Ergonomic interventions for treating work‐related complaints of the arm, neck or shoulder in adults

Objectives

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To determine the effect of ergonomic interventions for work‐related complaints of the arm, neck or shoulder (CANS) in adults on pain, function and work‐related outcomes.

Background

Description of the condition

Work‐related upper limb disorder (WRULD), repetitive strain injury (RSI), cumulative trauma disorders (CTD), occupational overuse syndrome (OOS) or work‐related complaints of the arm, neck or shoulder (CANS) are frequently used umbrella terms for disorders that develop as a result of repetitive movements, awkward postures and impact of external forces such as when operating vibrating tools (Boocock 2009). Many different classification systems have been introduced for the working population. The systems differ in the disorders they include, in the labels used to identify the disorders and in the criteria used to describe the disorders. CANS is defined as "Musculoskeletal complaints of [the] arm, neck and/or shoulder not caused by acute trauma or by any systemic disease" (Huisstede 2007). We preferred to use the CANS model for this review, which, as suggested in the original Delphi study, can increase accurate and meaningful communication among healthcare workers by facilitating the comparison of data of different studies (Huisstede 2007). These disorders are common in working populations including manual labourers and computer users (Gerr 2004; Klussmann 2008). Work‐related complaints can be divided into specific conditions with relatively clear diagnostic criteria and pathology, such as carpal tunnel syndrome, or non‐specific conditions, such as tension neck syndrome. Non‐specific conditions are primarily defined by the location of the complaint, when the pathophysiology is less clearly defined or relatively unknown (Staal 2007). Like any upper extremity musculoskeletal disorder(s), most CANS are characterised by recurrent episodes of pain, accompanied by disability, varying in severity and impact. Most episodes can be self‐limiting and may subside within days or weeks, while some become chronic problems (Andersen 2011).

In the USA, the incidence of work‐related musculoskeletal disorders (i.e. shoulders, arms, hands and fingers) has shown an increasing trend: from 23.2 per 10,000 workers in 2007, 22.9 in 2009, 31.5 in 2011, 31.6 in 2012, 31.5 in 2014, and 32.6 in 2015 in private industries (www.bls.gov/iif/oshcdnew.htm; Ma 2018). Overall, the prevalence of work‐related CANS is around 30% (Melhorn 1998; Punnett 2004), and several studies report a rapidly increasing incidence in low‐ to middle‐income countries (Alghadir 2015; Inbaraj 2013; Loghmani 2013; Meo 2013; Piedrahita 2006; Shabbir 2016; Vos 2012). Work‐related CANS affects the working population in both low‐ and middle‐income countries (Bongers 2006; Eltayeb 2008; Faryza 2015; Mohan 2019; Ranasinghe 2011). Approximately one‐third of worker compensation costs in the USA are due to work‐related CANS (Shanahan 2006; Staal 2007). As a result, these complaints are responsible for a large number of lost working days. In the UK, an estimated 4.1 million working days were lost in 2014 and 2015 through musculoskeletal disorders mainly affecting the upper limbs or neck, often caused or worsened by work. On average, this equates to 15% of all days lost due to work‐related ill‐health (HSE 2010).

The aetiology of CANS is considered multifactorial, and in most people no specific diagnosis can be made (Armstrong 1993; Huisstede 2007) and no pathological, neurological or radiological characteristics can be found to support the diagnosis of 'non‐specific' CANS (Staal 2007). Several personal and physical risk factors are associated with CANS (Feleus 2007; Karels 2007; Roquelaure 2009). There has been an increased focus on the treatment of CANS (IJmker 2007; Shanahan 2006; van Tulder 2007).

Description of the intervention

We will evaluate ergonomic interventions in the treatment of CANS, which include specially designed devices, such as computer keyboards and computer mice; biomechanical and ergonomic education; advice/guidance; postural behaviour change/modifications and work style. We will not evaluate physical activity/exercise interventions, or pharmacological and surgical interventions.

How the intervention might work

Ergonomic interventions play a major role in the treatment of CANS (Shariat 2018; Staal 2007; van Tulder 2007). There are several exposures in the workplace that might result in an occupational origin of CANS, such as the use of high and prolonged force, repetitive movements, awkward positions, prolonged static postures and work organisation factors (Andersen 2011; Bergqvist 1995). The aim of ergonomic interventions and workplace adjustments used as an intervention is to influence these exposures by correcting sitting and standing positions, and making keyboard or mouse adjustments to prevent repetitive movements. These interventions aim to reduce the physical strain to the musculoskeletal system, thus reducing the risk of injury.

Why it is important to do this review

Work‐related CANS is a common disorder that has considerable impact on individuals and society as a whole, and frequently results in a loss of work‐hours. The role of physical and psychosocial factors involved in the treatment of CANS is now well established. We also know that there is modest evidence that some ergonomic interventions have a significant effect on treating CANS (Hoe 2018). Ergonomic interventions can eliminate/reduce harmful load conditions to treat work‐related CANS. In the presence of already established disorders, these interventions act as a treatment tool for any work‐related musculoskeletal disorders.

