium term and found no significant difference in low back symptoms (MD ‐0.40, 95% CI ‐1.95 to 1.15; 1 RCT; low‐quality evidence), upper back symptoms (MD ‐0.70, 95% CI ‐2.12 to 0.72; low‐quality evidence), and leg symptoms (MD ‐0.80, 95% CI ‐2.49 to 0.89; low‐quality evidence). There was no significant difference in the proportion of participants reporting low back symptoms (RR 0.89, 95% CI 0.57 to 1.40; 2 RCTs; low‐quality evidence), neck symptoms (RR 0.67, 95% CI 0.41 to 1.08; two RCTs; low‐quality evidence), and upper back symptoms (RR 0.52, 95% CI 0.08 to 3.29; 2 RCTs; low‐quality evidence) for interventions using a multi‐component approach compared to no intervention in the long term. There was a statistically significant reduction in pain‐related disability following a multi‐component intervention compared to no intervention in the medium term (MD ‐8.80, 95% CI ‐17.46 to ‐0.14; 1 RCT; low‐quality evidence).

Authors' conclusions

Currently available limited evidence does not show that interventions to increase standing or walking in the workplace reduced musculoskeletal symptoms among sedentary workers at short‐, medium‐, or long‐term follow up. The quality of evidence is low or very low, largely due to study design and small sample sizes. Although the results of this review are not statistically significant, some interventions targeting the physical work environment are suggestive of an intervention effect. Therefore, in the future, larger cluster‐RCTs recruiting participants with baseline musculoskeletal symptoms and long‐term outcomes are needed to determine whether interventions to increase standing or walking can reduce musculoskeletal symptoms among sedentary workers and can be sustained over time.

Plain language summary

Workplace interventions for increasing standing or walking for decreasing musculoskeletal symptoms in sedentary workers

Why is it important to increase standing or walking at work?

The number of people working in sedentary jobs has increased in recent decades. Many of these people complain of musculoskeletal symptoms. Walking or standing interventions at work have been effective in reducing sitting time at work. However, it is still unclear if these interventions are effective in reducing the intensity or presence of musculoskeletal symptoms among office workers.

The purpose of this review  We wanted to find out the effects of interventions aimed at increasing standing or walking for decreasing musculoskeletal symptoms in sedentary workers. We searched the literature in various databases up to January 2019.

What trials did review authors find?  We found 10 studies conducted with a total of 955 employees with musculoskeletal complaints from high‐income countries. Four studies evaluated changes to the physical work environment through provision of sit‐stand or treadmill workstations, two studies evaluated individual approaches involving use of an activity tracker, and five studies used multi‐component interventions and counselling interventions. However, no studies solely targeted interventions at the organisation level.

Effects of changes to the physical work environment

The available evidence is insufficient to show the effectiveness of sit‐stand desk or treadmill workstations in reducing the intensity of low back and upper back symptoms.

Effects of interventions targeted at the individual

The effectiveness of an activity tracker compared to an alternative intervention or no intervention in reducing the intensity or presence of low back, upper back, neck, shoulder, and elbow/wrist and hand symptoms cannot be determined based on available evidence at short‐term follow‐up (less than six months).

Effects of interventions targeted at the organisation

No available studies have examined the effectiveness of interventions targeted solely at the organisational level.

Effects of combining multiple interventions

Available evidence is insufficient to show the effectiveness of combining multiple interventions in reducing the proportions of people with low back or upper back pain at short‐term follow‐up (less than six months), medium‐term follow‐up (between six and 12 months), or long‐term follow‐up (12 months or longer).

Conclusions

The review did not find conclusively that interventions to increase standing or walking are effective in reducing the intensity or presence of musculoskeletal symptoms among sedentary workers in the short, medium, or long term. This may be due in part to the quality of the evidence, which is low or very low largely due to study design and small sample sizes. Some interventions that targeted changes to the work environment such as the use of sit‐stand desks are suggestive of an improvement in musculoskeletal symptoms. Therefore, additional studies of larger scale and longer duration that recruit people with baseline musculoskeletal symptoms are needed to determine whether interventions to increase standing or walking can reduce musculoskeletal symptoms among sedentary workers, and whether these changes can be maintained.

Summary of findings

Background

Description of the condition

Musculoskeletal symptoms (such as pain and discomfort in various body areas including back, neck, and lower and upper extremities) are a common problem, with approximately 40% of the general population reporting pain annually (Hoy 2012), and with transient pain at high risk for eventually leading to chronic symptoms (Kovacs 2005). Musculoskeletal symptoms are among the most prevalent occupational problems (Andersen 2007; Janwantanakul 2008), placing a large burden on the working population. Among the top ten causes of years lived with disability, low back pain and neck pain are ranked first and fourth, respectively (GBDSC 2015); they also impact medical costs, work productivity, work disability, and absenteeism (Bevan 2015; Buchbinder 2013; CDC 2013; Lambeek 2011).

In particular among sedentary workers, the prevalence of musculoskeletal symptoms is high (Cho 2012), and these symptoms are reported in more than 90% of office workers (Widanarko 2011). Occupational sedentary behaviour has been associated with musculoskeletal symptoms including pain in the low back and in the lower extremities (Al‐Eisa 2006; Messing 2008; Reid 2010). Spinal loading associated with sustained sitting (Pope 2002), increased activation of spinal muscles in specific sitting postures (Curran 2015; Waongenngarm 2015), and lack of variation in movement is among suggested mechanisms explaining the occurrence of musculoskeletal symptoms during sitting (Srinivasan 2012). Moreover, prolonged keyboard and mouse use, high mental workload, and stress are hypothesised to contribute to the occurrence of musculoskeletal symptoms among sedentary office workers (Chiu 2002; Cho 2012; Coenen 2019; Hannan 2005; Hush 2009; Huysmans 2012; Jensen 2003; Kiss 2012). Despite this, evidence of an association between sedentary behaviour and the occurrence of musculoskeletal symptoms remains inconsistent (Bakker 2009; Chen 2009; da Costa 2010; Lin 2011; Waersted 2010).

Innovations in technology have resulted in a shift of the workforce into more sedentary roles (Borodulin 2007; Brownson 2005; Juneau 2010), causing a substantial increase in sedentary occupations in developed countries over past decades (Church 2011; Kohl 2012). Recent studies of accelerometer determined sedentary time estimate that office workers spend 77% to 82% of their working time being sedentary (Parry 2013; Thorp 2012). This large amount of sedentary time at work combined with its musculoskeletal (and other) health risks underlines the importance of gaining a better understanding of the development of musculoskeletal symptoms in sedentary workers.

Description of the intervention

As sedentary workers can spend most working hours in sedentary activities (Parry 2013; Thorp 2012), the workplace is a convenient and practical venue for targeting interventions to modify these behaviours. Growing evidence suggests that these interventions might reduce or break up sedentary behaviour (Commissaris 2016; Shrestha 2018), thereby reducing cardiometabolic risk factors (Peddie 2013; Thorp 2014a). However, the impact of these interventions on reducing musculoskeletal symptoms is not well understood. Workplace interventions that will be examined in this review are interventions that specifically aim to reduce or break up sedentary behaviour by increasing standing or walking, which may fall into the following categories.

Interventions targeted at the physical work environment – including provision of an activity permissive workstation such as a treadmill or a sit‐stand workstation, or changes to the built environment.
Interventions targeted at the individual – including tailored walking programmes during work breaks or ‘incidental’ walking programmes, promoting the use of stairs during work hours, providing break‐reminding software, and providing individual counselling programmes.
Interventions targeted at the organisation – such as workplace policy modifications to encourage workplace activity, for example, standing meetings and ‘active/walking’ emails.

Workplace interventions may also be multi‐component, whereby a combination of intervention approaches is employed.

How the intervention might work

Alternatives to sitting, such as standing and walking, may result in improvement in musculoskeletal symptoms (intensity or presence of symptoms or pain‐related disability) by reducing or breaking up prolonged sitting, thereby modifying the sustained spinal load that occurs in prolonged sitting. Breaking up periods of prolonged sitting by standing or walking can increase muscle activity and can create movement and postural variation, reducing the risk of static muscle overload and increasing blood circulation (Srinivasan 2012; Tikkanen 2013). Interventions that promote the graded introduction of standing and walking may therefore improve the general musculoskeletal health of workers. This is supported by findings from recent systematic reviews of laboratory studies showing that interventions targeted at breaking up sitting, in particular those involving sit‐stand workstations, were effective in reducing musculoskeletal discomfort (Healy 2012; Karakolis 2014; Thorp 2014b).

However, alternatives to sitting (e.g. standing, walking) have also been associated with musculoskeletal symptoms. Occupational standing has been linked with musculoskeletal symptoms, including pain in the low back (Andersen 2007; Coenen 2017; Tissot 2009), as well as in the lower extremities (Messing 2008; Reid 2010). Associations between musculoskeletal pain and non‐neutral (e.g. sway, lordotic) lumbar postures during standing have been reported (O'Sullivan 2011), with the proposed mechanism of altered patterns of loading on the spine (Smith 2017; van Deursen 2005). Other study authors have reported increased patterns of trunk muscle activity linked to musculoskeletal symptoms in sustained standing (Gregory 2008; Nelson‐Wong 2010). Potential mechanisms include muscle fatigue (Balasubramanian 2009), along with swelling of the lower limbs due to blood pooling (Chester 2002). However, evidence conclusively supporting the above hypotheses is lacking. Associations between occupational walking and the occurrence of musculoskeletal symptoms (including leg pain) have been reported (Engels 1996), but evidence is inconclusive (Roffey 2010). However, recent evidence about thresholds for prolonged standing suggest that standing in excess of 40 minutes could be associated with adverse musculoskeletal effects (Coenen 2017).

