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Cochrane Database of Systematic Reviews Review - Intervention

Ergonomic interventions for preventing work‐related musculoskeletal disorders of the upper limb and neck among office workers

Authors' declarations of interest

Version published: 23 October 2018 Version history

https://doi.org/10.1002/14651858.CD008570.pub3
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Background

Work‐related upper limb and neck musculoskeletal disorders (MSDs) are one of the most common occupational disorders worldwide. Studies have shown that the percentage of office workers that suffer from MSDs ranges from 20 to 60 per cent. The direct and indirect costs of work‐related upper limb MSDs have been reported to be high in Europe, Australia, and the United States. Although ergonomic interventions are likely to reduce the risk of office workers developing work‐related upper limb and neck MSDs, the evidence is unclear. This is an update of a Cochrane Review which was last published in 2012.

Objectives

To assess the effects of physical, cognitive and organisational ergonomic interventions, or combinations of those interventions for the prevention of work‐related upper limb and neck MSDs among office workers.

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, CINAHL, Web of Science (Science Citation Index), SPORTDiscus, Embase, the US Centers for Disease Control and Prevention, the National Institute for Occupational Safety and Health database, and the World Health Organization's International Clinical Trials Registry Platform, to 10 October 2018.

Selection criteria

We included randomised controlled trials (RCTs) of ergonomic interventions for preventing work‐related upper limb or neck MSDs (or both) among office workers. We only included studies where the baseline prevalence of MSDs of the upper limb or neck, or both, was less than 25%.

Data collection and analysis

Two review authors independently extracted data and assessed risk of bias. We included studies with relevant data that we judged to be sufficiently homogeneous regarding the interventions and outcomes in the meta‐analysis. We assessed the overall quality of the evidence for each comparison using the GRADE approach.

Main results

We included 15 RCTs (2165 workers). We judged one study to have a low risk of bias and the remaining 14 studies to have a high risk of bias due to small numbers of participants and the potential for selection bias.

Physical ergonomic interventions

There is inconsistent evidence for arm supports and alternative computer mouse designs. There is moderate‐quality evidence that an arm support with an alternative computer mouse (two studies) reduced the incidence of neck or shoulder MSDs (risk ratio (RR) 0.52; 95% confidence interval (CI) 0.27 to 0.99), but not the incidence of right upper limb MSDs (RR 0.73; 95% CI 0.32 to 1.66); and low‐quality evidence that this intervention reduced neck or shoulder discomfort (standardised mean difference (SMD) −0.41; 95% CI −0.69 to −0.12) and right upper limb discomfort (SMD −0.34; 95% CI −0.63 to −0.06).

There is moderate‐quality evidence that the incidence of neck or shoulder and right upper limb disorders were not considerably reduced when comparing an alternative computer mouse and a conventional mouse (two studies; neck or shoulder: RR 0.62; 95% CI 0.19 to 2.00; right upper limb: RR 0.91; 95% CI 0.48 to 1.72), and also when comparing an arm support with a conventional mouse and a conventional mouse alone (two studies) (neck or shoulder: RR 0.91; 95% CI 0.12 to 6.98; right upper limb: RR 1.07; 95% CI 0.58 to 1.96).

Workstation adjustment (one study) and sit‐stand desks (one study) did not have an effect on upper limb pain or discomfort, compared to no intervention.

Organisational ergonomic interventions

There is very low‐quality evidence that supplementary breaks (two studies) reduce discomfort of the neck (MD −0.25; 95% CI −0.40 to −0.11), right shoulder or upper arm (MD −0.33; 95% CI −0.46 to −0.19), and right forearm or wrist or hand (MD ‐0.18; 95% CI ‐0.29 to ‐0.08) among data entry workers.

Training in ergonomic interventions

There is low to very low‐quality evidence in five studies that participatory and active training interventions may or may not prevent work‐related MSDs of the upper limb or neck or both.

Multifaceted ergonomic interventions

For multifaceted interventions there is one study (very low‐quality evidence) that showed no effect on any of the six upper limb pain outcomes measured in that study.

Authors' conclusions

We found inconsistent evidence that the use of an arm support or an alternative mouse may or may not reduce the incidence of neck or shoulder MSDs. For other physical ergonomic interventions there is no evidence of an effect. For organisational interventions, in the form of supplementary breaks, there is very low‐quality evidence of an effect on upper limb discomfort. For training and multifaceted interventions there is no evidence of an effect on upper limb pain or discomfort. Further high‐quality studies are needed to determine the effectiveness of these interventions among office workers.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Ergonomic interventions for preventing work‐related musculoskeletal disorders of the upper limb and neck among office workers

What is the aim of this review?

The aim of this Cochrane Review was to find out if ergonomic interventions can prevent musculoskeletal pain or discomfort or both (musculoskeletal disorders; MSDs) among office workers. We collected and analysed all relevant studies to answer this question and found 15 studies.

Key messages

We found physical ergonomic interventions, such as using an arm support with a computer mouse based on neutral posture, may or may not prevent work‐related MSDs among office workers. We are still uncertain of the effectiveness of the other physical, organisational and cognitive ergonomic interventions.

What was studied in the review?

We selected office workers in our review, as they are a working population that has a higher risk for developing MSDs of the upper limb and neck. We assessed the effect of using ergonomic principles to improve the workplace and working process. Ergonomic refers to interactions among workers and other elements in the working environment, which includes physical, organisational and cognitive components. Physical ergonomic interventions include improving the equipment and environment of the workplace. The aim of these methods is to reduce the physical strain to the musculoskeletal system, thus reducing risk of injury. Meanwhile, organisational ergonomic interventions consist of allowing optimum workplace and rest time for the musculoskeletal system to recover from fatigue, thus reducing the risk of long‐term injury. Cognitive ergonomic interventions consist of improving mental processes such as perception, memory, reasoning and motor response through modifying work processes and training. The aim of these methods is to reduce mental workload, increase reliability and reduce error, which may have an indirect effect on reducing strain on the musculoskeletal system.

What are the main results of the review?

We found 15 studies that included 2165 workers. Fourteen of the studies conducted and reported their work poorly, and most of the studies had a small number of participants.

Out of the 15 studies, five studies evaluated the effectiveness of physical ergonomic interventions. Four studies evaluated the effectiveness of organisational ergonomic interventions, in the form of breaks or reduced working hours in preventing work‐related MSDs of the upper limb or neck, or both, among office workers. Five studies evaluated the effectiveness of ergonomic training, and one study evaluated multifaceted ergonomic interventions. We did not find any studies evaluating the effectiveness of cognitive ergonomic interventions.

Physical ergonomic interventions

We found that the use of an arm support or a mouse based on neutral posture may or may not prevent work‐related MSDs of the neck and shoulder. Workstation adjustment, and sit‐stand desks do not have an effect on upper limb pain compared to no intervention.

Organisational ergonomic interventions

We found that supplementary breaks may reduce neck and upper limb discomfort among data entry workers (two studies).

Cognitive ergonomic interventions

We found no studies using these methods.

Training interventions

There is no effect on upper limb pain compared to no intervention in five studies.

Mutlifaceted ergonomic interventions

There is no effect on pain or discomfort compared to no intervention in one study.

This means that there remains a need to conduct further studies to assess the effectiveness of ergonomic interventions.

How up‐to‐date is this review?

The review authors searched for studies that had been published up to 10 October 2018.

Authors' conclusions

Implications for practice

There is very low‐ to moderate‐quality evidence that arm supports or an alternatively designed computer mouse may or may not reduce the incidence of neck or shoulder musculoskeletal disorders (MSDs) among office workers.

There is low‐quality evidence showing that supplementary breaks may reduce discomfort of the neck, right shoulder, or upper limb or right forearm or wrist or hand in data entry workers.

While there is very low‐ to low‐quality evidence to suggest that training in ergonomic principles may not prevent work‐related MSDs of the upper limb or neck or both among office workers, this conclusion is limited by the number and heterogeneity of available studies.

Implications for research

We identified significant heterogeneity between the studies, and only one study had low risk of bias. Consequently, there is a need for more high‐quality randomised controlled trials (RCTs) examining ergonomic interventions for preventing disorders of the upper limb or neck, or both, among office workers. Most of the studies included in our review were conducted in the US, with only four studies from Canada, and one each from Finland and the UK. Studies from other parts of the world, especially from low‐ and middle‐income countries (LMICs), are therefore lacking. It is important to conduct studies of these interventions in developing countries, as differences in culture and work practices need to be considered. Conducting multicentre studies in both high‐income countries and LMICs will further increase the usefulness of the findings.

The main risk of bias that we identified in the included studies was concerning blinding (performance and detection bias). Although blinding of participants and personnel (performance bias) is difficult to achieve for ergonomic interventions, researchers need to consider minimising detection bias by having independent blinded assessors for diagnosing MSDs of the upper limb or neck, or both. Future studies also need to consider including independent medical examinations for diagnosis, or using injury records, workers' compensation records or other injury reporting systems to obtain more objective outcome data and minimise detection bias.