It is important to establish the most effective interventions to treat people with CANS to enable return to work as soon as possible. Cochrane first published two reviews on this topic (Karjalainen 2000a; Verhagen 2006). These were then replaced by a single review (Verhagen 2013), which found insufficient evidence on the effectiveness of frequently applied intervention strategies for CANS. However, several new studies have been published since that review. Therefore, it is important to determine if including these new studies can update this evidence, and to identify the most effective ergonomic interventions. Verhagen 2013 evaluated the effect of conservative interventions for work‐related CANS in adults on pain, function and work‐related outcomes. We have decided to divide this review into two separate reviews, one reporting ergonomic interventions and one reporting exercise for CANS. Each new review will have its own protocol. This is the protocol for the review that will report the effects of ergonomic interventions for work‐related CANS on pain, function and work‐related outcomes in adults. It will provide the most recent evidence on the topic.

Objectives

To determine the effect of ergonomic interventions for work‐related complaints of the arm, neck or shoulder (CANS) in adults on pain, function and work‐related outcomes.

Methods

Criteria for considering studies for this review

Types of studies

We will include randomised controlled trials (RCTs), quasi‐randomised trials (methods of allocating participants to a treatment which are not strictly random, e.g. by date of birth, hospital record number or alternation) evaluating ergonomic interventions for work‐related CANS in adults. We will also consider for inclusion: cluster‐RCTs (where randomisation is by groups of patients), and cross‐over RCTs (in which the participants, upon completion of the course of one treatment, are switched to the other intervention). We will include only trials specifically stating that the conditions under investigation are work‐related.

Types of participants

We will include studies conducted with adults (aged 18 years and over) where all participants are experiencing non‐specific CANS. We will exclude studies where participants had acute trauma, neoplasms, or inflammatory or neurological diseases. We will exclude studies where not all participants have work‐related pain. We will consider complaints to be work‐related when it is stated in the text, or when people are selected from a specific working population such as an office, factory or laboratory. For studies where only a subset of participants is eligible to be included in our review, we will only include the studies if the cohort contains more than 75% participants of our interest or the study has performed a subanalysis of interested set of participants and reported it in study, or both.

Types of interventions

We will include all trials studying ergonomic interventions for treating upper extremity work‐related disorders in adults. Ergonomic interventions used in the treatment of CANS include specially designed office furniture, such as computer keyboards and computer mice etc.; biomechanical and ergonomic education; advice/guidance about behaviour change/interventions with regard to posture or work style, or both. Examples of the behaviour and ergonomic interventions are awareness of their own work place and body posture, adjusting sitting positions, adjusting screen height, keyboard or mouse adjustments in computer users, frequent breaks and physical activity. These adjustments or interventions should be applied within the workplace.

Trials may investigate single ergonomic interventions or combinations of ergonomic interventions versus single conservative interventions (exercises, relaxation, biopsychosocial rehabilitation programmes, physical applications such as ultrasound, biofeedback (a method of treatment that provides feedback to patients about their physiological information of which they are normally unaware), myofeedback (a form of biofeedback specifically focusing on muscular activity)) or combinations of ergonomic interventions versus either no intervention (e.g. waiting list control), a placebo control or a conservative intervention.

The intervention or adjustment may be the only intervention or an add‐on intervention. We will exclude two arm trials testing interventions such as exercise/physical activity, drug treatments, injections and surgical treatments.

Types of outcome measures

Primary outcomes

• Pain (e.g. Visual Analogue Scale (VAS) (Sriwatanakul 1983), West Haven‐Yale Multidimensional Pain Inventory (WHYMPI) (Kerns 1985), and ordinal scale (von Korff 2000)).

• Functional status (e.g. Health Assessment Questionnaire (Fries 1982), and Disabilities of the Arm, Shoulder and Hand Measurement Tool (DASH) (Hudak 1996)).

• Work‐related outcomes (e.g. sickness absence (days off work), return to work, productivity loss at work, and change of occupation).

Secondary outcomes

• Global perceived effect (e.g. overall improvement) (Beurskens 1996).

• Quality of life (e.g. 36‐item Short Form Survey (SF‐36) (Ware 1992), EQ‐5D (a generic measure of health status; Williams 1990), and Sickness Impact Profile (de Bruin 1994)).

• Healthcare consumption (e.g. physician consultations, physiotherapy, ergonomic adjustments and intake of analgesics).

• Recurrence of injury, disorder or complaint.

Search methods for identification of studies

Electronic searches

Verhagen 2013 was the last Cochrane Review to cover this topic with searches to 31 May 2013. As we are dividing Verhagen 2013 into two new separate reviews (one reporting ergonomic interventions (covered by this protocol) and one reporting exercise for CANS (covered by another protocol)), we will perform the searches from 2013.