Therefore, although reduced occupational sitting may result in improvement of some musculoskeletal symptoms, replacing it with standing or walking may cause alternate problems. For example, in a study among bank tellers who just sat, just stood, or alternated sitting and standing every 30 minutes, it was shown that workers had greater discomfort in the upper limbs while sitting, and greater discomfort in the lower limbs while standing (Roelofs 2002). This is highlighted in a review examining the effects of activity permissive workstations among office workers (i.e. sit‐stand workstations, but also under‐desk cycling and treadmill workstations), which reported both beneficial and detrimental effects on musculoskeletal outcomes (Neuhaus 2014b).

Given that there may be individual vulnerability to musculoskeletal discomfort in standing and sitting, the response to standing or walking interventions is likely to vary between workers (Gregory 2008). Personal factors, such as gender (Hooftman 2004), age (Viester 2013), and adiposity (Hooftman 2004; Moreira‐Silva 2013; Oha 2014), are known to play a role in the occurrence and recurrence of musculoskeletal symptoms among workers. Such factors may impact the effectiveness of these interventions.

Why it is important to do this review

Musculoskeletal disorders contribute significantly to the global burden of disease (GBDSC 2015), and they are associated with substantial economic and productivity costs within work settings (Bevan 2015; Buchbinder 2013). Sedentary workers report a high prevalence of musculoskeletal symptoms (Cho 2012; Harcombe 2009; Janwantanakul 2008), and they may be at increased risk of adverse cardiometabolic, cancer, and even mental health outcomes (Carson 2014; Chau 2014; Dunstan 2012; Parry 2013; Straker 2014; Vallance 2011). Because of these risks, there has been a rapid increase in workplace interventions provided to reduce sedentary behaviour, such as the introduction of activity permissive workstations. However, it is not clear whether such workplace changes aimed at reducing sedentary behaviour will have any impact on musculoskeletal symptoms.

Previous reviews have focused on workplace interventions to increase physical activity (Freak‐Poli 2013), or to reduce sitting (Shrestha 2018), but these reviews have not specifically explored the potential impact of changing workplace activity on musculoskeletal symptoms. Therefore, in relation to interventions that aim to reduce workplace sedentary behaviour by increasing standing or walking, it is important to examine not only changes to sedentary behaviour and cardiometabolic health outcomes, as considered in previous reviews, but also musculoskeletal health. The findings of this review will provide evidence to assist in the management of work‐related musculoskeletal symptoms.

This is a partner to another review on similar workplace interventions for preventing, rather than decreasing, musculoskeletal symptoms in sedentary workers (Parry 2017a).

Objectives

To investigate the effectiveness of workplace interventions to increase standing or walking for decreasing musculoskeletal symptoms in sedentary workers.

Methods

Criteria for considering studies for this review

Types of studies

We have included all eligible randomised controlled trials (RCTs), quasi‐RCTs (in which methods of allocating participants are not random, such as alternate allocation or allocation by date of birth or day of the week), and cluster‐RCTs (randomisation of a group of people such as a work group or workplace rather than randomisation of individual people). For some workplace interventions, the implementation of interventions is difficult to apply to an individual, so interventions operate on a group level (Ijaz 2014). In this situation, when the intervention takes place at a group level or within the one organisation where due to workplace or environmental restrictions, randomisation is not possible, we have also included controlled before‐and‐after studies (CBAs), which use a concurrent control group for the intervention. We have included studies reported as full text, those published as abstract only, and unpublished data.

Types of participants

We have included studies conducted with adult workers aged 18 or older, working in sedentary occupations (workers sedentary for more than 50% of the working day), such as seated office workers and laboratory technicians. We have excluded sedentary workers for whom it may not be possible to modify workplace posture, such as transport workers. Studies that did not report the proportion of sedentary time but described workers as ‘sedentary workers’ have been included. When studies included workers from different occupations, we included only results from participants identified as ‘sedentary workers’, or we reported sedentary time of more than 50%. We excluded studies that specifically focused on participants with the following comorbidities or characteristics.

Inflammatory systematic diseases such as rheumatoid arthritis.
Diseases of the central nervous system such as stroke and multiple sclerosis.

Sedentary workers who report the presence of musculoskeletal symptoms in at least one of the following regions ‐ cervical spine, mid‐back, lower back, upper limb, hip, or lower limb ‐ have been included as participants with symptoms.

In studies that include a mixture of participants reporting and not reporting musculoskeletal symptoms, only participants with symptoms at baseline have been included in the analyses.

We have included studies conducted with participants who report pain. ‘Participants with pain’ thresholds are defined as:

‘yes’ on a dichotomous symptom scale;
‘greater than 0’ on a visual analogue symptoms scale out of 10;
‘greater than 0’ on a numerical rating scale out of 10;
‘greater than 0’ on the McGill Pain Questionnaire;
‘greater than 0’ on the 18‐, 23‐, or 24‐point version of the Roland Morris Disability Questionnaire; or
‘greater than 0%' for overall score on the Oswestry Disability Index.

Types of interventions

We included trials that evaluated the effectiveness of interventions to reduce or break up workplace sitting by encouraging standing or walking at the workplace. Eligible interventions include the following.

Interventions targeted at the physical work environment.
- Provision of an activity permissive workstation (sit/stand or treadmill).
- Interventions that modify the built environment such as modifications to office layout that encourage standing or walking.
Interventions targeted at the individual.
- Behavioural modification or counselling programmes that promote increased standing or walking.
- Working style interventions that promote standing or walking, such as promotion of 'active' work breaks.
- Workplace walking programmes including ‘pedometer challenges’.
- Promoting the use of stairs during work hours.
- Using break‐reminding software.
Interventions targeted at the organisation.
- Workplace policy modifications such as standing meetings and ‘active/walking’ emails.

We included multi‐component trials that combine elements of the above interventions.

We included trials that compare the effectiveness of workplace interventions to increase standing or walking with usual care, with no intervention, or with another active intervention such as specific targeted musculoskeletal interventions.

We excluded interventions that focus on specific strengthening or stretching programmes that do not promote standing or walking. For example, an exercise programme that replaces sedentary time (with standing or walking) would be included as an intervention, whereas a seated exercise programme (seated stretching/strengthening programme) would not be included.

Types of outcome measures

Primary outcomes

We included trials that evaluated the effectiveness of interventions for self‐reported musculoskeletal symptoms by body region.

Musculoskeletal symptoms may be reported as pain on a scale (as listed below) or may be reported as 'discomfort' or 'trouble' on similar scales.
- Presence of musculoskeletal symptoms may be reported on a dichotomous scale (yes/no) by outcome measures such as the Nordic Musculoskeletal Questionnaire (Kuorinka 1987).
- Intensity of musculoskeletal symptoms may be reported on a visual analogue scale (or similar), a numerical rating scale, a Likert scale (Bond 1966; Harland 2015), or a McGill Pain Questionnaire (Melzack 1975).
Impact of pain such as pain‐related disability.

- Disability may be assessed by outcome measures such as the Oswestry Disability Index, the Roland Morris Disability Questionnaire (Roland 2000), or the Neck Disability Index (Vernon 2008).

Secondary outcomes

The following secondary outcomes were reported.

Work performance and productivity.
- Level of work function, change in work productivity, work time loss assessed by outcome measures such as the Work Ability Index (de Zwart 2002; van den Berg 2008).
Sickness absenteeism.
Adverse events such as venous disorders or perinatal complications.

Reporting one or more of the secondary outcomes listed here was not an inclusion criterion for this review. In addition, secondary outcomes were used only to support the conclusions of the primary outcomes and not to draw conclusions on the effectiveness of the interventions.

The primary measurement time points have been short term (less than six months). We have categorised additional follow‐up times as medium term (six months to less than 12 months) and long term (12 months or longer).

Search methods for identification of studies

Electronic searches

We conducted a systematic literature search to identify all published and unpublished trials that can be considered eligible for inclusion in this review. The literature search identified studies in all languages. We arranged for the translation of key sections of potentially eligible non‐English language papers, or we arranged that people who are proficient in the language of the publications fully assess them for potential inclusion in the review as necessary.

We searched the following electronic databases from inception to January 2019.

The Cochrane Central Register of Controlled Trials (CENTRAL), in the Wiley Online Library.
MEDLINE (PubMed).
Embase (embase.com).
National Institute for Occupational Safety and Health's (NIOSH) electronic, bibliographic database of literature in the field of occupational safety and health (NIOSHTIC) (Occupational Safety and Health (OSH)‐UPDATE).
NIOSHTIC‐2 (OSH‐UPDATE).
UK Health and Safety Executive Information Services (HSELINE) (OSH‐UPDATE).
Archived OSH Bibliographic Datbase (CISDOC) (OSH‐UPDATE).
Physiotherapy Evidence Database (PEDro).

We also conducted a search of unpublished trials at ClinicalTrials.gov (www.ClinicalTrials.gov) and at the World Health Organization (WHO) trials portal (www.who.int/ictrp/en/). We imposed no restrictions on language of publication.

Searching other resources

We checked the reference lists of all primary studies and review articles for additional references. We contacted experts in the field to identify additional unpublished materials.

Data collection and analysis

Selection of studies

We conducted the selection of eligible studies in two stages. First, two review authors (SP and PC) independently screened titles and abstracts of all potentially relevant studies identified through our systematic search to identify studies for inclusion. The same review authors coded them as 'include' (eligible or potentially eligible/unclear) or 'exclude'. At this stage, we excluded all references that clearly do not fulfil our inclusion criteria or that do fulfil our exclusion criteria. At the second stage, we retrieved the full‐text study reports/publications, and two review authors (SP and PC) independently assessed the full text and identified studies for inclusion. At this stage, we included all references that do fulfil our inclusion criteria. We recorded reasons for exclusion of ineligible studies assessed as full texts, so that we could report these in a Characteristics of excluded studies table. We resolved any disagreement through discussion, or, if required, we consulted a third review author (NS). We identified and excluded duplicates and collated multiple reports of the same study, so that each study rather than each report is the unit of interest in the review. We recorded the selection process in sufficient detail to complete a PRISMA study flow diagram.