Studies included in this review used a number of different outcomes to measure discomfort and disability. The lack of standardisation in the methods used to assess these outcomes is therefore evident. Future research should therefore use standardised methods and validated instruments, especially when assessing discomfort and disability.

The majority of studies did not report details of random sequence generation or allocation concealment. Future studies should include a clear description of the randomisation process and include both random sequence generation and allocation concealment in their methods to minimise selection bias.

Summary of findings

Open in table viewer
Summary of findings for the main comparison. Arm support combined with alternative mouse versus conventional mouse alone

Patient or population: office workers
Settings: office environment using visual display units (> 20 h/week)
Intervention: an arm support combined with an alternative computer mouse
Comparison: conventional mouse alone (with no arm support)

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Conventional mouse alone

Arm support with alternative mouse

Incidence of upper body disorders (neck, shoulder, and upper extremity)
Questionnaire followed by medical examination
Follow‐up: 12 months

333 per 1000

220 per 1000
(140 to 347)

RR 0.66
(0.42 to 1.04)

191
(2 studies)

⊕⊕⊕⊝
moderate1

Incidence of neck or shoulder disorder
Questionnaire followed by medical examination
Follow‐up: 12 months

232 per 1000

120 per 1000
(63 to 229)

RR 0.52
(0.27 to 0.99)

186
(2 studies)

⊕⊕⊕⊝
moderate1

Incidence of right upper extremity disorder
Questionnaire followed by medical examination
Follow‐up: 12 months

174 per 1000

127 per 1000
(56 to 289)

RR 0.73
(0.32 to 1.66)

181
(2 studies)

⊕⊕⊕⊝
moderate1

Neck or shoulder discomfort score
Questionnaire
Follow‐up: 12 months

The mean neck or shoulder discomfort score in the intervention groups was
0.41 standard deviations lower
(0.69 to 0.12 lower) 4

194
(2 studies)

⊕⊕⊝⊝
low2,3

SMD −0.41 (−0.69 to −0.12) clinically meaningful difference

Right upper extremity discomfort score
Questionnaire
Follow‐up: 12 months

The mean right upper extremity discomfort score in the intervention groups was
0.34 standard deviations lower
(0.63 to 0.06 lower)4

194
(2 studies)

⊕⊕⊝⊝
low2,3

SMD −0.34 (−0.63 to −0.06) clinically meaningful difference

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio; VDU: visual display unit;SMD: standardised mean difference

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because the total number of participants is less than 300 (small sample size for a categorical variable).
2 Downgraded one level because total number of participants is less than 400 (small sample size for a continuous variable).
3 Downgraded one level because of study limitations (measure of outcome was based on subjective symptoms (detection bias)).
4 Lower discomfort score indicates beneficial effects.

Open in table viewer
Summary of findings 2. Arm support with conventional mouse versus conventional mouse alone

Patient or population: office workers
Settings: VDU users (more than 20 hours per week)
Intervention: arm support board (with conventional computer mouse)
Comparison: no arm support board (with conventional mouse)

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

No arm support board (with conventional mouse)

Arm support board (with conventional mouse)

Incidence of upper body disorders
Questionnaire followed by medical examination
Follow‐up: 12 months

333 per 1000

290 per 1000
(140 to 600)

RR 0.87
(0.42 to 1.80)

191
(2 studies)

⊕⊕⊝⊝
low1,2

Incidence of neck or shoulder disorder
Questionnaire followed by medical examination
Follow‐up: 12 months

232 per 1000

211 per 1000
(28 to 1000)

RR 0.91
(0.12 to 6.98)

186
(2 studies)

⊕⊕⊝⊝
low1,2

Incidence of right upper extremity disorders
Questionnaire followed by medical examination
Follow‐up: 12 months

185 per 1000

195 per 1000
(116 to 308)

OR 1.07
(0.58 to 1.96)

178
(2 studies)

⊕⊕⊕⊝
moderate2

Neck or shoulder discomfort score
Questionnaire
Follow‐up: 12 months

The mean neck or shoulder discomfort score in the intervention groups was
0.02 standard deviations higher
(0.26 lower to 0.3 higher) 5

195
(2 studies)

⊕⊕⊝⊝
low2,3

SMD 0.02 (−0.26 to 0.30) ‐ no significant difference

Right upper extremity discomfort score
Questionnaire
Follow‐up: median 12 months

The mean right upper extremity discomfort score in the intervention groups was
0.07 standard deviations lower
(0.35 lower to 0.22 higher) 5

195
(2 studies)

⊕⊕⊝⊝
low2,3

SMD −0.07 (−0.35 to 0.22) ‐ no significant difference

Right upper‐limb strain scale

Questionnaire

Follow‐up: 6 weeks

The mean right upper‐limb strain scale in the intervention groups was

3.00 lower

(34.47 lower to 28.47 higher) 5

14

(1 study)

⊕⊝⊝⊝
very low2,3,4

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; RR: Risk ratio; OR: Odds ratio; SMD: standardised mean difference; MD: mean difference

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because of high I² value (more than 50%), indicating heterogeneity.
2 Downgraded one level because of total number of participants less than 300 (small sample size for a categorical variable).
3 Downgraded one level because of limitations in studies (measure of outcome based on subjective symptoms (detection bias)).
4 Downgraded one level because of there is no information on sequence generation (selection bias).
5 Lower score indicates beneficial effects.

Open in table viewer
Summary of findings 3. Alternative mouse alone versus conventional mouse alone

Patient or population: office workers
Settings: VDU users (more than 20 hours per week)
Intervention: alternative computer mouse alone (no arm support)
Comparison: conventional mouse alone (no arm support)

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Conventional mouse alone (no arm support)

Alternative mouse alone (no arm support)

Incidence of upper body disorder (neck, shoulder and upper extremity)
Questionnaire followed by medical examination
Follow‐up: 12 months

333 per 1000

263 per 1000
(173 to 403)

RR 0.79
(0.52 to 1.21)

190
(2 studies)

⊕⊕⊕⊝
moderate1

Incidence of neck or shoulderdisorder
Questionnaire followed by medical examination
Follow‐up: 12 months

232 per 1000

144 per 1000
(44 to 463)

RR 0.62
(0.19 to 2)

182
(2 studies)

⊕⊕⊝⊝
low1,2

Incidence of right upper extremity disorder
Questionnaire followed by medical examination
Follow‐up: 12 months

185 per 1000

168 per 1000
(89 to 318)

RR 0.91
(0.48 to 1.72)

182
(2 studies)

⊕⊕⊕⊝
moderate1

Neck or shoulder discomfort score
Questionnaire
Follow‐up: 12 months

The mean neck or shoulder discomfort score in the intervention groups was
0.04 standard deviations higher
(0.26 lower to 0.33 higher) 5

195
(2 studies)

⊕⊕⊝⊝
low3,4

SMD 0.04 (−0.26 to 0.33) ‐ no significant difference

Right upper extremity discomfort score
Questionnaire
Follow‐up: 12 months

The mean rt upper extremity discomfort score in the intervention groups was
0 standard deviations higher
(0.28 lower to 0.28 higher) 5

195
(2 studies)

⊕⊕⊝⊝
low3,4

SMD 0 (−0.28 to 0.28) ‐ no significant difference

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; RR: Risk ratio; SMD: standardised mean difference

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because total number of participants less than 300 (small sample size for a categorical variable).
2 Downgraded one level because high I² value (over 50%), indicating heterogeneity.
3 Downgraded one level because limitations in studies (measure of outcome based on subjective symptoms (detection bias)).
4 Downgraded one level because total number of participants less than 400 (small sample size for a continuous variable).
5 Lower discomfort score indicates beneficial effects.

Open in table viewer
Summary of findings 4. Alternative workstation adjustment compared to no workstation adjustment

Patient or population: office workers
Settings: administrative work
Intervention: alternative workstation adjustment intervention
Comparison: no workstation adjustment

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

No workstation adjustment

Alternative workstation adjustment intervention

Neck or shoulder symptoms
Questionnaire
Follow‐up: 6 months

314 per 1000

248 per 1000

RR 1.08
(0.73 to 1.59)

254
(1 study)

⊕⊝⊝⊝
very low1,2,3

Arm or hand pain or discomfort
questionnaire
Follow‐up: 6 months

175 per 1000

210 per 1000

RR 0.83
(0.50 to 1.19)

245
(1 study)

⊕⊝⊝⊝
very low1,2,3

Intensity or severity of musculoskeletal pain

no data

no data

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; HR: Hazard ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because of limitations in studies (high risk of bias due to large dropout rate).
2 Downgraded one level because only one study available and thus inconsistency cannot be assessed.
3 Downgraded one level because total number of events (symptoms) is less than 300.