We will search the following sources from 2013 to date of search:

• Cochrane Bone, Joint and Muscle Trauma Group Specialised Register;

• Cochrane Occupational Safety and Health Group Specialised Register;

• Cochrane Central Register of Controlled Trials (the Cochrane Library);

• MEDLINE (Ovid);

• Embase (Elsevier);

• CINAHL (EBSCOhost);

• AMED (Ovid);

• PsycINFO (EBSCOhost);

• PEDro – the Physiotherapy Evidence Database;

• OTseeker – The Occupational Therapy Systematic Evaluation of Evidence Database.

We will also search the World Health Organization International Clinical Trials Registry Platform (to date of search) for any unpublished and ongoing studies. We will apply no language restrictions.

In MEDLINE, we will combine the subject‐specific strategy with the sensitivity‐ and precision‐maximising version of the Cochrane Highly Sensitive Search Strategy for identifying randomised trials (Lefebvre 2022), and modify it for use in other databases. Search strategies for all the databases are shown in Appendix 1.

Searching other resources

We will also search reference lists of relevant articles and contact experts in the field.

Data collection and analysis

Selection of studies

Two review authors (from PM, PS and ST) will independently select trials by inspecting titles, keywords and abstracts to determine whether the studies meet the inclusion criteria regarding design, participants and intervention. We will retrieve the full publications of any possibly relevant studies for final assessment. Next, the review authors will independently perform a final selection of the trials to be included in the review using a standardised form. We will resolve disagreements by consensus and, if necessary, by third‐party adjudication (APV). We will record studies rejected at this or subsequent stages in the characteristics of excluded studies table, and record our reasons for exclusion.

We will collate multiple reports of the same study, so that each study, rather than each report, is the unit of interest in the review.

We will record the selection process in sufficient detail to complete a PRISMA flow diagram.

Data extraction and management

Two review authors (from PM, PS and ST) will independently extract data on trial methods, participants, settings, interventions, care providers, type of outcome measures, duration of follow‐up, loss to follow‐up and results using a standardised data extraction form used in Verhagen 2006. We will resolve disagreements by consensus and, if necessary, by third‐party adjudication (APV).

Assessment of risk of bias in included studies

Two review authors (from PM, PS and ST) will independently assess the risk of bias using a modified version of the assessment tool developed by Cochrane (Furlan 2009; Higgins 2022) (Table 1). This tool incorporates the Delphi list (Verhagen 1998), and consists of 12 items that can be scored: 'yes', 'no' or 'don't know'. This risk of bias tool involves assessment of randomisation (sequence generation and allocation concealment), blinding (participants, care providers and outcome assessors), completeness of outcome data, selection of outcomes reported and other sources of bias. We will resolve disagreement by consensus or if disagreement persists, a third review author (APV) will make a final decision. We will contact trial authors if further information is required.

1. Criteria for assessing risk of bias in randomised controlled trials.

Item	Judgement
A. 1. Was the method of randomisation adequate?	Yes/No/Unsure
B. 2. Was the treatment allocation concealed?	Yes/No/Unsure
C. Was knowledge of the allocated interventions adequately prevented during the study? 3. Was the participant blinded to the intervention? 4. Was the care provider blinded to the intervention? 5. Was the outcome assessor blinded to the intervention?	Yes/No/Unsure Yes/No/Unsure Yes/No/Unsure
D. Were incomplete outcome data adequately addressed? 6. Was the dropout rate described and acceptable? 7. Were all randomly assigned participants analysed in the group to which they were allocated?	Yes/No/Unsure Yes/No/Unsure
E. 8. Are reports of the study free of suggestion of selective outcome reporting?	Yes/No/Unsure
F. Other sources of potential bias 9.  Were the groups similar at baseline regarding the most important prognostic indicators? 10. Were co‐interventions avoided or similar? 11. Was compliance acceptable in all groups? 12. Was the timing of the outcome assessment similar in all groups?	Yes/No/Unsure Yes/No/Unsure Yes/No/Unsure Yes/No/Unsure

We will assess risk of bias using the 12 criteria above (Furlan 2009). The criteria for a judgement of 'Yes' are outlined in Appendix 2.

We will define a study to have a low risk of bias, when it is at low risk of bias on all domains. We will define a study to have some concerns, if the study is judged to raise some concerns in at least one domain, but not to be at high risk of bias for any domain. High risk of bias studies will be defined as high risk in at least one domain for this result, or the study is judged to have some concerns for multiple domains, in a way that substantially lowers confidence in the result. 

Measures of treatment effect

We will present the various outcome measures separately. For dichotomous data, we will express results, if possible, as risk ratios (RR) or risk differences (RD) with corresponding 95% confidence intervals (CI). We will calculate mean differences (MD) or, where outcome measures are dissimilar, standardised mean differences (SMD) with 95% CIs for continuous data (Lau 1997).