When our systematic searches identified studies conducted by authors of this review, we avoided conflicts of interest by having all decisions concerning inclusion and exclusion made by review authors who were not involved with the study.

Data extraction and management

We used a data collection form for study characteristics and outcome data that had been piloted on at least one study in the review. Two review authors (SP and PC) extracted the following study characteristics from included studies.

Study authors and year of publication.
Methods: study design, total duration of study, study location, study setting, withdrawals, date of study.
Participants: N, mean age or age range, sex/gender, severity of condition, intensity of sedentary work (percentage of workday sedentary), type of sedentary work, diagnostic criteria if applicable, inclusion criteria, exclusion criteria.
Interventions: description of intervention, comparison, duration, intensity, content of both intervention and control conditions, co‐interventions.
Outcomes: description of primary and secondary outcomes specified and collected, time points reported.
Notes: funding for trial, notable conflicts of interest of trial authors.

Two review authors (SP and PC) independently extracted outcome data from included studies. We noted in the Characteristics of included studies table if outcome data were not reported in a usable way. We resolved disagreements by consensus or by involving a third review author (NS). One review author (NS) transferred data into the Review Manager file (RevMan 2014). We double‐checked that data were entered correctly by comparing the data presented in the systematic review with the study reports. A second review author (PC) spot‐checked study characteristics for accuracy against the trial report. When included studies published in one or more languages in which our author team is not proficient, we arranged for a native speaker or someone sufficiently qualified in each foreign language to fill in a data extraction form for us.

Assessment of risk of bias in included studies

Two review authors (SP and PC) independently assessed risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved any disagreements by discussion or by consultation with another review author (NS). We assessed risk of bias according to the following domains.

Random sequence generation.
Allocation concealment.
Blinding of participants and personnel.
Blinding of outcome assessment.
Incomplete outcome data.
Selective outcome reporting.
Other bias such as baseline imbalance.

In addition, if cluster‐randomised trials were identified and included in the review, we considered the following additional biases.

Recruitment bias.
Baseline imbalance.
Loss of clusters.
Incorrect analysis.
Comparability with individually randomised trials.

We graded each potential 'Risk of bias' item as high, low, or unclear, and we provided a quote from the study report together with a justification for our judgement in the 'Risk of bias' table. We summarised 'Risk of bias' judgements across different studies for each of the domains listed. We considered blinding separately for different key outcomes when necessary (e.g. for unblinded outcome assessment, risk of bias for work productivity may be very different than for a patient‐reported pain scale). When information on risk of bias related to unpublished data or correspondence with a trialist, we noted this in the 'Risk of bias' table.

We consider allocation concealment, blinding of participants and outcome assessors, and incomplete outcome data to be key domains. We judged a study to have high risk of bias when one or more key domains had high risk of bias. Conversely, we judged a study to have low risk of bias when we judged that most of the key domains had low risk of bias.

For CBA studies, we used the instrument for appraising risk of bias of CBA studies validated by Downs (Downs 1998). The instrument has been shown to have good reliability and internal consistency and validity. The list consists of five different subscales: reporting, external validity, bias, confounding, and power. We used the combined score on the two internal validity subscales (bias and confounding) to judge risk of bias only for the included CBA studies. We used an arbitrary cut‐off score of 50% of the maximum attainable score of the internal validity scale to discern low from high risk of bias. We modified the criteria for risk of bias so that they fit the 'Risk of bias' tool as implemented in RevMan by changing them from 0 and 1 to high, low, and unclear (RevMan 2014).

We also checked for relevant and considerable baseline differences between control and intervention groups based on age and gender.

When considering treatment effects, we took into account the risk of bias for studies that contributed to that outcome.

Assessment of bias in conducting the systematic review

We conducted the review according to the published protocol and reported any deviations from it in the Differences between protocol and review section of the systematic review.

Measures of treatment effect

We entered the outcome data for each study into the data tables in RevMan to calculate treatment effects (RevMan 2014). We used odds ratio/risk ratio for dichotomous outcomes, and mean differences or standardised mean differences for continuous outcomes, or another type of data as reported by study authors. For outcomes reported as dichotomous data in some studies and as continuous data in other studies, we re‐expressed the odds ratio as the standardised mean difference. This method assumes logistic distribution and comparable variability for both intervention and control groups according to the methods described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). If only effect estimates and their 95% confidence intervals or standard errors were reported in studies, we entered these data into RevMan using the generic inverse variance method. We ensured that higher scores for continuous outcomes have the same meaning for the particular outcome, explained the direction to the reader, and reported where the directions were reversed if this was necessary. When results could not be entered either way, we described them in the Characteristics of included studies table, or we entered the data into additional tables.

Unit of analysis issues

For studies that employ a cluster‐randomised design and that report sufficient data for inclusion in the meta‐analysis but do not make an allowance for the design effect, we calculated the design effect based on a fairly large assumed intracluster correlation of 0.10. We based this assumption of 0.10 being a realistic estimate by analogy on studies about implementation research (Campbell 2001). We followed the methods provided in the Cochrane Handbook for Systematic Reviews of Interventions when performing the calculations (Higgins 2011).

Dealing with missing data

We contacted investigators or study sponsors to verify key study characteristics and to obtain missing data when possible (e.g. when a study is identified as abstract only). When this was not possible, and missing data were thought to introduce serious bias, we explored the impact of including such studies in the overall assessment of results by performing a sensitivity analysis.

If data such as standard deviations or correlation coefficients were missing and they could not be obtained from the study authors, we calculated them from other available statistics such as P values according to the methods described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

Assessment of heterogeneity

We assessed the clinical homogeneity of the results of included studies based on similarity of population, intervention, outcome, and follow‐up. We considered populations as similar when sedentary work is being conducted for more than 50% of working hours, or when participants are described as 'sedentary workers'. Populations that report musculoskeletal symptoms in one or more body region, of any intensity, were considered as similar. We considered interventions as similar when they target workplace sedentary behaviour by promoting standing or walking according to the category of the intervention as defined under Types of interventions. We did not consider interventions that implement exercise or educational programmes to target specific muscle groups such as neck/shoulder or low back exercise as similar to sedentary behaviour modification programmes (as stated under Types of interventions). We considered all outcome measures of pain or discomfort including dichotomous measures, Likert scale, visual analogue scale, and standardised questionnaires such as the Nordic Musculoskeletal Questionnaire as similar. For measurement of work performance, pain‐related disability, and work productivity, we considered all self‐reported outcomes from standardised questionnaires (e.g. Work Performance Index, Neck Disability Index) as similar. We regarded follow‐up times of up to six months as short term, from six months to less than 12 months as medium term, and from 12 months onward as long‐term outcomes, and we treated these outcomes as different.

Assessment of reporting biases

We were not able to pool more than five trials in any single meta‐analysis; therefore we did not explore possible small‐study biases using a funnel plot.

Data synthesis

We pooled data from studies judged to be clinically homogeneous using Review Manager 5.3 software (RevMan 2014). If more than one study provided usable data in any single comparison, we performed a meta‐analysis. We calculated the standardised mean difference when data for the same outcome were presented in some studies as dichotomous data and in other studies as continuous data (Section 9.4.6, Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011)), or when studies measured the same outcome on different scales. We used a random‐effects model when I² was above 40%; otherwise we used a fixed‐effect model. When I² was higher than 75%, we did not pool study results in a meta‐analysis.

We narratively described skewed data reported as medians and interquartile ranges.

When multiple trial arms were reported in a single trial, we included only the relevant arms. When two comparisons (e.g. provision of sit‐stand desk vs standard desk and behavioural modification vs standard desk) were combined in the same meta‐analysis, we halved the control group to avoid double‐counting.

We considered minimally important differences for validated outcome measures when we discussed the magnitude of the effect size. We considered pooled effect sizes greater than the minimally important difference to be clinical significant.

'Summary of findings' table

We reported the presence or intensity of musculoskeletal symptoms for the following regions ‐ low back, upper back, neck, and shoulder ‐ and disability at short‐term follow‐up in the 'Summary of findings' table.

We used the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness, and publication bias) to assess the quality of a body of evidence as it relates to studies that contributed data to the meta‐analyses for pre‐specified outcomes. We used methods and recommendations as described in Section 8.5 and Chapter 12 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011), using GRADEpro software. We justified all decisions to downgrade or upgrade the quality of evidence by using footnotes.

Subgroup analysis and investigation of heterogeneity

We planned to carry out the following subgroup analyses.

Intervention approach (workstation design, workplace built environment, workplace policy, interventions in non‐productive periods (work breaks)).
Intervention effects on different body regions (cervical spine, mid‐back, lower back, upper limb/shoulder, lower limb).
Participant characteristics (age, gender, body mass index).
Participant work group characteristics (specific occupations).

We planned to use the following outcomes in subgroup analyses.

Musculoskeletal symptoms (pain/discomfort).
Pain‐related disability.

As studies were insufficient, we were not able to conduct planned subgroup analyses.

Sensitivity analysis

We planned to perform sensitivity analyses to determine whether our findings are affected by high risk of bias and baseline pain of low intensity. To perform sensitivity analysis, we defined ‘high quality’ as studies with appropriate random allocation and concealment and attrition bias of less than 20%. We defined the low‐intensity pain threshold as 3 out of 10 on a pain intensity scale (Moore 2013). As studies were insufficient, we were not able to conduct the planned sensitivity analyses.

Reaching conclusions

We based our conclusions only on findings from the quantitative or narrative synthesis of included studies for this review. We avoided making recommendations for practice based on more than just the evidence, such as values and available resources. Our implications for research have suggested priorities for future research and have outlined remaining uncertainties in this area.

Results

Description of studies

See Figure 1, Characteristics of included studies, Characteristics of excluded studies, and Characteristics of ongoing studies.