Open in table viewer
Summary of findings 5. Workstation adjustment according to OSHA/NIOSH recommendation compared to no workstation adjustment

Patient or population: office workers
Settings: office
Intervention: workstation adjustment according to Occupational Safety and Health Administration (OSHA)/Nastinal Institute of Occupational Safety and Health (NIOSH) recommendation
Comparison: no workstation adjustment

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

No workstation adjustment

Workstation adjustment according to OSHA/NIOSH recommendation

Neck or shoulder symptoms
questionnaire
Follow‐up: 6 months

295 per 1000

248 per 1000

RR 1.19
(0.79 to 1.79)

255
(1 study)

⊕⊝⊝⊝
very low1,2,3

Arm or hand symptoms
Ouestionnaire
Follow‐up: 6 month

192 per 1000

210 per 1000

RR 0.92
(0.56 to 1.50)

249
(1 study)

⊕⊝⊝⊝
very low1,2,3,

Intensity or severity of musculoskeletal pain

no data

no data

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; HR: Hazard ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because of high risk of bias due to high dropout rate.
2 Downgraded one level because of small sample size (only one study available and thus inconsistency cannot be assessed).
3 Downgraded one level because total number of events (symptoms) is less than 300.

Open in table viewer
Summary of findings 6. Sit‐stand workstation versus normal workstation

Patient or population: office workers
Settings: office setting
Intervention: sit‐stand workstation versus normal workstation

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Normal workstation

Sit‐stand workstation

Incidence or prevalence of musculoskeletal disorders

no data

no data

Intensity of neck and shoulder discomfort and pain
Self‐reported questionnaire
Follow‐up: 8 weeks

The mean discomfort and pain score was 1.9

The mean intensity of neck and shoulder discomfort and pain in the intervention groups was
0.3 lower
(1.69 lower to 1.09 higher)5

46
(1 study)

⊕⊝⊝⊝
very low1,2,3,4

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because the allocation of participants to the intervention and control arm were not concealed.
2 Downgraded one level because of limitations in studies (measured of outcome was based on subjective symptoms (detection bias)).
3 Downgraded one level because of limitations in studies (lack of prognostic balance: male/female participants were not distributed equally between intervention and control group).
4 Downgraded one level because of small number of participants (less than 400) in analysis using continuous variables.
5 Lower discomfort score indicates beneficial effects.

Open in table viewer
Summary of findings 7. Supplementary breaks versus normal breaks

Patient or population: office workers
Settings: office setting
Intervention: supplementary breaks versus normal breaks

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Normal breaks

Supplementary breaks

Incidence or prevalence of musculoskeletal disorders

no data

no data

After shift discomfort rating for neck (range 1 to 5)
Self‐reported questionnaire
Follow‐up: 4‐8 weeks

Mean discomfort rating was 1.55 4

The mean after shifts discomfort rating for neck (4‐8 weeks) in the intervention groups was
0.25 lower
(0.40 to 0.11 lower)5

186
(2 studies)

⊕⊝⊝⊝
very low1,2,3

After shift discomfort rating for right shoulder or upper arm
Self‐reported questionnaire
Follow‐up: 4‐8 weeks

Mean discomfort rating was 1.55 4

The mean after shifts discomfort ratings for right shoulder or upper arm (4‐8 weeks) in the intervention groups was
0.33 lower
(0.46 to 0.19 lower)5

186
(2 studies)

⊕⊝⊝⊝
very low1,2,3

After shift discomfort rating for right forearm or wrist or hand
Self‐reported questionnaire
Follow‐up: 4‐8 weeks

Mean discomfort rating was 1.45 4

The mean after shifts discomfort ratings for right forearm or wrist or hand (4‐8 weeks) in the intervention groups was
0.18 lower
(0.29 to 0.08 lower)5

186
(2 studies)

⊕⊝⊝⊝
very low1,2,3

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because of limitations in studies (possibility of carry‐over effects of cross‐over trials).
2 Downgraded one level because of limitations in studies (measured of outcome was based on subjective symptoms (detection bias)).
3 Downgraded one level because of small number of participants (less than 400) in analysis using continuous variables.
4 Taken from figure 1 in Galinsky 2007.
5 Lower discomfort rating indicates beneficial effect.

Open in table viewer
Summary of findings 8. Ergonomic training programme for preventing work‐related musculoskeletal disorders of the upper limb and neck in adults

Patient or population: office workers
Settings: working 5 hours or more per week with a VDU
Intervention: ergonomic training programme versus no training programme

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Ergonomic training program

Prevalence of Neck Musculoskeletal symptoms

Questionnaire

Follow‐up: at 6‐month

196 per 1,000

149 per 1,000

(96 to 234)

RR 0.76

(0.47 to 1.21)

614
(2 studies)

⊕⊕⊝⊝
low1,2

Prevalence of shoulder musculoskeletal symptoms

Questionnaire

Follow‐up: 6‐10 month

181 per 1,000

150 per 1,000

(107 to 212)

RR 0.82

(0.59 to 1.17)

614
(2 RCTs)

⊕⊕⊝⊝
low1,2

Prevalence of hand or wrist musculoskeletal symptoms

Questionnaire

Follow‐up: 6‐10 month

75 per 1,000

47 per 1,000

(27 to 81)

RR 0.63

(0.36 to 1.09)

724
(2 studies)

⊕⊕⊝⊝
low1,2

Prevalence of neck or shoulder MSD

Medical examination

Follow‐up: 6‐month

77 per 1,000

86 per 1,000

(46 to 161)

RR 1.12

(0.60 to 2.09)

455
(1 study)

⊕⊕⊝⊝
low1,3

Prevalence of hand or wrist MSD

Medical examination

Follow‐up: 6‐month

14 per 1,000

24 per 1,000

(6 to 87)

RR 1.73

(0.47 to 6.37)

503
(1 study)

⊕⊕⊝⊝
low1,3

Intensity of upper extremity pain

Questionnaire

Follow‐up: 3‐week

The mean intensity of upper extremity pain was 0

MD 0.08 higher
(0.22 lower to 0.38 higher) 4

‐

82
(1 study)

⊕⊝⊝⊝
very low1,2,3

Frequency of upper extremity pain

Questionnaire

Follow‐up: 3‐week

The mean frequency of upper extremity pain was 0

MD 0.03 lower
(0.45 lower to 0.39 higher) 4

‐

82
(1 study)

⊕⊝⊝⊝
very low1,2,3

Duration of upper extremity pain

Questionnaire

Follow‐up: 3‐week

The mean duration of upper extremity pain was 0

MD 0.13 higher
(0.25 lower to 0.51 higher) 4

‐

82
(1 study)

⊕⊝⊝⊝
very low1,2,3

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; RR: Risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because of limitations in studies (there is no information on sequence generation (selection bias)).
2 Downgraded one level because of limitations in studies (measured of outcome was based on subjective symptoms (detection bias)).
3 Downgraded one level because only one study available and thus inconsistency cannot be assessed.
4 Lower score indicates beneficial effect.

Open in table viewer
Summary of findings 9. Biofeedback (vibration) to reduce hand idle time on mouse versus no intervention

Patient or population: office workers
Settings: working in the office environment with a computer for at least 4 h/day
Intervention: biofeedback (vibration) to reduce hand idle time on mouse versus no intervention

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Biofeedback (vibration) to reduce hand idle time on mouse versus no intervention

Incidence or prevalence of musculoskeletal disorders

no data

no data

Shoulder pain intensity
Questionnaire survey
Follow‐up: 25 weeks

The mean shoulder pain intensity in the control groups was 1.58

The mean shoulder pain intensity in the intervention groups was
0.79 lower
(2.57 lower to 0.99 higher)4

23
(1 study)

⊕⊕⊝⊝
low1,2,3

Upper extremity pain intensity
Self‐administered questionnaire
Follow‐up: 25 weeks

The mean upper extremity pain intensity in the control groups was 2.94

The mean upper extremity pain intensity in the intervention groups was
1.64 lower
(6.85 lower to 3.57 higher) 4

23
(1 study)

⊕⊕⊝⊝
low1,2,3

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because of limitations in studies (measure of outcome based on subjective symptoms (detection bias)).
2 Downgraded one level because of total number of participants less than 400 (small sample size for a continuous variable).
3 Downgraded one level because of imprecision (95% confidence interval includes no effect).
4 Lower score indicate beneficial effect.

Background

Description of the condition

Work‐related musculoskeletal disorders (MSDs) are the most common occupational disorders around the world, and have been recognised as a problem since the 17th century (Ramazzini 1964). Other general terms for these disorders include repetitive strain injury, occupational overuse syndrome and cumulative trauma disorders (Yassi 1997). Work‐related upper limb and neck MSDs are musculoskeletal disorders of the neck and upper limbs, which include the shoulders, upper arms, elbows, forearms, wrists, and hands (Buckle 1999). These are also known as complaints of the arm, neck and/or shoulder (CANS) (Huisstede 2006). MSDs can be divided into specific conditions with clear diagnostic criteria and pathological findings, which include tendon‐related disorders (e.g. tendonitis), peripheral‐nerve entrapment (e.g. carpal tunnel syndrome), neurovascular/vascular disorders (e.g. hand‐arm vibration syndrome), and joint/joint‐capsule disorders (e.g. osteoarthritis) or non‐specific conditions where the main complaint is pain or tenderness, or both, with limited or no pathological findings (Buckle 1997; Su 2013; Yassi 1997).