Unit of analysis issues

Although we anticipate most ergonomic interventions will be targeted to individuals, treatment allocation may be randomised by groups or clusters rather than individuals in some trials. If cluster‐randomised trials are included in the analyses along with individually randomised trials, we intend to adjust their sample sizes using an estimate of the intracluster correlation coefficient (ICC) derived from the trial or another source. When that is not possible, we will conduct sensitivity analyses that include treating cluster‐randomised trials as being individually randomised. Unless the methodology of any cross‐over trial is appropriate and sound, we will only use data from the first phase of cross‐over trials. When that is not possible, we will exclude them from the meta‐analysis.

Dealing with missing data

We will contact trial authors to request missing data. Where possible, we will perform intention‐to‐treat analyses to include all people randomised. For dichotomous data, we will perform a worst‐case scenario, where all missing people in the intervention group have a poor outcome whereas none of the missing people in the control group do. However, for continuous data, where there are dropouts, we will use the actual number of participants contributing data at the relevant outcome assessment. Unless missing standard deviations can be derived from CIs or standard errors (from the same study), we will not assume values in order to present these in the analyses.

Assessment of heterogeneity

Clinicians in the review team (SS, BK) will access clinical heterogeneity based on information on study population, ergonomic interventions, control interventions and outcomes. We will assess statistical heterogeneity between pooled trials using a combination of visual inspection of the graphs along with consideration of the Chi² test and the I² statistic (Higgins 2003).

Assessment of reporting biases

If sufficient data are available, we will attempt to assess publication bias by preparing a funnel plot. 

Data synthesis

We will use Review Manager Web to analyse the data (RevMan Web 2022). In the previous review (Verhagen 2013), we pooled studies that we judged to be clinically similar with regard to participants, interventions, comparisons and outcomes. Should pooling be possible again with new trials included, we will pool results of comparable groups of trials using a random‐effects model and 95% CIs.

We will use GRADE as implemented in software GRADEpro GDT to evaluate the overall certainty of the evidence and the strength of the recommendations (GRADE 2004; GRADEpro GDT). We will downgrade the certainty of the evidence for a specific outcome by one level for each of the following factors that are encountered (Dijkers 2013; Higgins 2003). We will justify all decisions to downgrade the certainty of the evidence using footnotes and we will make comments to aid the reader's understanding of the review where necessary.

• Limitations in design (greater than 25% of participants from studies with a high risk of bias).

• Inconsistency of results (statistical heterogeneity (I² greater than 40%) or inconsistent findings among studies (75% or less of participants reported findings in the same direction)).

• Indirectness (i.e. generalisability of the findings assumed).

• Imprecision (total number of participants: fewer than 300 for a dichotomous outcome and fewer than 400 for continuous outcome).

• Other factors (e.g. publication bias, flawed design, extensive dropout).

We will apply the following labels for the certainty of the evidence.

• High certainty: further research is very unlikely to change the level of evidence; all domains are fulfilled.

• Moderate certainty: further research is likely to have an important impact on confidence in the estimate of effects and may change the estimate; one of the domains is not fulfilled.

• Low certainty: further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change it; two of the domains are not fulfilled.

• Very low certainty: great uncertainty about the estimate; three of the domains are not fulfilled.

Single studies with fewer than 300 or 400 participants will start at low‐certainty evidence as they are imprecise and consistency cannot be evaluated.

Subgroup analysis and investigation of heterogeneity

If data allow, we will perform the following subgroup analyses.

• Specific work‐related CANS (e.g. a specific cause and diagnosis is established) versus non‐specific work‐related CANS.

• Setting of treatment (work versus outside work location).

• Ergonomic intervention provider (general practitioner, physiotherapist or occupational therapist).

• Location of the complaint (neck/shoulder versus arm).

• Duration of the complaint (chronic versus (sub)acute).

We will assess the level of heterogeneity within meta‐analyses by calculating the I² statistic using Review Manager Web (RevMan Web 2022). We will use the thresholds indicated by the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2022): 0% to 40%: might not be important; 30% to 60%: may represent moderate heterogeneity; 50% to 90%: may represent substantial heterogeneity; 75% to 100%: considerable heterogeneity.

Sensitivity analysis

Where possible, we will perform sensitivity analyses examining various aspects of trial and review methodology, including the effects of missing data and inclusion of quasi‐randomised trials, and of data from cluster‐randomised trials. 

Summary of findings and assessment of the certainty of the evidence

We will include the following information in the summary of findings table.

• Pain.

• Functional status.

• Work‐related outcomes.

• Global perceived effect.

• Quality of life.

• Healthcare consumption.

• Recurrence of injury, disorder or complaint.

We will conduct the review according to this published protocol, and report any deviations from it in the Differences between protocol and review section.