Results of the search

We conducted systematic electronic database searches and handsearching of the literature. In total, we identified 5420 studies through electronic database searching and found four studies in other sources (January 2019): 51 from the Cochrane Central Register of Controlled Trials (CENTRAL; Appendix 1); 781 from the Cumulative Index to Nursing and Allied Health Literature (CINAHL; Appendix 2); 2169 from Embase (Appendix 3); 2308 from MEDLINE (Appendix 4); 16 from the Occupational Safety and Health (OSH) UPDATE (Appendix 5); 95 from the Physiotherapy Evidence Database (PEDro; Appendix 6); 2 from ClinicalTrials.gov (Appendix 7); and 0 from the World Health Organization (WHO) trials search portal (Appendix 8). We found three additional papers by reviewing the reference lists of the included papers and systematic reviews. After removal of duplicate studies, 4942 studies remained. After title and abstract screening, we retrieved 77 studies for full‐text screening. Of these studies, we excluded 64 studies (see Excluded studies), classified one study as awaiting classification (study authors could not be contacted), and found two ongoing studies that could not be included. Therefore, we included ten studies in this review.

Included studies

Study design

Eight studies that were included in the review were randomised controlled trials (RCTs). Of these, five were cluster‐RCTs (Brakenridge 2016; Danquah 2017; Edwardson 2018; Healy 2016; Parry 2015). For these studies, we used unadjusted data provided by the study authors. We adjusted their results for the design effect according to the calculation methods stated in Section 16.3 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). The two remaining studies that were included in this review were controlled before‐and‐after studies (CBAs) (Alkhajah 2012; Healy 2013). Although study authors described Alkhajah 2012 as a quasi‐RCT, we categorised this study as a CBA study because the risk of baseline differences for studies with only two clusters is very high. Details of each study can be found in the Characteristics of included studies section.

Participants

The total number of participants in the included studies was 955 employees, and sample sizes ranged from 15 in Alkhajah 2012 to 317 in Danquah 2017. However, not all of these participants had baseline musculoskeletal symptoms. With the exception of Gibbs 2018 and Ognibene 2016, which had an inclusion criterion of the presence of musculoskeletal symptoms, all other included studies provided outcomes only for those participants with baseline musculoskeletal symptoms when we contacted study authors. The number of participants with baseline musculoskeletal symptoms across the included studies ranged from one participant with baseline hip discomfort in Healy 2013 to 140 participants with baseline neck pain in Danquah 2017. Neck/shoulder and low back symptoms were most frequently reported in the included studies. Four studies predominantly included participants recruited from a university setting (Alkhajah 2012; Gibbs 2018; Graves 2015; Ognibene 2016), and the other six studies recruited participants from a combination of government and private organisations (Brakenridge 2016; Danquah 2017; Edwardson 2018; Healy 2013; Healy 2016; Parry 2015).

Gender

Eight of the included studies included participants who were predominantly female (66% to 94% female) (Alkhajah 2012; Danquah 2017; Edwardson 2018; Gibbs 2018; Healy 2013; Healy 2016; Ognibene 2016; Parry 2015). Female participation was 37% in Graves 2015) and 54% in Brakenridge 2016.

Country

The included studies were conducted in Australia, Denmark, Greenland, the United States of America, and the United Kingdom.

Interventions

Interventions targeted at the physical work environment

Four studies examined activity permissive workstations (treadmill workstation or sit‐stand workstation) to increase standing or walking and their effects on musculoskeletal symptoms (Alkhajah 2012; Graves 2015; Ognibene 2016; Parry 2015).

Sit‐stand workstation

Three studies examined the effectiveness of sit‐stand workstations (Alkhajah 2012; Graves 2015; Ognibene 2016). Graves 2015 incorporated personalised training and ergonomic information, whereas Alkhajah 2012 and Ognibene 2016 did not provide specific instructions or information on recommended time intervals or duration of use.

Treadmill workstation

One study assessed the effectiveness of a treadmill workstation in combination with promoting incidental office activity (Parry 2015). This study compared the effectiveness of (1) the treadmill workstation and promoting incidental office activity, (2) traditional physical activity promotion (pedometer challenge), and (3) ergonomic advice.

Interventions targeted at the individual

Two studies assessed the use of an activity tracker (Brakenridge 2016; Parry 2015). One study assessed the effectiveness of providing an activity tracker with organisational support for reducing musculoskeletal symptoms (Brakenridge 2016). The other study provided a pedometer to promote physical activity at work and during non‐work hours (Parry 2015).

Activity tracker

The effectiveness on an activity tracker was examined as part of a multi‐component trial that also provided organisational intervention strategies such as informational booklets, weekly emails, and workplace health promotion presentations. The activity tracker provided individual feedback with respect to standing, sitting, posture, and sleep (Brakenridge 2016). The other study provided a pedometer to monitor and promote workplace and non‐work daily steps as part of a 'pedometer challenge' (Parry 2015).

Interventions targeted at the organisation

No studies were found that specifically looked at modifying workplace policy to encourage workplace standing or walking.

Multi‐component interventions

Five studies incorporated multi‐component interventions (Danquah 2017; Edwardson 2018; Gibbs 2018; Healy 2013; Healy 2016). One study used a multi‐component approach to develop and tailor a programme to an organisation (Danquah 2017). Components of the intervention comprised both individual interventions and organisational interventions. Edwardson 2018 implemented "SMArt Work", a multi‐component intervention based on behavioural change theories, incorporating organisational strategies (management involvement), environmental strategies (provision of sit‐stand workstation with brief training), and individual and group strategies (educational seminar, feedback from baseline sit/stand/stepping measurements, provision of DARMA cushion that tracks sitting and prompts user to regularly break up sitting, provision of educational posters, individual coaching sessions). In Gibbs 2018, the multi‐component intervention incorporated personal behavioural counselling with follow‐up monthly phone calls, a sit‐stand desk attachment, and an activity prompter to reduce sedentary behaviour and enhance pain self‐management. Healy 2013 and Healy 2016 targeted the multi‐component interventions to "Stand Up, Sit Less, Move More". These interventions incorporated organisational strategies (workshops with managers, recruitment of team champions), environmental strategies (provision of sit‐stand workstations installed for 12 months), and individual strategies (individual coaching sessions for three months).

Control interventions

Waiting list control

Two studies had a waiting list control intervention (Graves 2015; Ognibene 2016). In both studies, participants in the control intervention maintained their normal duties and were then offered a sit‐stand workstation at the end of the intervention period.

No intervention

In six studies, the control group was not provided with any intervention and continued with usual work (Alkhajah 2012; Danquah 2017; Edwardson 2018; Gibbs 2018; Healy 2013; Healy 2016.) Gibbs 2018 provided no intervention to the control group but offered a 60‐minute educational session following the intervention period. Similarly, in Danquah 2017, the control group continued with the usual working practice. For this workplace, participants in the control group had previously been provided with a sit‐stand workstation. In two studies, participants were provided with feedback about physiological outcomes (Edwardson 2018; Healy 2016), and one study also provided feedback about physical activity at three months and 12 months (Healy 2016)

Written information

In Brakenridge 2016, written materials and emails developed from a multi‐component organisational intervention were provided as the control intervention. In another study, participants were provided with ergonomic advice in reviewing workstation set‐up (Parry 2015).

Outcomes

Musculoskeletal symptoms

Four studies assessed musculoskeletal symptom intensity on a numerical pain scale or a visual analog scale (0 to 10) (Brakenridge 2016; Gibbs 2018; Graves 2015; Ognibene 2016), and six studies used a dichotomous measure of the presence or absence of musculoskeletal symptoms (Alkhajah 2012; Danquah 2017; Edwardson 2018; Healy 2013; Healy 2016; Parry 2015). Two studies, upon assessing a sit‐stand workstation intervention, reported low back and upper back symptoms at short‐term follow‐up on different scales. Graves 2015 assessed intensity of pain using a Likert scale from 0 (no discomfort) to 10 (maximal discomfort); Ognibene 2016 used a modified pain inventory from 0 (better) to 10 (worse). Therefore the standardised mean difference for the pooled effect estimate was reported for these outcomes. We converted odds ratios from two studies for musculoskeletal outcomes at various sites to standardised mean differences, so that they could be pooled in a meta‐analysis.

We calculated the mean difference between intervention and control groups adjusted for baseline for two studies (Brakenridge 2016; Gibbs 2018), using pre‐post correlation data for musculoskeletal outcomes at various sites obtained from the Parry 2015 study.

Pain‐related disability

Gibbs 2018 and Ognibene 2016) assessed pain‐related disability. Gibbs 2018 used the Oswestry Disabilty Index, and Ognibene 2016 used the Roland Morris Disability Questionnaire.

Follow‐up times

In six studies, the longest follow‐up was six months or less (Alkhajah 2012; Danquah 2017; Graves 2015; Healy 2013; Ognibene 2016; Parry 2015), which we categorised as short‐term follow‐up. Gibbs 2018 followed participants between six and less than 12 months, which we categorised as medium‐term follow‐up. Brakenridge 2016,Edwardson 2018, and Healy 2016 provided follow‐up for 12 months, which we defined as long‐term follow‐up.

Excluded studies

Of the 77 papers that we assessed as full text, 67 did not meet our inclusion criteria, and we excluded them. Forty‐one studies provided the wrong intervention, and 15 studies used an inappropriate study design. Four studies were not conducted with employees with musculoskeletal symptoms, three studies were not conducted in the workplace setting, one study did not report musculoskeletal symptoms, two were ongoing studies, and one study is awaiting classification. See the Characteristics of excluded studies table for further details.

Risk of bias in included studies

Risk of bias for the eight included RCTs was assessed based on the seven criteria as outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). For the two CBA studies, we assessed risk of bias using the five Cochrane criteria (blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and baseline imbalance) and the two additional criteria (confounding and selection bias) modified from Downs (Downs 1998). We combined the risk of bias for all studies and illustrated this in Figure 2 and Figure 3. Risk of bias varied considerably across the studies (Figure 2).