Based on the Global Burden of Disease 2010 study, the global point prevalence of neck pain was estimated to be 4.9% (95% confidence interval: 4.6 to 5.3), and was ranked fourth highest in terms of disability as measured by years lived with disability (YLDs) and 21st in term of overall burden (Hoy 2014). Moreover the cost of work‐related upper limb MSDs in the European Union (EU) has been reported to be high, with estimates ranging from 0.5% and 2% of gross national product (Buckle 1999). In Australia, disorders of the muscles, tendons, and soft tissue (excluding back pain) were estimated to cost AUD 519 million or 17% of the total health system costs in 1993 and 1994 (Mathers 1999). In the United Kingdom (UK), MSDs were recorded as the second highest reason for sickness certification in 2005, with an average of 22.84 sickness certificates being issued per 1000 person‐years (Wynne‐Jones 2009). In the UK in 2014/15 an estimate of 4.1 million working days were lost due to work‐related upper limb MSDs, which represents around 15% of all days lost due to work related ill‐health (HSE 2015). In the United States, the costs associated with musculoskeletal conditions accounted for 5.73% of GDP and 74% of the total work days lost in 2012. The direct per‐person healthcare costs for those with MSDs were estimated to be 7,104 USD in 2009‐2011 and accounted for around 30% of the injuries involving days absent from work. Those people with MSDs who were absent from work were away for a median of 11 days(USBJI 2015).

Over the past decades there has been an increase in the number of office workers in both developing and developed nations. This has been primarily attributed to the rapid development of knowledge‐based economies, which are directly based on the production, distribution and use of knowledge and information (OECD 1996). The emergence of new technologies, including the proliferation of personal computers, the internet and mobile devices has also contributed to the growth (Powell 2004). The nature of office‐based work has also subsequently changed from administrative and clerical work, to the production, distribution and use of knowledge. The office boundaries have expanded and are not limited to physical space but may include mobile workers and other offices throughout the world due to the ease of communication. Data processing, customer support, sales, and many other office processes may now be performed in developing countries (Subbarayalu 2013). Thus, not only has the office workers’ workforce grown in numbers it has also changed and diversified.

While we were not able to identify any systematic reviews that specifically reported prevalence of MSDs, including work‐related upper limb and/or neck MSDs, among office workers, several large cohort studies have reported these data. A Danish study of 5033 computer users reported the 12‐month prevalence for shoulder MSDs and wrist‐hand MSDs to be 44.7% and 25.8% respectively (Jensen 2003). Moreover, a UK study reported the 12‐month prevalence of neck MSDs to be 58% among data processing workers and 33% among other office workers (Woods 2005), while a Belgian study reported, the 12‐month prevalence of neck MSDs among office workers was 45.5%, (Cagnie 2007) and in Sweden the 12‐month prevalence of neck or shoulder MSDs among visual display terminal workers was 61.5% (Bergqvist 1995). In a large multicentre study involving 18 countries among more than 4000 office workers, the prevalence of disabling wrist and hand pain in the past month ranged from 2.2% in Pakistan and 2.3% in Japan to 31.3% in Brazil and 31.6% in Nicaragua (Coggon 2012; Coggon 2013a). The differences in prevalence rates reported by these studies may be a result of: the absence of a universally accepted definition of MSDs, the use of different diagnostic criteria (e.g. self‐reported or medical examination), and the variation in office work and office environments between these cultures and countries (Buckle 1999; Coggon 2013b; Huisstede 2006 ).

A number of studies have examined risk factors for MSDs and identified a variety of factors. These include individual factors (e.g. inadequate strength, poor posture, mental health, somatisation tendency, work‐causation beliefs, fear‐avoidance beliefs, cultural factors), physical requirements at the workplace (e.g. work requiring prolonged static posture, highly repetitive work, use of vibrating tools), and organisational and psychosocial factors (e.g. poor work‐rest cycle, shift work, low job security, little social support) (Bernard 1997; Buckle 1997; Coggon 2013a; Coggon 2013b; Hoe 2012b; Marras 2009; NIOSH 2001; Shanahan 2006; Yassi 1997).

Description of the intervention

Ergonomics as defined by the International Ergonomics Association (IEA) is the scientific discipline concerned with the understanding of the interactions among humans and other elements of a system. Ergonomics in the workplace refers to interactions among workers and other elements in the working environment. It is essentially about fitting the job to the worker. The IEA categorised ergonomics into three specific domains: physical, organisational and cognitive ergonomics.

The physical domain is concerned with human anatomical, anthropometric, physiological and biomechanical characteristics as they relate to physical activity. This domain consists of work environment and equipment, for example keyboard, mouse, hand tools, workstations, visual display units (VDUs) and lighting that are fitted to the workers.

The organisational domain is concerned with the optimisation of socio‐technical systems, including the organisational structures, policies and processes; for example work pace, work‐rest cycle and worker's participation in decision making.

The cognitive domain is concerned with mental processes, such as perception, memory, reasoning and motor response.

Ergonomic interventions have been heavily promoted for the prevention of work‐related upper limb or neck MSDs, or both (NIOSH 1997; NIOSH 2001). The current review will encompass interventions that focus on all three domains: the physical, organisational and cognitive domains.

How the intervention might work

Many studies have found that ergonomic factors correlate with musculoskeletal symptoms (Bernard 1994; Bonfiglioli 2006; Ortiz‐Hernandez 2003; Szeto 2009; Werner 2005). Adjusting physical, organisational and cognitive ergonomic factors to reduce the physical and mental load on workers is likely to reduce the risk of workers developing work‐related MSDs of the upper limb, neck or both.

Physical ergonomic interventions include providing workspace and equipment based on ergonomic principles and the anthropometry of workers. This will reduce the physical strain to the musculoskeletal system, thus reducing risk of injury. An example is the use of a split keyboard that has been found to reduce the severity of pain in computer users with MSDs (Tittiranonda 1999).

Organisational ergonomic interventions consists of allowing optimum work pace and rest time for the musculoskeletal system to recover from fatigue, thus reducing the risk of long term injury. An example is allowing supplementary breaks for data entry workers (Galinsky 2000). It can also include participatory interventions, where the workers participate in decision making on improvement and changes made at the workplace (Bohr 2000), and training in ergonomic principles and practices (Baydur 2016).

Cognitive ergonomics intervention consists of improving mental processes such as perception, memory, reasoning and motor response through modifying work process and training. This will reduce mental workload, increase reliability and reduce error, this may have an indirect effect in reducing strain on the musculoskeletal system.

Why it is important to do this review

A systematic review of interventions for the prevention and treatment of work‐related upper limb MSDs by Boocock 2007 evaluated studies published between 1999 and 2004. The authors concluded that there is some evidence to support the use of mechanical and modifier interventions for preventing and managing neck or upper extremity musculoskeletal conditions (Boocock 2007). However, there is a limitation in that the authors did not identify specific worker groups. Another systematic review by Kennedy 2010, which focused on the role of occupational health and safety interventions, found that the use of arm supports reduced upper extremity musculoskeletal diseases (MSDs) in office workers. However, Kennedy 2010 did not clearly define their search period. A more recent systematic review by Van Eerd 2016, which is an update of the Kennedy 2010 systematic review (updated search period between 2008 and 2013), found moderate evidence for vibration feedback about static mouse use and forearm supports in preventing work‐related MSDs of the upper limb or neck, or both, in office workers. Van Eerd 2016 also found moderate evidence for no effect for electric myogram (EMG) biofeedback, job stress management training, and office workstation adjustment for work‐related MSDs of the upper limb or neck, or both. However, in addition to randomised controlled trials (RCTs), Boocock 2007, Kennedy 2010 and Van Eerd 2016 included in their reviews other study designs that are at greater risk of bias. What is more, the three systematic reviews did not conduct meta‐analysis.

Our review extends and updates the search period covered by these three reviews and considers all published and unpublished randomised and quasi‐randomised trials investigating the use of physical, organisational and cognitive ergonomic interventions for the prevention of work‐related upper limb MSDs among office workers. We also conducted meta‐analysis of results from studies with comparable interventions and outcomes. Furthermore, this review is an update of our previous Cochrane Review (Hoe 2012a). In our previous review (Hoe 2012a), we included all workplaces and work settings, whereas in this review we focus only on the office setting. Other Cochrane Reviews will examine the effectiveness of interventions in different work settings. One example is Mulimani 2014, which investigates ergonomic interventions among dental care practitioners.

Objectives

To assess the effects of physical, organisational and cognitive ergonomic interventions, or combinations of those interventions for the prevention of work‐related upper limb and neck musculoskeletal disorders (MSDs) among office workers.

Methods

Criteria for considering studies for this review

Types of studies

We included randomised controlled trials (RCTs), quasi‐randomised trials (trials which use methods of allocating participants to a treatment that are not strictly at random, e.g. by date of birth, hospital record number or alternative), cluster‐RCTs (i.e. where the unit of randomisation is a group of people, such as people working in the same office or shift rather than individual workers) and cross‐over trials (i.e. where participants are randomly allocated to a sequence of interventions).