Appendices

Appendix 1. Search strategies

The Cochrane Central Register of Controlled Trials (Wiley InterScience interface)

#1 MeSH descriptor Cumulative Trauma Disorders explode all trees

#2 MeSH descriptor Occupational Diseases, this term only

#3 MeSH descriptor Hand‐Arm Vibration Syndrome, this term only

#4 MeSH descriptor Occupational Health, this term only

#5 ((occupational overuse or tension neck) NEXT syndrome):ti,ab

#6 (cumulative trauma*):ti,ab

#7 (work related):ti,ab

#8 (repetit* NEXT (strain or stress or industr* or motion or movement or trauma)):ti,ab

#9 (vibration NEXT (induced or related or syndrome*)):ti,ab

#10 (#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9)

#11 MeSH descriptor Neck Pain, this term only

#12 MeSH descriptor Shoulder Pain, this term only

#13 MeSH descriptor Hand Injuries explode all trees

#14 MeSH descriptor Wrist Injuries, this term only

#15 MeSH descriptor Musculoskeletal Diseases, this term only

#16 (neck* or shoulder* or arm* or upper limb* or upper extremit* or elbow* or forearm* or wrist* or hand* or finger*):ti,ab 

#17 (carpal tunnel syndrome*):ti,ab

#18 (elbow tendinopath*);ti,ab

#19 (tennis elbow);ti,ab

#20 (#11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19)

#21 (ergonomic intervention*):ti,ab 

#22 (ergonomic design*):ti,ab 

#23 (ergonomic training):ti,ab

#24 (ergonomic*);ti,ab

#25 (work station design):ti,ab

#26 (job posture* OR work posture* OR working posture* OR rest period* OR taking break* OR work schedul* OR workplace practic*):ti,ab 

#27 (ergon* OR design*):ti,ab

#28 (#21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27)

#29 (#10 AND #20 AND #28)

MEDLINE (Ovid)

1. exp Cumulative Trauma Disorders/

2. Occupational Diseases/ or Hand‐Arm Vibration Syndrome/

3. Occupational Health/

4. ((occupational overuse or tension neck) adj syndrome).tw.

5. cumulative trauma$.tw.

6. work related.tw.

7. (repetit$ adj (strain or stress or industr$ or motion or movement or trauma)).tw.

8. (vibration adj (induced or related or syndrome$)).tw.

9. or/1‐8

10. Neck Pain/ or Shoulder Pain/ or exp Hand Injuries/ or Wrist Injuries/

11. Musculoskeletal Diseases/

12. (neck$1 or shoulder$1 or arm$1 or upper limb$1 or upper extremit$ or elbow$1 or forearm$1 or wrist$1 or hand$1 or finger$1).tw.

13. Carpal Tunnel Syndrome/ or carpal tunnel syndrome$.tw.

14. exp elbow tendinopathy/

15. (elbow tendinopath* or tennis elbow?).tw. 

16. or/10‐15

17. and/9,16

18. Randomized Controlled Trial.pt.

19. Controlled Clinical Trial.pt.

20. randomized.ab.

21. placebo.ab.

22. Clinical Trials as Topic/

23. randomly.ab.

24. trial.ti.

25. or/18‐24

26. (ergonomic intervention$ OR ergonomic design$ OR ergonomic training OR ergonomics).tw.

27. (job posture$ OR work posture$ OR working posture$ OR rest period$ OR taking break$).tw.

28. (ergon$ OR design$).tw.

29. or/26‐28

30.and/17,25,29

Embase (Elsevier)

(’Cumulative Trauma Disorder’/exp OR (’Occupational Disease’:de OR ’Hand Arm Vibration Syndrome’:de) OR ’Occupational Health’:de OR ((’occupational overuse’ OR ’tension neck’) NEAR/1 syndrome*):ti,ab,de OR (cumulative NEAR/1 trauma*):ti,ab,de OR ’work related’:ti,ab,de OR (repetitive NEAR/1 (strain* OR stress* OR industr* OR motion* OR movement* OR trauma*)): ti,ab,de OR (vibration NEAR/1 (induced OR related OR syndrome*)):ti,ab,de) AND (’Neck Pain’:de OR ’Shoulder Pain’:de OR ’Hand Injury’:de OR ’Wrist Injury’:de OR ’Musculoskeletal Disease’:de OR neck:ti,ab,de OR shoulder:ti,ab,de OR arm:ti,ab,de OR ’upper limb’:ti,ab,de OR (upper NEAR/1 extremit*):ti,ab,de OR elbow*:ti,ab,de OR forearm:ti,ab,de OR wrist:ti,ab,de OR hand: ti,ab,de OR finger:ti,ab,de OR thumb:ti,ab,de OR necks:ti,ab,de OR shoulders:ti,ab,de OR arms:ti,ab,de OR ’upper limbs’:ti,ab,de OR elbow*s:ti,ab,de OR forearms:ti,ab,de OR wrists:ti,ab,de OR hands:ti,ab,de OR fingers:ti,ab,de OR thumbs:ti,ab,de OR (’carpal tunnel’ NEAR/1 syndrome*):ti,ab,de OR (elbow tendinopath*);ti,ab,de OR (tennis elbow);ti,ab,de) AND (’randomized controlled trial’/de OR ’controlled clinical trial’/de OR random*:ti,ab OR placebo:ti,ab OR ’clinical trial’/de OR trial:ti) AND ((‘ergonomic intervention*’ OR ‘ergonomic design*’ OR 'ergonomic training' OR ergonomics OR 'work station design' OR job posture* OR work posture* OR working posture* OR rest period* OR taking break* OR ergon* OR design*);ti,ab,de)