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

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

Allocation

For the eight included RCTs, although all used randomisation procedures for either participants ‐ Gibbs 2018; Graves 2015; Ognibene 2016 ‐ or clusters ‐ Brakenridge 2016; Danquah 2017; Edwardson 2018; Healy 2016; Parry 2015 ‐ only two studies included participants who all had baseline musculoskeletal symptoms (Gibbs 2018; Ognibene 2016). For these studies, the randomisation sequence was sufficiently described and was rated at low risk of bias for this criterion. For the other six studies (Brakenridge 2016; Danquah 2017; Edwardson 2018; Healy 2016; Graves 2015; Parry 2015), as only data from participants with baseline musculoskeletal symptoms were included in the analyses, randomisation of participants from these studies was rated as unclear. Five of the studies reported concealment of allocation (Brakenridge 2016; Danquah 2017; Gibbs 2018; Healy 2016; Parry 2015), and we rated these studies at low risk of bias. For the other three studies (Edwardson 2018; Graves 2015; Ognibene 2016), allocation concealment was not described, and we judged the risk of bias as unclear for this criterion.

Blinding

Due to the nature of the interventions, it was not possible to blind participants to the interventions that they were receiving, so for all of the included studies, the risk of performance bias was high. Self‐reported musculoskeletal symptoms was the main outcome for this review, and as participants were not blinded to the intervention, even if studies reported blinding of the outcome assessor (Edwardson 2018; Danquah 2017), the risk of bias could be judged at best to be unclear, as not being blinded to the intervention may contribute to bias in the self‐reporting of musculoskeletal symptoms. Parry 2015 stated that the researcher responsible for data analysis was not blinded to participant allocation; for this study, we judged the risk of detection bias to be high. For two studies (Gibbs 2018; Ognibene 2016), self‐reported musculoskeletal symptoms was the primary outcome measure and participants were not blinded to the intervention, so we judged the risk of risk of bias to be high for these studies.

Incomplete outcome data

Two studies were judged to be at high risk of attrition bias due to incomplete outcome data (Brakenridge 2016; Parry 2015). Both of these studies used stratified data for participants with baseline musculoskeletal symptoms and loss to follow‐up was substantial ‐ in excess of 40% for most body regions. We judged five studies to have unclear risk of attrition (Danquah 2017; Edwardson 2018; Healy 2013; Healy 2016; Ognibene 2016). For Edwardson 2018, Healy 2013, and Healy 2016, attrition details for participants with baseline pain were not provided. In Ognibene 2016, attrition was 19%, and it was unclear whether the data were analysed by intention‐to‐treat. We judged Alkhajah 2012,Gibbs 2018, and Graves 2015 to have low risk of attrition bias due to use of intention‐to‐treat analyses in Graves 2015 and low attrition rate in Alkhajah 2012 and Gibbs 2018; sensitivity analysis comparing only completers with reported data showed similar results (Gibbs 2018).

Selective reporting

All of the included RCTs were judged to have low risk of reporting bias. All studies reported outcomes that were consistent with the published trial protocols. For the two CBA studies (Alkhajah 2012; Healy 2013), we judged the risk of reporting bias to be unclear, as there was no published trial protocol for each of these studies.

Other potential sources of bias

Another source of potential bias that was examined was imbalance of baseline characteristics such as gender, age, baseline musculoskeletal symptoms, and work‐related factors. We judged Brakenridge 2016,Gibbs 2018, and Healy 2016 to have low risk of bias for this criterion, as identified baseline differences were adjusted for in the analyses. We judged Danquah 2017,Edwardson 2018,Graves 2015, and Ognibene 2016 to have unclear risk of bias for baseline imbalance, as baseline data for only the full group (not for intervention and control groups separately) were provided. For Alkhajah 2012, Healy 2013, and Parry 2015, we judged risk of bias due to baseline imbalance as high due to large differences in musculoskeletal symptoms at baseline for some body regions.

Confounding bias CBA

We judged Alkhajah 2012 to have high risk of confounding bias, as it was not possible to adjust for all potential confounders due to the small sample. For Healy 2013, even though adjustments were made for baseline values, unmeasured confounders such as baseline activity levels or job tasks may have influenced the results, so we judged the risk of confounder bias to be unclear.

Selection bias CBA

For both CBAs (Alkhajah 2012; Healy 2013), we judged risk of selection bias to be low, as intervention and control participants were recruited from the same organisation over the same time period.

Overall risk of bias

Overall, we judged only one study to have low risk of bias (Gibbs 2018). None of the included studies were able to blind participants or personnel due to the nature of the interventions. In eight of the included studies (Alkhajah 2012; Brakenridge 2016; Danquah 2017; Edwardson 2018; Graves 2015; Healy 2013; Healy 2016; Parry 2015), only data for select participants with baseline musculoskeletal symptoms were included in the analyses. This has compromised the randomisation process of the study; therefore we judged these studies to have high risk of bias. For these studies, some of the risk of bias criteria were unclear, as musculoskeletal symptoms were secondary outcomes, so full details were not reported in the studies for this outcome. In addition, high risk of bias overall was due to blinding of outcome assessors (Gibbs 2018; Ognibene 2016; Parry 2015); incomplete outcome data (Brakenridge 2016; Parry 2015); and baseline imbalances (Alkhajah 2012; Healy 2013; Parry 2015). We have illustrated the summary of judgements for each item in the risk of bias for included studies in Figure 3.

Effects of interventions

See: Table 1; Table 2; Table 3; Table 4

Summary of findings for the main comparison. Sit‐stand desk compared to no intervention for increasing standing or walking for decreasing musculoskeletal symptoms in sedentary workers.

Sit‐stand desk compared to no intervention for increasing standing or walking for decreasing musculoskeletal symptoms in sedentary workers
Patient or population: sedentary workers with musculoskeletal symptoms  Setting: office setting  Intervention: sit‐stand desk  Comparison: no intervention
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect  (95% CI)	№ of participants  (studies)	Certainty of the evidence  (GRADE)	Comments
Outcomes	Risk with no intervention	Risk with sit‐stand desk	Relative effect  (95% CI)	№ of participants  (studies)	Certainty of the evidence  (GRADE)	Comments
Mean difference in low back pain follow‐up short‐term		SMD 0.35 lower  (0.8 lower to 0.1 higher)	‐	79  (2 RCTs)	⊕⊕⊝⊝  Low^a,b
Mean difference in upper back pain follow‐up short‐term		SMD 0.48 lower  (0.96 lower to 0)	‐	71  (2 RCTs)	⊕⊕⊝⊝  Low^a,b
Mean difference in neck and shoulder pain/discomfort follow‐up short‐term	Mean difference in neck and shoulder pain/discomfort follow‐up short‐term: 2.2 score	MD 0.6 score lower  (1.5 lower to 0.3 higher)	‐	31  (1 RCT)	⊕⊕⊝⊝  Low^b,c
Mean difference in physical disability caused by LBP, RMDQ score follow‐up short‐term	Mean difference in physical disability caused by LBP, RMDQ score follow‐up short‐term: 5.67 score	MD 0.4 score lower  (2.7 lower to 1.9 higher)	‐	46  (1 RCT)	⊕⊕⊝⊝  Low^a,b
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).    CI: confidence interval; LBP: low back pain; MD: mean difference; RCT: randomised controlled trial; RMDQ: Roland Morris Disability Questionnaire; SMD: standardised mean difference.
GRADE Working Group grades of evidence.  High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.  Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.  Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.  Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

Treadmill workstation compared to no intervention for increasing standing or walking for decreasing musculoskeletal symptoms in sedentary workers
Patient or population: sedentary workers with musculoskeletal symptoms  Setting: office setting  Intervention: treadmill workstation  Comparison: no intervention
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect  (95% CI)	№ of participants  (studies)	Certainty of the evidence  (GRADE)	Comments
	Risk with no intervention	Risk with treadmill workstation
Proportion of participants with low back pain/discomfort follow‐up short‐term	714 per 1000	750 per 1000  (357 to 1000)	RR 1.05  (0.50 to 2.19)	11  (1 RCT)	⊕⊕⊝⊝  Low^a,b
Proportion of participants with neck pain/discomfort follow‐up short‐term	571 per 1000	714 per 1000  (320 to 1000)	RR 1.25  (0.56 to 2.77)	14  (1 RCT)	⊕⊕⊝⊝  Low^a,b
Proportion of participants with shoulder pain/discomfort follow‐up short‐term	667 per 1000	753 per 1000  (340 to 1000)	RR 1.13  (0.51 to 2.50)	10  (1 RCT)	⊕⊕⊝⊝  Low^a,b
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).    CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio.
GRADE Working Group grades of evidence.  High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.  Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.  Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.  Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

Activity tracker compared to alternate intervention or no intervention for increasing standing or walking for decreasing musculoskeletal symptoms in sedentary workers
Patient or population: sedentary workers with musculoskeletal symptoms  Setting: office setting  Intervention: activity tracker  Comparison: alternate intervention or no intervention
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect  (95% CI)	№ of participants  (studies)	Certainty of the evidence  (GRADE)	Comments
Outcomes	Risk with alternate intervention or no intervention	Risk with activity tracker	Relative effect  (95% CI)	№ of participants  (studies)	Certainty of the evidence  (GRADE)	Comments
Mean difference in low back pain/discomfort follow‐up short‐term		SMD 0.05 lower  (0.87 lower to 0.77 higher)	‐	31  (2 RCTs)	⊕⊕⊝⊝  Low^a,b
Mean difference in upper back pain/discomfort follow‐up short‐term		SMD 0.04 lower  (0.92 lower to 0.84 higher)	‐	23  (2 RCTs)	⊕⊕⊝⊝  Low^a,b
Mean difference in neck pain/discomfort follow‐up short‐term		SMD 0.05 higher  (0.68 lower to 0.78 higher)	‐	33  (2 RCTs)	⊕⊕⊝⊝  Low^a,b
Mean difference in shoulder pain/discomfort follow‐up short‐term		SMD 0.14 higher  (0.63 lower to 0.9 higher)	‐	31  (2 RCTs)	⊕⊕⊝⊝  Low^a,b
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).    CI: confidence interval; RCT: randomised controlled trial; SMD: standardised mean difference.
GRADE Working Group grades of evidence.  High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.  Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.  Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.  Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