Types of participants

We included studies where participants were office workers at the time of the intervention. Office workers were defined as those working in an office environment where their main tasks involved performing professional, managerial or administrative work. Because this review is focused on prevention of work‐related musculoskeletal disorders (MSDs) of the upper limb or neck or both, the majority of participants (75% or more) were required to be free of MSDs of the upper limb or neck, or both, at the time of the intervention. We only included studies conducted at the workplace.

We excluded studies evaluating treatment interventions for people with established MSDs of the upper limb or neck, or both (there are Cochrane systematic reviews conducted by Aas 2011, and Verhagen 2013, that have already covered workplace interventions for neck pain in workers and conservative interventions for treating work‐related complaints of the arm, neck or shoulder in adults). We also excluded studies that focus on rehabilitation of people with acute or chronic conditions (e.g. trauma, neoplasm, and inflammatory or neurological diseases).

Types of interventions

We included studies that examined at least one physical, organisational or cognitive ergonomic intervention in the workplace, aimed at the prevention of work‐related MSDs of the upper limb or neck, or both, among office workers. We excluded studies that tested ergonomic interventions for the treatment of individuals diagnosed with work‐related MSDs of the upper limb or neck, or both, or for prevention of work‐related MSDs of the upper limb or neck, or both, outside the office environment.

Interventions and specific comparisons

We categorised interventions as:

  1. physical ergonomic interventions, such as the use of a specially designed computer mouse or arm support;

  2. organisational ergonomic interventions, such as a different work‐rest cycle;

  3. cognitive ergonomic interventions, such as job design;

  4. training in ergonomic principles; and

  5. multifaceted interventions that consist of a combination of one or more physical, organisational or cognitive interventions.

We planned the following main comparisons:

  1. physical ergonomic intervention versus no intervention, placebo, or alternative intervention;

  2. organisational ergonomic intervention versus no intervention, placebo, or alternative intervention;

  3. cognitive ergonomic intervention versus no intervention, placebo, or alternative intervention;

  4. training versus no training in ergonomic principles or versus alternative training; and

  5. multifaceted interventions versus a single intervention or a different combination of interventions.

Types of outcome measures

We included studies based on the following primary and secondary outcomes.

Primary outcomes

  1. Number of workers with newly diagnosed or verified MSDs of the upper limb or neck, or both (incident cases).

  2. Presence or severity or intensity of complaints or symptoms of pain or discomfort in the upper limb or neck, or both, using a dichotomised scale (e.g. yes/no), Likert scale, visual analogue scale (VAS), or any similar scale measuring pain or discomfort.

  3. Work‐related function as measured by number of work days lost, loss of or change in job, work disability, and level of functioning. For the level of functioning, we included studies using validated outcome measures e.g. Disability of the Arm, Shoulder, and Hand (DASH) questionnaire (Kitis 2009), and Northwick Park Neck Pain Questionnaire (Leak 1994).

Secondary outcomes

Secondary outcomes included the following.

  1. Time and comfort in work positions or postures.

  2. Change in productivity.

  3. Costs (including costs of implementation of the intervention and treatment).

  4. Compliance (attitude and practice). Compliance is the degree of how well study participants adhere to the prescribed intervention. We considered compliance as a secondary outcome as it indicates the intervention take‐up rate.

We only included studies that reported one or more primary outcomes in this review. If a study only reported one or more secondary outcomes, then we excluded that study from this review.

Search methods for identification of studies

Electronic searches

We systematically searched the following databases:

  1. Cochrane Central Register of Controlled Trials (Issue 9, September 2018) in the Cochrane Library (Appendix 1);

  2. Ovid MEDLINE(R) and In‐Process & Other Non‐Indexed Citations and Daily (1948 to 17 September, 2018 (Appendix 2);

  3. Embase (1980 to 29 May 2017) (Appendix 3);

  4. Web of Science (Search date: 18 September, 2018) (Appendix 4);

  5. CINAHL (EBSCOhost) (Search date: September 18, 2018) (Appendix 5);

  6. SPORTDiscus (1949 to 10 October, 2018) (Appendix 6);

  7. Scopus (Search date: 21 September, 2018, limit to 2017 and 2018 studies) (Appendix 7);

  8. NIOSHTIC‐2 (Search date: 21 September, 2018) (Appendix 8)

From May 2017 onwards we replaced the Embase search with a search in Scopus because of ease of access and because the latter contains everything included in the former.

We searched the following websites and databases for unpublished and ongoing studies:

  1. World Health Organization International Clinical Trials Registry Platform (10 October 2018);

We considered reports published in all languages. The searches were based on the MEDLINE search strategy combined with the sensitivity‐ and precision‐maximising version of the Cochrane Highly Sensitive Search Strategy for identifying RCTs (Lefebvre 2011) (see Appendix 2). We modified the search strategy to use in the other databases.

Searching other resources

We contacted experts in the field to identify theses and unpublished studies. We looked for additional studies by checking the bibliographies of relevant articles.

Data collection and analysis

Selection of studies

Two review authors (VCWH and ENZ) obtained and screened abstracts and citations identified by the systematic searches. The full‐text articles of studies identified as being potentially eligible for the review were retrieved to further determine their inclusion (VCWH and ENZ). We resolved all disagreements by discussion between the review authors to reach a consensus. Where there was uncertainty, we contacted the corresponding author to ascertain whether a potentially relevant study met the inclusion criteria.

Data extraction and management

Two review authors (VCWH and ENZ) performed data extraction independently, with checks for discrepancies and processing as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved all discrepancies by discussion and consensus. We used a standard data extraction form based on the form recommended by the Cochrane Bone, Joint and Muscle Trauma Group. We performed all statistical analyses using Review Manager 5.3 (RevMan 2014) software.

Assessment of risk of bias in included studies

Two review authors (VCWH and ENZ) assessed the risk of bias of included studies independently using Cochrane's 'Risk of bias' tool (Appendix 9) (Higgins 2011). We assessed each study for risk of bias in each of the following domains: sequence generation, allocation concealment, blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data, selective outcome reporting, and 'other', such as contamination bias and reliability of instruments. We assessed the risk of bias associated with (a) blinding and (b) completeness of outcomes separately for self‐reported outcomes and objective outcomes. We resolved disagreements between authors regarding the risk of bias for domains by discussion and consensus.

We considered a study to have low risk of bias overall if we judged it to have a low risk of bias in the domains random sequence generation (selection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias) and other forms of bias. We did not include allocation concealment (selection bias), blinding of participants and personnel (performance bias), and blinding of outcome assessment (detection bias) in the criteria for classifying the included studies' overall risk of bias because of the nature of the intervention, which requires fully aware participation of participants and personnel, and because the main outcome, pain, is a subjective symptom (International Association for the Study of Pain).

Measures of treatment effect

We plotted the results of each trial as point estimates, using risk ratios (RRs) for dichotomous outcomes, and means and standard deviations (SDs) for continuous outcomes. When studies reported different outcome measures but measured the same concept, we calculated the standardised mean difference (SMD) with 95% confidence interval (CI). For studies that had reported outcome data for both the right and left upper limb, we only used the outcome data for the right upper limb.

Unit of analysis issues

If studies employed a cluster‐randomised design, but did not take the cluster effect into account, we tried to adjust the data for the effect of clustering by calculating the design effect based on an assumed intra cluster correlation of 0.1.

Dealing with missing data

We dealt with missing data according to the recommendations in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011), that is, we contacted study authors to request missing data.

Assessment of heterogeneity

First, we assessed whether studies were sufficiently homogeneous to be included in one comparison. We based this judgment on the similarity of the type of interventions, what the control condition was, the outcome and when the outcome was measured (short term: three to eight weeks, intermediate: eight weeks to six months, or long‐term: six months or longer).

Second, we tested for statistical heterogeneity by means of the I² statistic as presented in the meta‐analysis graphs generated by the Review Manager 5 software (RevMan 2014). When this test statistic was greater than 50% we considered there to be substantial heterogeneity between studies. In such cases we employed the random‐effects meta‐analysis and we downgraded the quality of evidence according to the GRADE system for the relevant comparisons.

Assessment of reporting biases

If, in future updates of this review, we are able to pool more than ten trials in any single meta‐analysis, we will create and examine a funnel plot to explore possible small study biases.

Data synthesis

We pooled results of studies if they had a similar type of intervention, control conditions, and outcome. When studies were statistically heterogeneous, we used a random‐effects model; otherwise we used a fixed‐effect model. We pooled study results data with Review Manager 5 software (RevMan 2014).

We considered the types of interventions evaluated in each of the studies and found the studies assessing the effectiveness of ergonomic computer mouse or arm support (physical ergonomic interventions), supplementary breaks or reduced work hours (organisational ergonomic interventions), and ergonomic training (cognitive ergonomic interventions) to be sufficiently similar to be pooled for comparison.