CINAHL (EBSCOhost)

S1 (MH "Cumulative Trauma Disorders+")

S2 (MH "Occupational Diseases")

S3 (MH "Occupational Health")

S4 TI occupational overuse OR AB occupational overuse

S5 TI tension neck OR AB tension neck

S6 TI cumulative trauma* OR AB cumulative trauma*

S7 TI work related OR AB work relate

S8 TI repetit* strain OR AB repetit* strain

S9 TI repetit* stress OR AB repetit* stress

S10 TI repetit* indust* OR AB repetit* indust*

S11 TI repetit* motion OR AB repetit* motion

S12 TI repetit* movement* OR AB repetit* movement*

S13 TI repetit* trauma OR AB repetit* trauma

S14 TI vibration induced OR AB vibration induced

S15 TI vibration related OR AB vibration related

S16 TI vibration syndrome* OR AB vibration syndrome*

S17 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16

S18 (MH "Neck Pain")

S19 (MH "Shoulder Pain")

S20 (MH "Hand Injuries+")

S21 (MH "Wrist Injuries")

S22 (MH "Musculoskeletal Diseases")

S23 ( TI neck* OR AB neck* ) OR ( TI shoulder* OR AB shoulder* ) OR ( TI arm* OR AB arm* ) OR ( TI elbow* OR AB elbow* ) OR ( TI forearm* OR AB forearm* ) OR ( TI wrist* OR AB wrist* ) OR ( TI hand* OR AB hand* ) OR ( TI finger* OR AB finger* ) OR ( TI upper limb* OR AB upper limb* ) OR ( TI upper extremit* OR AB upper extremit*) OR (TI carpal tunnel OR AB carpal tunnel) OR (TI elbow tendinopath* OR AB elbow tendinopath*) OR (TI tennis elbow OR AB tennis elbow)

S24 S18 OR S19 OR S20 OR S21 OR S22 OR S23

S25 (MH “ergonomic intervention*”)

S26 (MH “ergonomic design*”)

S27 (MH “ergonomic training”)

S28 (MH “ergonomic*”)

S29 (TI ergonomic intervention* OR AB ergonomic intervention*) OR (TI ergonomic design* OR AB ergonomic design*) OR (TI ergonomic training OR AB ergonomic training) OR (TI ergonomic* OR AB ergonomic*) OR (TI work station design OR AB work station design) OR (TI job posture* OR AB job posture*) OR (TI work posture* OR AB work posture*) OR (TI working posture* OR AB working posture*) OR (TI rest period* OR AB rest period*) OR (TI taking break* OR AB taking break*)

S30 S25 OR S26 OR S27 OR S28 OR S29

S31 S17 AND S24 AND S30

AMED (Ovid)

1. exp Arm/ or exp Human engineering/ or exp Injuries/ or cumulative trauma.mp. or exp Occupational disease/ or exp Rehabilitation vocational/ or exp Methods/ or exp Repetition strain injury/ or exp Risk/

2. occupational disease/

3. vibration/

4. 2 or 3

5. occupational health/

6. ((occupational overuse or tension neck) adj syndrome).tw.

7. work related.tw.

8. (repetit$ adj (strain or stress or industr$ or motion or movement or trauma)).tw.

9. (vibration adj (induced or related or syndrome$)).tw.

10. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9

11. Neck Pain/ or shoulder pain/ or exp hand injuries/ or wrist injuries/

12. musculoskeletal disease/

13. (neck$1 or shoulder$1 or arm$1 or upper limb$1 or upper extremit$ or elbow$1 or forearm$1 or wrist$1 or hand$1 or finger$1).tw.

14. carpal tunnel syndrome/

15. carpal tunnel syndrome$.tw.

16. Elbow tendinopathy$/

17. Elbow tendinopathy$.tw.

18. Tennis elbow/

19. Tennis elbow.tw.

20. 14 or 15 or 16 or 17 or 18 or 19

21. 11 or 12 or 13 or 20

22. 10 and 21

23. (ergonomic intervention$1 or ergonomic design$1 or ergonomic training or ergonomic$1 or work station design or job posture$1 or work posture$1 or working posture$1 or rest period$1 or taking break$1).tw.

24. 22 and 23

25. Randomized controlled trial.pt.

26. controlled clinical trial.pt.

27. randomized.ab.

28. placebo.ab.