Multi‐component intervention compared to no intervention for increasing standing or walking for decreasing musculoskeletal symptoms in sedentary workers
Patient or population: sedentary workers with musculoskeletal symptoms  Setting: office setting  Intervention: multi‐component intervention  Comparison: no intervention
Outcomes	*Anticipated absolute effects (95% CI)**		Relative effect  (95% CI)	№ of participants  (studies)	Certainty of the evidence  (GRADE)	Comments
Outcomes	Risk with no intervention	Risk with multi‐component intervention	Relative effect  (95% CI)	№ of participants  (studies)	Certainty of the evidence  (GRADE)	Comments
Proportion of participants with low back pain/discomfort follow‐up short‐term	625 per 1000	581 per 1000  (431 to 794)	RR 0.93  (0.69 to 1.27)	107  (3 RCTs)	⊕⊕⊝⊝  Low^a,b
Proportion of participants with upper back pain/discomfort follow‐up short‐term	353 per 1000	311 per 1000  (141 to 692)	RR 0.88  (0.40 to 1.96)	40  (2 RCTs)	⊕⊕⊝⊝  Low^a,b
Proportion of participants with neck pain/discomfort follow‐up short‐term	623 per 1000	623 per 1000  (473 to 822)	RR 1.00  (0.76 to 1.32)	115  (3 RCTs)	⊕⊕⊝⊝  Low^a,b
Proportion of participants with shoulder pain/discomfort follow‐up short‐term	207 per 1000	172 per 1000  (25 to 1000)	RR 0.83  (0.12 to 5.80)	66  (2 RCTs)	⊕⊝⊝⊝  Very low^a,b,c
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).    CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio.
GRADE Working Group grades of evidence.  High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.  Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.  Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.  Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mean difference in low back pain follow‐up short‐term	2	79	Std. Mean Difference (Random, 95% CI)	‐0.35 [‐0.80, 0.10]
2 Mean difference in upper back pain follow‐up short‐term	2	71	Std. Mean Difference (Random, 95% CI)	‐0.48 [‐0.96, 0.00]
3 Mean difference in neck and shoulder pain/discomfort follow‐up short‐term	1		Mean Difference (Random, 95% CI)	Totals not selected
4 Mean difference in physical disability caused by LBP, RMDQ score follow‐up short‐term	1		Mean Difference (Fixed, 95% CI)	Totals not selected
5 Proportion of participants with low back pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
6 Proportion of participants with upper back pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
7 Proportion of participants with neck pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
8 Proportion of participants with shoulder pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
9 Proportion of participants with wrist/hand pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
10 Proportion of participants with hip pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Outcome or subgroup title	No. of studies	Statistical method	Effect size
1 Proportion of participants with low back pain/discomfort follow‐up short‐term	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
2 Proportion of participants with upper back pain/discomfort follow‐up short‐term	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
3 Proportion of participants with neck pain/discomfort follow‐up short‐term	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
4 Proportion of participants with shoulder pain/discomfort follow‐up short‐term	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
5 Proportion of participants with elbow/wrist/hand pain/discomfort follow‐up short‐term	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
6 Proportion of participants with knee pain/discomfort follow‐up short‐term	1	Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mean difference in low back pain/discomfort follow‐up short‐term	2	31	Std. Mean Difference (Fixed, 95% CI)	‐0.05 [‐0.87, 0.77]
2 Mean difference in upper back pain/discomfort follow‐up short‐term	2	23	Std. Mean Difference (Fixed, 95% CI)	‐0.04 [‐0.92, 0.84]
3 Mean difference in neck pain/discomfort follow‐up short‐term	2	33	Std. Mean Difference (Fixed, 95% CI)	0.05 [‐0.68, 0.78]
4 Mean difference in shoulder pain/discomfort follow‐up short‐term	2	31	Std. Mean Difference (Fixed, 95% CI)	0.14 [‐0.63, 0.90]
5 Mean difference in elbow, wrist/hand pain/discomfort follow‐up short‐term	2	18	Std. Mean Difference (Fixed, 95% CI)	‐0.30 [‐1.44, 0.85]
6 Mean difference in hip/thigh/buttock pain/discomfort follow‐up short‐term	1		Mean Difference (Fixed, 95% CI)	Totals not selected
7 Mean difference in knee pain/discomfort follow‐up short‐term	1		Mean Difference (Fixed, 95% CI)	Totals not selected
8 Mean difference in ankle/feet pain/discomfort follow‐up short‐term	1		Mean Difference (Fixed, 95% CI)	Totals not selected
9 Mean difference in low back pain/discomfort follow‐up long‐term	1		Mean Difference (Fixed, 95% CI)	Totals not selected
10 Mean difference in upper back pain/discomfort follow‐up long‐term	1		Mean Difference (Fixed, 95% CI)	Totals not selected
11 Mean difference in neck pain/discomfort follow‐up long‐term	1		Mean Difference (Fixed, 95% CI)	Totals not selected
12 Mean difference in shoulder pain/discomfort follow‐up long‐term	1		Mean Difference (Random, 95% CI)	Totals not selected
13 Mean difference in hip/thigh/buttock pain/discomfort follow‐up long‐term	1		Mean Difference (Fixed, 95% CI)	Totals not selected
14 Mean difference in knee pain/discomfort follow‐up long‐term	1		Mean Difference (Fixed, 95% CI)	Totals not selected
15 Mean difference in ankle/feet pain/discomfort follow‐up long‐term	1		Mean Difference (Fixed, 95% CI)	Totals not selected

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Proportion of participants with low back pain/discomfort follow‐up short‐term	3	107	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.69, 1.27]
2 Proportion of participants with upper back pain/discomfort follow‐up short‐term	2	40	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.40, 1.96]
3 Proportion of participants with neck pain/discomfort follow‐up short‐term	3	115	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.76, 1.32]
4 Proportion of participants with shoulder pain/discomfort follow‐up short‐term	2	66	Risk Ratio (Random, 95% CI)	0.83 [0.12, 5.80]
5 Proportion of participants with wrist/hand pain/discomfort follow‐up short‐term	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
6 Proportion of participants with elbow pain/discomfort follow‐up short‐term	2	20	Risk Ratio (M‐H, Fixed, 95% CI)	0.31 [0.09, 1.06]
7 Proportion of participants with hip pain/discomfort follow‐up short‐term	2	34	Risk Ratio (M‐H, Fixed, 95% CI)	1.15 [0.56, 2.34]
8 Proportion of participants with knee pain/discomfort follow‐up short‐term	2	43	Risk Ratio (M‐H, Random, 95% CI)	1.25 [0.28, 5.68]
9 Proportion of participants with legs/feet/ankles pain/discomfort follow‐up short‐term	2	37	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.34, 1.15]
10 Proportion of participants with extremity pain/discomfort follow‐up short‐term	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
11 Mean difference in low back pain/discomfort follow‐up medium‐term	1		Mean Difference (Fixed, 95% CI)	Totals not selected
12 Mean difference in upper back pain/discomfort follow‐up medium‐term	1		Mean Difference (Fixed, 95% CI)	Totals not selected
13 Mean difference in leg pain/discomfort follow‐up medium‐term	1		Mean Difference (Fixed, 95% CI)	Totals not selected
14 Mean difference in disability follow‐up medium‐term	1		Mean Difference (Fixed, 95% CI)	Totals not selected
15 Proportion of participants with low back pain/discomfort follow‐up long‐term	2	67	Risk Ratio (M‐H, Fixed, 95% CI)	0.89 [0.57, 1.40]
16 Proportion of participants with upper back pain/discomfort follow‐up long‐term	2	40	Risk Ratio (M‐H, Random, 95% CI)	0.52 [0.08, 3.29]
17 Proportion of participants with neck pain/discomfort follow‐up long‐term	2	60	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.41, 1.08]
18 Proportion of participants with shoulder pain/discomfort follow‐up long‐term	2	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.93 [0.57, 1.54]
19 Proportion of participants with wrist/hand pain/discomfort follow‐up long‐term	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
20 Proportion of participants with legs/feet/ankle pain/discomfort follow‐up long‐term	2	37	Risk Ratio (M‐H, Fixed, 95% CI)	1.48 [0.74, 2.96]
21 Proportion of participants with hip pain/discomfort follow up long‐term	2	34	Risk Ratio (M‐H, Random, 95% CI)	0.92 [0.36, 2.37]
22 Proportion of participants with knee pain/discomfort follow‐up long‐term	2	43	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.46, 1.79]
23 Proportion of participants elbow pain/discomfort follow‐up long‐term	2	20	Risk Ratio (M‐H, Fixed, 95% CI)	0.35 [0.08, 1.52]
24 Proportion of participants with low back pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
25 Proportion of participants with upper back pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
26 Proportion of participants with neck pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
27 Proportion of participants with shoulder pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
28 Proportion of participants with elbow pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
29 Proportion of participants with wrist/hand pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
30 Proportion of participants with legs/feet/ankles pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
31 Proportion of participants with hip pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected
32 Proportion of participants with knee pain follow‐up short‐term (CBA)	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Methods	Study design: controlled before‐and‐after trial Study duration: 3 months Dropout: 6% of all participants (0 to 18 in intervention group and 2 to 15 in control group); no specific information provided about participants with baseline musculoskeletal symptoms Location: Australia Recruitment: 2 academic institutions in Brisbane; to reduce contamination, participants in the comparison group were separated from intervention participants by at least 1 building level
Participants	Population: office workers Intervention group: 18 participants (total) with 0 to 7 participants with baseline pain Control group: 15 participants (total) with 0 to 4 participants with baseline pain Included criteria: between 20 and 65 years of age with a non‐adjustable workstation and a desktop computer Excluded criteria: non‐ambulatory, pregnant at baseline, working less than 0.5 full‐time equivalent, planned relocation to another work site within 3 months Baseline characteristics: imbalance in the proportion of participants in intervention and control groups that reported baseline musculoskeletal symptoms
Interventions	Intervention Description of intervention: installation of a sit‐stand workstation; brief verbal training and ergonomic information provided. Written instructions were also provided Duration of intervention: 3 months Intensity of intervention: not stated Control Description of intervention: maintained normal work duties Duration of intervention: 3 months Intensity of intervention: not stated
Outcomes	Outcome name, measurement tool, body region Musculoskeletal health Standardised Nordic Questionnaire for 9 body regions ‐ neck, shoulder, upper back, elbow, wrist, lower back, hip, knee, and ankle ‐ over last week and last 3 months Workplace sitting/standing/stepping time and sit‐stand transitions Measured by activPAL3 accelerometer/inclinometer device Physiological outcomes BMI, glucose, cholesterol Other health outcomes Fatigue, eye strain, self‐rated work performance, headaches, digestion, sleep problems, absenteeism
Identification
Notes	Sponsorship source: nil relevant reported
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Counfounding CBA	High risk	Quote: "the sample is not widely representative of workplaces and workers, and some confounding is possible. Further, models adjusted for baseline levels but not for other potential confounders because of insuffıcient sample size" Judgement comment: due to the small sample size in this study, adjustment for potential confounders was not possible
Selection Bias CBA	Low risk	Judgement comment: intervention and control participants were recruited from the same organisation and over the same time period
Blinding of participants and personnel	High risk	Judgement comment: due to the nature of the intervention of a sit‐stand workstation provided, it would not have been possible to blind researchers or participants from the intervention
Blinding of outcome assessment	Unclear risk	Judgement comment: in this study, musculoskeletal outcomes were a secondary outcome, so it is unclear whether the fact that participants were not blinded to the intervention would contribute to bias in self‐reporting of musculoskeletal outcomes
Incomplete outcome data	Low risk	Judgement comment: only 1 participant in the control group was excluded from analyses due to monitor malfunction
Selective reporting	Unclear risk	Judgement comment: all outcomes were reported in the paper, but there was no published protocol for the study, so it is not possible to determine if additional outcomes were proposed that were not reported
Baseline imbalance	High risk	Judgement comment: there were considerable differences in baseline symptoms for some body regions (e.g. neck, shoulder)