We assessed the overall quality of the evidence contributing to the primary outcomes for each important intervention, using the GRADEpro GDT software (GRADEpro GDT).

Our judgement of the quality of the evidence for a specific intervention‐outcome combination was based on performance against the five GRADE domains: limitations of study design, inconsistency, indirectness (inability to generalise), imprecision (insufficient or imprecise data) of results, and publication bias across all studies that measured that particular outcome. The overall quality of the evidence for each outcome is the result of a combination of the assessments in all domains.

There are four grades of evidence:

  1. high‐quality evidence: there are consistent findings among at least 75% of RCTs with no limitations of the study design, consistent, direct and precise data and no known or suspected publication biases. Further research is unlikely to change either the estimate or our confidence in the results;

  2. moderate‐quality evidence: one of the domains is not met. Further research is likely to have an important impact on our confidence in the estimate of effect and might change the estimate;

  3. low‐quality evidence: two of the domains are not met. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate;

  4. very‐low‐quality evidence: three of the domains are not met. We are very uncertain about the estimate.

Subgroup analysis and investigation of heterogeneity

If, in future updates of this review, we can include a sufficient amount of data we will conduct subgroup analyses based on: type of job, gender, and rigour of outcome measurement.

Sensitivity analysis

If, in future updates of this review, we can include a sufficient amount of data we will undertake sensitivity analyses by excluding the studies we judge to have a high risk of bias. In the current review this was not possible as we judged only one study to have a low risk of bias.

Results

Description of studies

Results of the search

Our search strategy identified 2547 potentially relevant references after duplicates had been removed. Two review authors (VCWH and ENZ) assessed the titles, keywords, and abstracts of these references, and selected 48 potentially eligible references. We obtained the full‐text publications for these 48 references.

We did not identify any additional references by searching the following additional databases: the US Centers for Disease Control and Prevention National Institute for Occupational Safety and Health (NIOSHTIC‐2) database, and the International Occupational Safety and Health Information Centre (CIS) database. Our search for unpublished and ongoing studies, through the World Health Organization International Clinical Trials Registry Platform, identified one additional registered trial (Shariat 2016).

We checked the reference lists of all articles that we retrieved as full‐text papers in order to identify potentially eligible studies. We did not identify any additional studies through this approach. Of the 48 full‐text reports and one registered trial identified, we included 15 studies reported in 17 publications. We excluded 24 studies reported in 30 publications. We also identified two ongoing studies (Johnston 2014; Shariat 2016). See the PRISMA study flow diagram (Figure 1) for our description of the whole study inclusion process.

Figure 1
PRISMA study flow diagram

PRISMA study flow diagram

Included studies

We included 15 studies reported in 17 publications. These studies recruited a total of 2165 participants. For further details regarding the study populations and settings, see the Characteristics of included studies table.

Study Design

All of the included studies were randomised controlled trials (RCTs); two used a cluster‐randomised design (Brisson 1999; Baydur 2016), and another two used a cross‐over design (Galinsky 2000; Galinsky 2007).

Location and settings

Nine studies were conducted in the United States (Bohr 2000; Bohr 2002; Conlon 2008; Galinsky 2000; Galinsky 2007; Gatty 2004; Gerr 2005; Greene 2005; Rempel 2006), three were conducted in Canada (Brisson 1999; McLean 2001; King 2013), and the remaining three studies were conducted in Finland (Lintula 2001), the United Kingdom (Graves 2015), and Turkey (Baydur 2016).

Three studies were conducted in data processing or call centres (Galinsky 2000; Galinsky 2007; Rempel 2006), four studies in universities or colleges (Brisson 1999; Gatty 2004; Greene 2005; Graves 2015), two studies in a transportation company (Bohr 2000; Bohr 2002), one study in an aerospace firm (Conlon 2008), one study among office workers in a municipality (Baydur 2016), one study among office employees and researchers (Lintula 2001), one study in a research organisation (King 2013), and two studies involved several sectors (insurance and financial companies, food product producers, government offices, and universities) (Gerr 2005; McLean 2001).

Type of work

All studies were conducted with participants who were using computers or who were conducting data processing in an office environment (Baydur 2016, Bohr 2000; Bohr 2002; Brisson 1999; Conlon 2008; Galinsky 2000; Galinsky 2007; Gatty 2004; Gerr 2005; Graves 2015; Greene 2005; King 2013; Lintula 2001; McLean 2001; Rempel 2006).

Type of interventions
Physical ergonomic interventions

Five studies evaluated physical ergonomic interventions alone, which consisted of alternative computer mouse or arm supports, or both (Conlon 2008; Rempel 2006), arm support alone (Lintula 2001), sit‐stand workstation (Graves 2015) and ergonomic posture intervention (Gerr 2005).

Organisational ergonomic interventions

Four studies evaluated organisational ergonomic interventions in the form of supplementary breaks or reduced work hours (Galinsky 2000; Galinsky 2007; McLean 2001; King 2013). Although the intervention was a biofeedback mouse in one study (King 2013), the objective of the mouse was to ensure workers take breaks from using the mouse.

Cognitive ergonomic interventions

No study specifically addressed cognitive processes.

Training programmes

Five studies evaluated ergonomic training programmes (Baydur 2016; Bohr 2000; Bohr 2002; Brisson 1999; Greene 2005).

Multifaceted ergonomics interventions

One study evaluated a combination of organisational and physical ergonomic interventions (Gatty 2004), which consisted of training, workstation redesign and task modification.

Follow‐up period

Five studies had a short follow‐up period of between four and eight weeks (Galinsky 2000; Galinsky 2007; Graves 2015; Greene 2005; Lintula 2001; McLean 2001). One study had an intermediate‐term follow‐up period of 16 weeks (Gatty 2004), and eight studies had a long‐term follow‐up period of between six and 13 months (Baydur 2016, Bohr 2000; Bohr 2002; Brisson 1999; Conlon 2008; Gerr 2005; King 2013; Rempel 2006).

Outcomes

The incidence of musculoskeletal disorders (MSDs) was measured in three studies (Conlon 2008; Gerr 2005; Rempel 2006), and the prevalence of MSDs was measured in a further three studies (Brisson 1999; Gatty 2004; Greene 2005). The severity, intensity, discomfort, and strain associated with musculoskeletal conditions were measured in 13 studies (Baydur 2016; Bohr 2000; Bohr 2002; Conlon 2008; Galinsky 2000; Galinsky 2007; Gatty 2004; Graves 2015; Greene 2005; King 2013; Lintula 2001; McLean 2001; Rempel 2006).

One study assessed disability (Baydur 2016).

Seven studies assessed compliance to interventions (Bohr 2000; Bohr 2002; Brisson 1999; Gatty 2004; Gerr 2005; Graves 2015; King 2013).

Unit of analysis

Brisson 1999, reported the number of clusters and the intracluster correlation coefficients (ICCs) for the neck or shoulder (0.0161) and for the wrist or hand (0.0007). The design effect of the study is calculated using the formula 1 + (average cluster size −1) x ICC. The results of the design effect are then used to calculate the effective (reduced) sample size. Baydur 2016 also provided us with the number of clusters. Based on the intracluster correlation coefficients of Brisson 1999 we adjusted the effective sample size for this study as well.

Dealing with missing data

We contacted five authors for clarification and additional data relating to six studies (Baydur 2016; Bohr 2000; Bohr 2002; Brisson 1999; Galinsky 2000; Galinsky 2007; McLean 2001), and we were able to use the additional data for four studies (Baydur 2016; Brisson 1999; Galinsky 2000; Galinsky 2007).

For Baydur 2016 we received the additional information that the number of clusters was 16 in the control group with a total of 58 workers and similarly there were 16 clusters in the intervention group with a total of 58 workers. For the cross‐over trials, Galinsky 2000 and Galinsky 2007, we conducted our own paired analysis. For the analysis we received from the author data about the means and standard deviations of discomfort ratings after the intervention and after the control condition. We used the square root of the F‐value as reported by the authors as a best estimate of the T‐value to enable the calculation of the SE of the MD. We also calculated the SE based on assumed correlations of 0.5, 0.7 and 0.9 between the discomfort ratings of the intervention and control condition as proposed in the Handbook chapter 16.4.6. The assumption of a correlation of 0.85 agreed best with the values derived of the F‐value and we took this correlation for imputing the SE values for both studies.