29. clinical trials/

30. randomly.ab.

31. trial.ti.

32. 25 or 26 or 27 or 28 or 29 or 30 or 31

33. 24 and 3234. limit 33 to yr="2013 ‐Current"

PsycINFO (EBSCOhost)

S1 cumulative trauma disorder*

S2 occupational disease* OR vibration syndrome*

S3 MA occupational health

S4 TI Occupational overuse syndrome* OR AB occupational overuse syndrome* OR TI tension neck syndrome* OR AB tension neck syndrome

S5 cumulative trauma*

S6 Work related

S7 repetit* strain OR repetit* stress OR repetit* industr* OR repetit* motion OR repetit* movement* OR repetit* trauma

S8 vibration induced OR vibration related

S9 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8

S10 neck pain* OR shoulder pain* OR hand injur* OR wrist injur*

S11 musculoskeletal disease*

S12 neck* OR shoulder* OR arm* OR upper limb* OR upper extremit* OR elbow* OR forearm* OR wrist* OR hand* OR finger*

S13 carpal tunnel syndrome*

S14 Elbow tendinopath*

S15. Tennis elbow

S16 S10 OR S11 OR S12 OR S13 OR S14 OR S15

S17 ergonomic intervention* OR ergonomic design* OR ergonomic training OR ergonomic* OR work station design OR job posture* OR work posture* OR working posture* OR rest period* OR taking break*

S18 S9 AND S16 AND S17

S19 randomised controlled trial OR controlled clinical trial OR randomised OR placebo OR clinical trials OR randomly OR trial

S20 S18 AND S19

PEDRO – Physiotherapy Evidence Database

Limitations: Methods: Clinical Trials; Year: 31 May 2013 onwards

Search terms:

1. Overuse

2. Occupation* (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

3. Work (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

4. Repetit* (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

5. Strain (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

6. Stress (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

7. Industr*

8. Motion (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

9. Mov* (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

10. Trauma*

11. Vibrat*

12. Musculoskeletal disease*

13. Carpal tunnel

14. Elbow tendinopath*

15. Tennis elbow

16. Neck* (Searched separately for subheadings: Musculoskeletal; and orthopaedics)

17. Shoulder* (Searched separately for subheadings: Musculoskeletal; and orthopaedics)

18. Arm* (Searched separately for subheadings: Musculoskeletal; and orthopaedics)

19. Upper limb* (Searched separately for subheadings: Musculoskeletal; and orthopaedics)

20. Upper extremit* (Searched separately for subheadings: Musculoskeletal; and orthopaedics)

21. Elbow* (Searched separately for subheadings: Musculoskeletal; and orthopaedics)

22. Forearm* (Searched separately for subheadings: Musculoskeletal; and orthopaedics)

23. Wrist* (Searched separately for subheadings: Musculoskeletal; and orthopaedics)

24. Hand* (Searched separately for subheadings: Musculoskeletal; and orthopaedics)

25. Finger* (Searched separately for subheadings: Musculoskeletal; and orthopaedics)

26. Ergonomic intervention (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

27. Ergonomic design* (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

28. Ergonomic training (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

29. Work station design (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

30. Job posture* (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

31. Work posture* (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

32. Working posture* (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

33. Rest period* (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

34. Taking break* (Searched under sub headings: Head & Neck; Upper arm, Shoulder & shoulder girdle; forearm & elbow; hand & wrist)

OTseeker – The Occupational Therapy Systematic Evaluation of Evidence Database

[Method] like ‘Randomised controlled trial’ NOT [Diagnosis/Subdiscipline] like ‘Neurology’ NOT [Diagnosis/Subdiscipline] like ‘Mental health/behavioural difficulties’ NOT [Diagnosis/Subdiscipline] like ‘Cardiovascular disorders’ NOT [Diagnosis/Subdiscipline] like ‘Developmental disorders/learning difficulties’ NOT [Diagnosis/Subdiscipline] like ‘Endocrine system disorders’ NOT [Diagnosis/Subdiscipline] like ‘Immune system dysfunction’ AND [Year Published] = ‘2013’ to 2019

The Cochrane Bone, Joint and Muscle Trauma Group Specialised Register

We will search the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register at bjmt.cochrane.org/our-evidence.

• By subtopic

• New‐update

The Cochrane Occupational Safety and Health Group Specialised Register 

We will search the Cochrane Occupational Safety and Health Group Specialised Register at work.cochrane.org/cochrane-reviews-about-occupational-safety-and-health.

• By subtopic

• New‐update

World Health Organization International Clinical Trials Registry Platform

1. ergonomic*

2. posture* And work*

3. rest period* AND work*

4. break* AND work*

5. design* AND work*

6. biomechanic* AND pain

7. computer* AND pain

Appendix 2. Criteria for a judgement of 'Yes' for the sources of risk of bias

See Table 1.