Methods	Study design: cluster‐randomised controlled trial Study duration: 12 months Dropout: 55% (baseline pain participants) Location: Australia Recruitment: 1 large Australian organisation with offices around the country. Participants attended an information session and were invited to participate in the study
Participants	Population: office workers from a private organisation with mean age of 23 to 58 years Intervention group: 66 participants (total) with 2 to 22 participants with baseline pain Control group: 87 participants (total) with 5 to 32 participants with baseline pain Included criteria: working at study locations or working nearby or visiting a location regularly; working 50% or more than full‐time equivalent, able to walk 10 m Excluded criteria: pregnant at baseline, allergies to adhesive tape, planned absence from work for longer than 2 weeks during the first 3‐month study period, having an activity permissive workstation at baseline assessment Baseline characteristics: at baseline, the control group had a higher proportion of males, senior leaders, and overweight participants. This group also had fewer managers and reported more lower extremity musculoskeletal problems when compared to the intervention group. Baseline activity levels between groups were comparable
Interventions	Intervention Description of intervention: organisation level strategy with activity tracker. Strategy consists of workplace champion delivering organisation level intervention strategies (e.g. a booklet with information on sitting and health implications, weekly emails, workplace presentations). The activity tracker 'LUMOback' provided feedback on sitting, standing, stepping, sitting breaks, posture, and sleep Duration of intervention: 12 months Intensity of intervention: booklet and 1 email every 2 weeks; LUMOback self‐directed. Encouraged to use LUMOback for first 3 months Control Description of intervention: organisational support ‐ informational booklet and emails Duration of intervention: 12 months Intensity of intervention: booklet and 1 email every 2 weeks
Outcomes	Outcome name, measurement tool, body region Musculoskeletal pain Nordic Musculoskeletal Survey ‐ presence by region and intensity of pain in each region (neck, shoulder, upper back, lower back, elbow, hand, hip/thigh, knee, ankle/foot) Changes in sitting/standing/stepping during work hours measured with activPAL accelerometer/inclinometer device Self‐reported health and work‐related outcomes
Identification
Notes	Sponsorship source: the National Heart Foundation of Australia; the Office Ergonomics Research Committee (OERC); the National Health and Medical Research Council (NHMRC) of Australia; Australian Postgraduate Award; the Victorian Government’s Operational Infrastructure Support Program; Lendlease
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation	Unclear risk	Quote: "randomisation occurred after the final list of team managers for each location had been obtained and prior to the staff information session and baseline assessment. A university staff member not involved in the study randomised teams by strata (location B/small location A teams/large location A teams) to either Group ORG or Group ORG + Tracker, using a randomisation website" Judgement comment: randomisation (at cluster level) was performed by a researcher not involved in the study using a randomisation website. Although the overall randomisation procedure was low risk, as only a select group of participants with baseline pain were included in the review, the randomisation was compromised
Allocation concealment	Low risk	Judgement comment: randomisation occurred after the final list of team managers for each location had been obtained and before the staff information session and baseline assessment. A research team member informed the champion of the allocation. Randomisation was conducted by a staff member not involved in the study using a randomisation website (third party) to conceal allocation; then a research team member applied the randomisation schedule to the list of teams
Blinding of participants and personnel	High risk	Judgement comment: due to the nature of the intervention of workplace support with and without an activity tracker, it would not have been possible to blind researchers or participants from the intervention
Blinding of outcome assessment	Unclear risk	Judgement comment: in this study, musculoskeletal outcomes were a secondary outcome, so it is unclear whether the fact that participants were not blinded to the intervention would contribute to bias in self‐reporting of musculoskeletal outcomes
Incomplete outcome data	High risk	Judgement comment: loss to follow‐up was substantial (e.g. 13/30 in the control group and 18/26 in the intervention group for the neck pain outcome measure). Although missing data were imputed by chained equations, it is unclear whether musculoskeletal data were imputed, as the primary outcome in this review was only a secondary outcome in the study; it appears that no further analyses were conducted
Selective reporting	Low risk	Judgement comment: outcomes reported are consistent with the published protocol; (upon request) study authors provided results of all musculoskeletal outcomes measured
Baseline imbalance	Low risk	Judgement comment: although some baseline imbalances were reported, analyses were adjusted for potential confounders

Methods	Study design: randomised controlled trial Study duration: 6 months Dropout: 3% at 1 month Location: USA Recruitment: via fliers, University‐based electronic mailings and University of Pittsburgh research registries
Participants	Population: office employees from the greater Pittsburgh area working at least 20 hours per week at a desk Intervention group: 13 participants, all with baseline pain Control group: 14 participants, all with baseline pain Included criteria: chronic LBP defined as persistent pain for at least 3 months resulting in pain on more than half the days over the last 6 months; LBP disability as defined by an Oswestry Diability Index > 10%; current desk work ≥ 20 hours/week; stable employment; approval from supervisor to participate and install a desk attachment, Internet access to complete questionnaires Excluded criteria: not providing informed consent; cardiovascular event in the last 6 months; comorbidity that limited ability to reduce sedentary behaviour; recent or planned back surgery; symptoms consistent with more serious spinal condition; currently using a height‐adjustable/standing workstation; currently planning to get pregnant; blood pressure ≥ 160/100 mmHg Baseline characteristics: intervention group participated in more occupational MVPA than control group, but overall MVPA was consistent between groups. Education level was higher in the control group, so group comparisons were adjusted for education
Interventions	Intervention Description of intervention: behavioural counselling, use of sit‐stand attachment, activity prompter to reduce prolonged sedentary behaviour Duration of intervention: 6 months Intensity of intervention: monthly counselling session with physical therapist or trained interventionist Control Description of intervention: no intervention but offered 60‐minute learning session at end of 6‐month intervention Duration of intervention: 6 months Intensity of intervention: not stated
Outcomes	Outcome name, measurement tool, body region Musculoskeletal pain Visual analog scale (VAS) from 0 (better) to 10 (worse) Usual, worst, and best LBP in the past week Usual neck, upper back, and leg pain Disabilty Oswestry Disability Index ‐ % disability from ODI
Identification
Notes	Sponsorship source: nil relevant
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation	Low risk	Judgement comment: randomisation was done using sealed envelopes in blocks of 4 participants
Allocation concealment	Low risk	Judgement comment: randomisation was done using sealed envelopes in blocks of 4 participants
Blinding of participants and personnel	High risk	Quote: "most participants worked in separate locations, with the exception of some university employees working on the same floor of a building (one cluster of 2; one cluster of 3); the investigators asked these participants not to discuss the study among each other to limit contamination" Judgement comment: attempts were made to avoid contamination between intervention and control participants, but blinding was not possible
Blinding of outcome assessment	High risk	Judgement comment: physical function measured by blinded researcher but for the other outcome assessment, blinding of outcome personnel not reported. In addition, as self‐reported musculoskeletal symptoms was the primary outcome measure and participants were not blinded to the intervention, risk of bias is high
Incomplete outcome data	Low risk	Judgement comment: 1 intervention participant withdrew after 1 month for personal reasons. One control participant withdrew at 2 months for personal reasons, and 1 control participant withdrew due to extended work leave for a medical procedure unrelated to LBP. Completion rate of monthly assessment questionnaires was 93%. Sensitivity analysis between completers only; reported data were similar
Selective reporting	Low risk	Judgement comment: all pain and disability data were reported according to the protocol in the trial registry
Baseline imbalance	Low risk	Judgement comment: there was baseline imbalance for education between intervention groups. Analyses were subsequently adjusted for education