Excluded studies

Altogether we excluded 24 studies published in 30 reports. We excluded 14 studies because more than 25% of the participants reported musculoskeletal symptoms of the upper limb or neck, or both, at baseline (Danquah 2017; Dropkin 2015; Esmaeilzadeh 2014; Fostervold 2006; Ketola 2002; Levanon 2012; Mahmud 2011; Mann 2013; Meijer 2009a; Meijer 2009b; Mekhora 2000; Parry 2015; Ripat 2006; Spekle 2010). We excluded three studies because they were not RCTs (Aaras 1998; Amick 2003; Amick 2012), and a further three studies because they had not measured the effectiveness of interventions on disorders of the upper limb or neck, or both (Chau 2014; De Cocker 2016; Krause 2010). We excluded two more studies (one of which, Thorp 2014, was reported in two reports) because they were conducted in a laboratory setting (Robertson 2013; Thorp 2014). We excluded two studies (one of which, Driessen 2008, was reported in six reports) where the participants consisted of workers other than office workers (Driessen 2008; Faucett 2002). For further details regarding the study populations and settings see the Characteristics of excluded studies table. In addition to the 24 studies excluded in this review update, we also excluded the studies that were not undertaken in office workers that had been included in the previous version of this review (Hoe 2012a): von Thiele 2008 and Yassi 2001.

Risk of bias in included studies

Allocation

Five studies (Conlon 2008; Gerr 2005; Graves 2015; King 2013; Rempel 2006) used a random number table or equivalent for generating a random sequence and therefore we judged them to have a low risk of allocation bias. In Graves 2015, it was indicated that they completed allocation by alternating between intervention and control, and that they did not conceal the allocation, so we judged this study as having high risk of bias. All the other studies did not report using adequate measures for concealing allocation, such as using sealed opaque envelopes, and thus we judged them to have an unclear risk of bias.

Blinding

Blinding of the interventions was not performed in most of the studies, as blinding of physical, organisational and cognitive ergonomic interventions is difficult to achieve. Therefore, we judged 12 studies to have a high risk for performance bias. The remaining three studies assessed organisational ergonomic interventions of work breaks and work hours (Galinsky 2000; Galinsky 2007; McLean 2001). Although complete blinding for breaks was not possible in these studies, the use of a strict protocol for taking breaks by the use of either custom‐made electrical timers, or the 'Ergobreak' computer programme, minimised the risk of bias. Therefore, we judged these three studies to have a low risk of performance bias.

Although in three studies (Brisson 1999; Conlon 2008; Rempel 2006), the physical examination for the detection of MSD was blinded, the examination was only performed on participants who self‐reported symptoms meeting the case definition, which may lead to detection bias. Thus, we rated the risk of detection bias as high for all 15 studies.

Incomplete outcome data

Four studies conducted an intention‐to‐treat (ITT) analysis (Conlon 2008; Gerr 2005; King 2013; Rempel 2006), one study had no loss to follow‐up (Lintula 2001), and four studies had a low drop‐out rate (Baydur 2016; Brisson 1999; Graves 2015; King 2013). We rated these nine studies as having a low risk of attrition bias. We rated five studies (Bohr 2000; Bohr 2002; Galinsky 2000; Galinsky 2007; Gatty 2004) as having a high risk of attrition bias, as they did not conduct ITT analyses. In addition, one of these five studies had an uneven drop‐out rate across the groups (Bohr 2000), and four studies had a high drop‐out rate (Galinsky 2000; Galinsky 2007; Gatty 2004; Bohr 2002). We rated two studies as having an unclear risk of attrition bias as they did not conduct ITT analyses and information on their drop‐out rate was limited (Greene 2005; McLean 2001).

Selective reporting

We judged all 15 included studies to be free of selective reporting because they reported all outcomes described in the methods.

Other potential sources of bias

We judged 11 studies to have a high risk of bias from other potential sources (Baydur 2016; Bohr 2000; Bohr 2002; Brisson 1999; Conlon 2008; Galinsky 2007; Gatty 2004; Gerr 2005; Graves 2015; Lintula 2001; McLean 2001), two studies to have a low risk of other bias (Galinsky 2000; Rempel 2006), and another two studies had an unclear risk of other bias (Greene 2005; King 2013).

Five studies did not report baseline data on the outcome measures (Baydur 2016; Bohr 2000; Brisson 1999; Lintula 2001; McLean 2001). In Gatty 2004, the intervention group had lower average wrist‐hand and upper back ache or pain intensity compared to the control group. In Conlon 2008, the participants who volunteered for the study had higher levels of discomfort than non‐participants. In two studies (Bohr 2000; Bohr 2002), the close proximity of the workstations may have led to contamination of the intervention effect. In another two studies (Gerr 2005; Bohr 2002), there were large numbers of dropouts in the intervention and control groups; and although in Gerr 2005, the authors conducted ITT analysis, the large number of dropouts may have affected the findings. In the two cluster‐RCTs (Brisson 1999; Baydur 2016), the latter did not report cluster size.

Of the two cross‐over RCTs (Galinsky 2000; Galinsky 2007), the latter had potential for a carry‐over effect. The authors did not report if they had a wash‐out period between the two data collection periods.

Overall risk of bias per study

Overall, we found that the risk of bias in the included studies was high. Of the 15 studies, we judged only one study, Rempel 2006, to have a low risk of bias overall. For details on our a priori criteria for assigning ‘Risk of bias’ judgements to studies overall, see Assessment of risk of bias in included studies. See Figure 2 for an overview of our judgements about each 'Risk of bias' item, presented as percentages across all included studies. Figure 3 shows the 'Risk of bias' summary of each 'Risk of bias' item for each included study.

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

Figure 3
'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study.

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

Effects of interventions

See: Summary of findings for the main comparison Arm support combined with alternative mouse versus conventional mouse alone; Summary of findings 2 Arm support with conventional mouse versus conventional mouse alone; Summary of findings 3 Alternative mouse alone versus conventional mouse alone; Summary of findings 4 Alternative workstation adjustment compared to no workstation adjustment; Summary of findings 5 Workstation adjustment according to OSHA/NIOSH recommendation compared to no workstation adjustment; Summary of findings 6 Sit‐stand workstation versus normal workstation; Summary of findings 7 Supplementary breaks versus normal breaks; Summary of findings 8 Ergonomic training programme for preventing work‐related musculoskeletal disorders of the upper limb and neck in adults; Summary of findings 9 Biofeedback (vibration) to reduce hand idle time on mouse versus no intervention

1. Physical ergonomic interventions

We found five studies that evaluated the effectiveness of interventions involving physical ergonomic interventions (Conlon 2008; Gerr 2005; Graves 2015; Lintula 2001; Rempel 2006) .

1.1 Arm support with an alternative computer mouse versus conventional mouse alone
1.1.1 Outcome: incidence of neck or shoulder disorders and severity/intensity of neck or shoulder discomfort at 12‐month follow‐up

We found low‐quality evidence, based on two studies (Conlon 2008; Rempel 2006), that the use of an arm support together with an alternative mouse decreased neck or shoulder discomfort scores when compared to using a conventional mouse alone (standardised mean difference (SMD) −0.41; 95% confidence interval (CI) −0.69 to −0.12; Analysis 1.1). In the same two studies, there is moderate‐quality evidence that using an arm support with an alternative mouse decreased the incidence of neck or shoulder disorders (risk ratio (RR) 0.52; 95% CI 0.27 to 0.99; Analysis 1.2) when compared with using a conventional mouse alone.

1.1.2 Outcome: incidence of right upper limb disorders and severity/intensity of right upper limb discomfort at 12‐month follow‐up

We found low‐quality evidence, from two studies (Conlon 2008; Rempel 2006), that the use of an arm support together with an alternative mouse decreased right upper limb discomfort scores when compared to using a conventional mouse alone (SMD −0.34; 95% CI −0.63 to −0.06; Analysis 1.3). However, the same two studies provided moderate‐quality evidence which showed no considerable difference between the interventions in the incidence of right upper limb disorders (RR 0.73; 95% CI 0.32 to 1.66; Analysis 1.4).

1.1.3 Outcome: incidence of upper body disorders at 12‐month follow‐up

We found moderate‐quality evidence, from two studies (Conlon 2008; Rempel 2006), that there is no considerable difference in the incidence of upper body disorders (RR 0.66; 95% CI 0.42 to 1.04; Analysis 1.5) between the group that used an arm support together with an alternative mouse and the group that used a conventional mouse alone.

1,1,4 Outcome: work‐related function

Data is not available for this outcome measure.

1.1.5 Outcome: change in productivity (secondary outcome)

In one study, Rempel 2006, an arm support together with an alternative mouse produced no significant difference in company‐tracked productivity when compared to using a conventional mouse alone, measured as change in percentage of work time (mean difference (MD) −0.10; 95% CI −5.09 to 4.89; Analysis 1.6), average time it takes to completely process a call (MD 8.00; 95% CI −24.23 to 40.53; Analysis 1.7), and calls per hour (MD −0.20; 95% CI −0.97 to 0.57; Analysis 1.8). The same study did, however, find an improvement in self‐perceived productivity with an arm support together with an alternative mouse compared to a conventional mouse alone (odds ratio (OR) 2.33; 95% CI 1.01 to 5.41; Analysis 1.9).

1.2 Arm support with a conventional mouse versus conventional mouse alone
1.2.1 Outcome: severity/intensity of neck‐shoulder‐arm musculoskeletal strain at 6‐week follow‐up

We found very low‐quality evidence, based on one study (Lintula 2001), of no considerable change in self‐reported musculoskeletal strain with the use of an arm support versus no arm support (MD −3.00; 95% CI −34.47 to 28.47; Analysis 2.1).