A. 1. Was the method of randomisation adequate?

A random (unpredictable) assignment sequence. Examples of adequate methods are coin toss (for studies with two groups), rolling of a dice (for studies with two or more groups), drawing of balls of different colours, drawing of ballots with the study group labels from a dark bag, computer‐generated random sequence, pre‐ordered sealed envelopes, sequentially ordered vials, telephone call to a central office and pre‐ordered list of treatment assignments.

Examples of inadequate methods include alternation, birth date, social insurance/security number, date on which they are invited to participate in the study and hospital registration number.

B. 2. Was the treatment allocation concealed?

Assignment was generated by an independent person not responsible for determining the eligibility of patients. This person has no information about the people included in the trial and has no influence on the assignment sequence or on the decision about eligibility of the patient.

C. Was knowledge of the allocated interventions adequately prevented during the study?

3. Was the participant blinded to the intervention?

This item should be scored 'Yes' if index and control groups were indistinguishable for the participants, or if the success of blinding was tested among the participants and it was successful.

4. Was the care provider blinded to the intervention?

This item should be scored 'Yes' if index and control groups were indistinguishable for the care providers, or if the success of blinding was tested among the care providers and it was successful.

5. Was the outcome assessor blinded to the intervention?

Adequacy of blinding should be assessed for the primary outcomes. This item should be scored 'Yes' if the success of blinding was tested among the outcome assessors and it was successful, or:

• for participant‐reported outcomes for which the participant is the outcome assessor (e.g. pain, disability): the blinding procedure is adequate for outcome assessors if participant blinding is scored 'Yes';

• for outcome criteria assessed during scheduled visit and that suppose a contact between participants and outcome assessors (e.g. clinical examination): the blinding procedure is adequate if participants are blinded, and if the treatment or adverse effects of the treatment cannot be noticed during clinical examination;

• for outcome criteria that do not suppose a contact with participants (e.g. radiography, magnetic resonance imaging): the blinding procedure is adequate if the treatment or adverse effects of the treatment cannot be noticed when the main outcome is assessed;

• for outcome criteria that are clinical or therapeutic events that will be determined by the interaction between participants and care providers (e.g. co‐interventions, hospitalisation length, treatment failure), in which the care provider is the outcome assessor: the blinding procedure is adequate for outcome assessors if item 'E' is scored 'Yes';

• for outcome criteria that are assessed from data extracted from the medical forms: the blinding procedure is adequate if the treatment or adverse effects of the treatment cannot be noticed in the extracted data.

D. Were incomplete outcome data adequately addressed?

6. Was the dropout rate described and acceptable?

The number of participants included in the study but who did not complete the observation period or were not included in the analysis must be described and reasons given. If the percentage of withdrawals and dropouts does not exceed 20% for short‐term follow‐up and 30% for long‐term follow‐up and does not lead to substantial bias, a 'Yes' is scored (note: these percentages are arbitrary, not supported by literature).

7. Were all randomly assigned participants analysed in the group to which they were allocated?

All randomly assigned participants are reported/analysed in the group to which they were allocated by randomisation for the most important moments of effect measurement (minus missing values), irrespective of non‐compliance and co‐interventions.

E. 8. Are reports of the study free of suggestion of selective outcome reporting?

To receive a 'Yes', the review author determines whether all results from all prespecified outcomes have been adequately reported in the published report of the trial. This information is obtained by comparing the protocol and the report or, in the absence of the protocol, by assessing that the published report includes enough information to make this judgement.

F. Other sources of potential bias

9.  Were the groups similar at baseline regarding the most important prognostic indicators?

To receive a 'Yes', groups have to be similar at baseline regarding demographic factors, duration and severity of complaints, percentage of participants with neurological symptoms and value of main outcome measure(s).

10. Were co‐interventions avoided or similar?

This item should be scored 'Yes' if there were no co‐interventions, or if they were similar between index and control groups.

11. Was the compliance acceptable in all groups?

The review author determines whether compliance with the interventions is acceptable, based on reported intensity, duration, number and frequency of sessions for both the index intervention and control intervention(s). For example, physiotherapy treatment is usually administered over several sessions; therefore, it is necessary to assess how many sessions each participant attended. For single‐session interventions (e.g. surgery), this item is irrelevant.

12. Was the timing of the outcome assessment similar in all groups?

Timing of outcome assessment should be identical for all intervention groups and for all important outcome assessments.

Note: these instructions are adapted from Furlan 2009 and the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2022).

Contributions of authors

PM, PS, SBZ, SS, BK and APV are responsible for drafting the protocol.

PM and PS will perform the search.

PM, PS, ST and APV will select studies and perform data extraction.

PM, PS, ST and APV will perform the analyses.

All authors will be responsible for the interpretation of results and for the final draft of the review.

Sources of support

Internal sources

• No sources of support provided

External sources

• No sources of support provided

Declarations of interest

PM: none.

PS: none.

ST: none.

SBZ: none.

SS: none.

BK: none.

APV: none.

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