Study	Reason for exclusion
Aghilinejad 2014	Wrong patient population
Andersen 2010	Wrong intervention
Baker 2013	Wrong study design
Bergman 2018	Wrong population
Bernaards 2006	Wrong intervention
Bernaards 2008	Wrong intervention
Bernaards 2011	Wrong intervention
Blangsted 2008	Wrong intervention
Blasche 2013	Wrong intervention
Brendbekken 2016	Wrong intervention
Carr 2013	Wrong intervention
Carr 2016	Wrong intervention
Castagnoli 2015	Wrong intervention
Chung 2009	Wrong study design
Cristancho 2012	Wrong study design
Curwin 2013	Wrong study design
Dahl 2001	Wrong patient population
delPozo Cruz 2012	Wrong intervention
delPozo Cruz 2013	Wrong intervention
Denis 2012	Wrong intervention
Doda 2015	Wrong intervention
Driessen 2011	Wrong intervention
Dugan 2006	Wrong study design
Ebara 2008	Wrong study design
Engelen 2014	Wrong study design
Esmaeilzadeh 2014	Wrong intervention
Estabrooks 2011	Wrong intervention
Fazioli 2004	Wrong intervention
Fewster 2017	Wrong study design
Gao 2016	Wrong patient population ‐ mixture of participants with and without baseline pain
Gerr 2005	Wrong intervention
Grunseit 2012	Wrong study design
Hillsdon 2002	Wrong intervention
Husemann 2009	Wrong intervention
Irmak 2012	Wrong intervention
Jay 2014	Wrong study design
Jay 2015	Wrong intervention
Jay 2016	Wrong intervention
Kilpikoski 2009	Wrong intervention
Kline 2017	Wrong outcome

Methods	Study design: non‐random allocation by clusters (floor): CBA, unblinded  Study duration: 3 months  Dropout: 12% at 3 months (all participants)  Location: Melbourne, Australia  Recruitment: an invitation email was sent to all potential participants to attend one of two 30‐minute study information sessions delivered by research staff. Participants who subsequently expressed interest were screened via telephone for eligibility
Participants	Population: office workers from a single workplace (Comcare: the government agency responsible for workplace safety, rehabilitation, and compensation for Australian government workplaces) in metropolitan Melbourne, Australia  Intervention group: 19 participants (whole group), 2 to 9 with baseline pain  Control group: 19 participants (whole group), 1 to 13 with baseline pain Included criteria: required to work at least 0.6 full‐time equivalent; 18 to 65 years of age; ability to speak English; access to telephone, Internet, and dedicated desk at the workplace Excluded criteria: pregnant, non‐ambulatory, planned absence from work for longer than 1 week during the intervention period, no pre‐existing musculoskeletal disorder Baseline characteristics: imbalance in the proportion of participants in intervention and control groups who reported baseline musculoskeletal symptoms
Interventions	Intervention Description of intervention: intervention targets were "Stand Up, Sit Less, Move More". Intervention incorporates organisational strategies (initial 45‐minute consultation with management, a workshop with managers, liaison period allocation to go between researchers and the organisation and send 2 health‐promoting emails), environmental strategies (provision of sit‐stand workstation installed for 4 weeks), and individual strategies (individual coaching sessions) Duration of intervention: 4 weeks Intensity of intervention: not stated Control Description of intervention: usual work practice Duration of intervention: 4 weeks Intensity of intervention: not stated
Outcomes	Outcome name, measurement tool, body region Musculoskeletal health Standardised Nordic Questionnaire for 9 body regions ‐ neck, shoulder, upper back, elbow, wrist, lower back, hip, knee, and ankle Workplace sitting time Work sitting and prolonged sitting measured by activPAL3 accelerometer/inclinometer device Activity outcomes Standing, stepping, stepping at light intensity, stepping at moderate to vigorous intensity measured by activPAL3 accelerometer/inclinometer device Physiological outcomes Weight, fat mass, and fat‐free mass by bioimpedance analysis scale; blood sampling of glucose, cholesterol, and triglycerides Socio‐demographic outcomes General health, fatigue, eye strain, headaches, digestion and sleep problems, work performance, absenteeism, presenteeism
Identification
Notes	This study was funded by an NHMRC project grant and the Victorian Health Promotion Foundation. Ergotron provided height‐adjustable desks (www.ergotron.com). No financial disclosures were reported by study authors, and they declared that there were no conflicts of interest
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Counfounding CBA	Unclear risk	Quote: "although we adjusted for baseline values and tested for confounding, unmeasured confounders may have affected the results" Judgement comment: there may have been influence from confounders that were not identified
Selection Bias CBA	Low risk	Judgement comment: intervention and control participants were recruited from the same organisation and over the same time period
Blinding of participants and personnel	High risk	Quote: "research staff, participants, and assessors were not blinded to group allocation"
Blinding of outcome assessment	Unclear risk	Quote: "research staff, participants, and assessors were not blind to group allocation" Judgement comment: in addition, for this study, musculoskeletal outcomes were a secondary outcome, so it is unclear whether the fact that participants were not blinded to the intervention would contribute to bias in self‐reporting of musculoskeletal outcomes
Incomplete outcome data	Unclear risk	Judgement comment: for the whole cohort ‐ at 4‐week follow‐up, 3/22 in the intervention group were lost to follow‐up and 2/21 in the control group. Attrition was greater in the intervention group (14%) than in the control group (10%). Attrition details for participants with baseline pain were not provided
Selective reporting	Unclear risk	Judgement comment: the study was not registered as a clinical trial, and there is protocol for comparison. However, all outcomes listed in the methods are reported in the paper
Baseline imbalance	High risk	Judgement comment: Differences in baseline symptoms were considerable for some body regions (e.g. neck, shoulder)

Methods	Study design: allocation by clusters, 2 groups randomly and 2 groups non‐randomly: CBA Study duration: 3 months Dropout: 10% at 3 months (all participants). Location: University of Queensland, Brisbane, Australia Recruitment: 3 sites on different campuses. A recruitment email was sent to all staff in the units
Participants	Population: office workers located on the same office floor  Intervention group: 16 participants multi‐component (whole group); 14 participants workstation only (whole group)  Control group: 14 participants (whole group) Included criteria: 18 to 65 years of age, able to speak English, ambulatory and working at least 0.5 full‐time equivalent Excluded criteria: pregnancy, allergies to medical tape (used to attach the activity monitor), planned absence from work for longer than 1 week during intervention period, no pre‐existing musculoskeletal disorder Baseline characteristics: stratified data not available, so not able to assess whether there were any baseline imbalances in the proportion of participants reporting baseline musculoskeletal symptoms
Interventions	Intervention ‐ multi‐component Description of intervention: multi‐component intervention drawing on social cognitive theory and an ecological model of sedentary behaviour. Intervention targets were "Stand Up, Sit Less, Move More" Duration of intervention: 3 months Intensity of intervention: 6 tailored emails Intervention ‐ workstation only Description of intervention: provision of workstation only Duration of intervention: 3 months Intensity of intervention: no further contact Control Description of intervention: maintenance of usual work practices Duration of intervention: 3 months Intensity of intervention: not stated
Outcomes	Outcome name, measurement tool, body region Musculoskeletal health Standardised Nordic Questionnaire for 9 body regions ‐ neck, shoulder, upper back, elbow, wrist, lower back, hip, knee, and ankle ‐ over last week and last 3 months Workplace sitting time Work sitting and prolonged sitting measured by activPAL3 accelerometer/inclinometer device Activity outcomes Standing, stepping, stepping at light intensity, stepping at moderate to vigorous intensity measured by activPAL3 accelerometer/inclinometer device Demographics Survey Work performance, absenteeism, and presenteeism
Notes	Study authors could not be contacted for stratified data for participants with baseline pain

Trial name or title	Modifying the Workplace to Decrease Sedentary Behavior and Improve Health
Methods	Randomised controlled trial
Participants	Overweight full‐time sedentary workers
Interventions	Treadmill workstation; sit‐to‐stand workstation; control (three 10‐minute walking bouts/week)
Outcomes	Primary: change in weight Secondary: cardiovascular and metabolic health variables, musculoskeletal discomfort, psychological affect, job stress
Starting date	April 2014
Contact information	Dinesh John, PhD
Notes	Study completed but no publication found

Trial name or title	Active Workplace Study
Methods	Randomised controlled trial
Participants	Call centre employees
Interventions	Total worker health: multi‐component organisational and individual level interventions
Outcomes	Primary: sedentary behaviour Secondary: multiple cardiovascular, work‐related, and other health outcomes including musculoskeletal discomfort
Starting date	June 2018
Contact information	Brad Wipfli, PhDl wipflib@ohsu.edu
Notes	Recruitment phase

PERMALINK

Workplace interventions for increasing standing or walking for decreasing musculoskeletal symptoms in sedentary workers

Sharon P Parry

Pieter Coenen

Nipun Shrestha

Peter B O'Sullivan

Christopher G Maher

Leon M Straker

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Primary outcomes

Secondary outcomes

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Assessment of bias in conducting the systematic review

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

'Summary of findings' table

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

Reaching conclusions

Results

Description of studies

1.

Results of the search

Included studies

Study design

Participants

Gender

Country

Interventions

Interventions targeted at the physical work environment

Sit‐stand workstation

Treadmill workstation

Interventions targeted at the individual

Activity tracker

Interventions targeted at the organisation

Multi‐component interventions

Control interventions

Waiting list control

No intervention

Written information

Outcomes

Musculoskeletal symptoms

Pain‐related disability

Follow‐up times

Excluded studies

Risk of bias in included studies

2.

3.

Allocation