1.2.2 Outcome: incidence of neck‐shoulder disorderand severity/intensity of neck‐shoulder discomfort at 12‐month follow‐up

We found low‐quality evidence, based on two studies (Conlon 2008; Rempel 2006), that there is no considerable difference in neck or shoulder discomfort scores when using an arm support with a conventional mouse versus using a conventional mouse alone (SMD 0.02; 95% CI −0.26 to 0.30; Analysis 2.2). The same two studies also produced inconsistent evidence that there is no considerable difference in the incidence of neck or shoulder disorders (RR 0.91; 95% CI 0.12 to 6.98; Analysis 2.3), but the heterogeneity between the two studies was high (I² = 86%), with one study showing a beneficial effect and one study showing a harmful effect. The outcome was included in the meta‐analysis although the heterogeneity was found to be high, as the other outcome measures from the two studies have been included in meta analysis in the other sections and was found to have low heterogeneity.

1.2.3 Outcome: incidence of right upper limb disorder and severity/intensity of right upper limb discomfort at 12‐month follow‐up

We found low‐quality evidence, based on two studies (Conlon 2008; Rempel 2006), that there is no considerable difference in right upper limb discomfort score when using an arm support with a conventional mouse versus using a conventional mouse alone (SMD −0.07; 95% CI −0.35 to 0.22; Analysis 2.4). The same two studies also produced moderate‐quality evidence of no difference between the interventions in the incidence of right upper limb disorders (RR 1.07; 95% CI 0.58 to 1.96; Analysis 2.5).

1.2.4 Outcome: incidence of upper body disorder (neck, shoulder, and upper limb) at 12‐month follow‐up

We found moderate‐quality evidence, based on two studies (Conlon 2008; Rempel 2006), that there is no considerable difference in neck, shoulder, or upper limb disorders when using an arm support with a conventional mouse versus using a conventional mouse alone (RR 0.87; 95% CI 0.42 to 1.80; Analysis 2.6).

1,2,5 Outcome: work‐related function

Data is not available for this outcome measure.

1.2.6 Outcome: change in productivity (secondary outcome)

One study, Rempel 2006, reported that there is no difference in company‐tracked productivity, measured as change in percentage of work time (MD 0.40; 95% CI −3.50 to 4.30; Analysis 2.7) or calls per hour (MD −0.30; 95% CI −0.92 to 0.32; Analysis 2.9) when using an arm support with a conventional mouse versus using a conventional mouse alone. However, the company‐tracked average time to process a call was shorter (MD 29.00; 95% CI 3.80 to 54.20; Analysis 2.8) and self‐perceived productivity improved (OR 2.92; 95% CI 1.25 to 6.81 Analysis 2.10) when using an arm support with a conventional mouse versus using a conventional mouse alone.

1.3 Arm support for both arms versus no arm support
1.3.1 Outcome: Incidence or prevalence of musculoskeletal disorders (MSDs)

Data is not available for this outcome measure.

1.3.2 Outcome: severity/intensity of neck‐shoulder‐arm musculoskeletal strain at 6‐week follow‐up

We found very low‐quality evidence, based on one study (Lintula 2001), that there is no considerable change in self‐reported musculoskeletal strain when using an arm support for both arms versus not using one (MD 3.00; 95% CI −19.29 to 25.29; Analysis 3.1).

1,3,3 Outcome: work‐related function

Data is not available for this outcome measure.

1.3.4 Outcome: secondary outcome

Data is not available for this outcome measure.

1.4 Alternative mouse versus conventional mouse
1.4.1 Outcome: incidence of neck or shoulder disorder and severity/intensity of neck or shoulder discomfort at 12‐month follow‐up

We found low‐quality evidence, based on two studies (Conlon 2008; Rempel 2006), that there is no considerable difference in neck or shoulder discomfort scores when using an alternative mouse versus using a conventional mouse (SMD 0.04; 95% CI −0.26 to 0.33; Analysis 4.1). The same two studies reported no considerable difference in the incidence of neck or shoulder disorders (RR 0.62; 95% CI 0.19 to 2.00; Analysis 4.2) but the heterogeneity between the studies was high (I² = 53%).

1.4.2 Outcome: incidence of right upper limb disorder and severity/intensity of right upper limb discomfort at 12‐month follow‐up

We found low‐quality evidence, based on two studies (Conlon 2008; Rempel 2006), that there is no difference in right upper limb discomfort scores when using an alternative mouse versus using a conventional mouse (SMD 0.00; 95% CI −0.28 to 0.28; Analysis 4.4). For the same two studies there is no difference in right upper limb disorders (RR 0.91; 95% CI 0.48 to 1.72; Analysis 4.3).

1.4.3 Outcome: incidence of upper body disorder at 12‐month follow‐up

We found moderate‐quality evidence, based on two studies (Conlon 2008; Rempel 2006), that there is no difference in upper body disorders when using an alternative mouse versus using a conventional mouse (RR 0.79; 95% CI 0.52 to 1.21; Analysis 4.5).

1,4,4 Outcome: work‐related function

Data is not available for this outcome measure.

1.4.5 Outcome: change in productivity (secondary outcome)

One study, Rempel 2006, found no difference in company‐tracked productivity, measured as change in percentage of working time (MD 2.74; 95% CI −1.04 to 6.52; Analysis 4.6), average time it takes to process a call (MD 15.00; 95% CI −7.21 to 37.21; Analysis 4.7), and calls per hour (MD 0.20; 95% CI −0.38 to 0.78; Analysis 4.8). However, self‐perceived productivity improved when using an alternative mouse versus using a conventional mouse (OR 2.33; 95% CI 1.01 to 5.41 Analysis 4.9).

1.5 Workstation adjustment versus usual arrangement
1.4.1 Outcome: Incidence or prevalence of musculoskeletal disorders (MSDs)

Data is not available for this outcome measure.

1.5.2 Outcome: severity/intensity of neck or shoulder symptoms at one‐week follow‐up

We found very low‐quality evidence, based on one study (Gerr 2005), that there is no difference in neck or shoulder symptoms when using an alternative workstation adjustment versus no intervention (RR 1.08; 95% CI 0.73 to 1.59; Analysis 5.1), or when using the Occupational Safety and Health Administration (OSHA), United State Department of Labour or the National Institute of Occupational Safety and Health (NIOSH), Center of Disease Control and Prevention prescribed workstation adjustment versus no intervention (RR 1.19; 95% CI 0.79 to 1.78; Analysis 6.1).

1.5.3 Outcome: severity/intensity of hand or arm symptoms at one‐week follow‐up

We found very low‐quality evidence, based on one study (Gerr 2005), that there is no difference in hand or arm symptoms when using an alternative workstation adjustment versus no intervention (RR 0.83; 95% CI 0.50 to 1.39; Analysis 5.2), or when using OSHA or NIOSH prescribed workstation adjustment versus no intervention (RR 0.92; 95 % CI 0.56 to 1.50; Analysis 6.2).

1,5,4 Outcome: work‐related function

Data is not available for this outcome measure.

1.5.5 Outcome: overall compliance to all components of intervention (secondary outcome)

We found very low‐quality evidence, based on one study (Gerr 2005), that the overall compliance with all components of the alternative workstation adjustment was attained in 25.4% to 31.9% of participants at different times of the intervention. The same study provided very low‐quality evidence showing that the overall compliance with all components of the OSHA or NIOSH prescribed workstation adjustment was attained in 37.6% to 42.4% of participants at different times of the intervention.

1.6 Sit‐stand workstation versus sitting desk
1.6.1 Outcome: Incidence or prevalence of musculoskeletal disorders (MSDs)

Data is not available for this outcome measure.

1.6.2 Outcome: severity/intensity of neck and shoulder discomfort at eight‐week follow‐up

We found low‐quality evidence, based on one study (Graves 2015), that using a sit‐stand workstation produced no difference in neck and shoulder discomfort and pain score when compared with usual working conditions (−0.30; 95% CI −1.69 to 1.09; Analysis 7.1).

1,6,3 Outcome: work‐related function

Data is not available for this outcome measure.

1.6.4 Outcome: compliance with intervention (secondary outcome)

One study, Graves 2015, found that the intervention group recorded less sitting time at eight weeks' follow‐up when compared to baseline. Sitting time was 385.9 (SD 57.6) minutes per eight‐hour workday at baseline, versus 322.0 (SD 99.3) minutes at eight weeks' follow‐up (MD −80.20 (95% CI −125.66 to −34.74; Analysis 7.2).

2. Organisational ergonomic interventions

2.1 Supplementary breaks versus conventional breaks
2.1.1 Outcome: Incidence or prevalence of musculoskeletal disorders (MSDs)

Data is not available for this outcome measure.

2.1.2 Outcome: severity/intensity of neck, right shoulder or upper arm discomfort at two‐month follow‐up

We included data from two studies in this meta‐analysis (Galinsky 2000; Galinsky 2007). We could not enter the data from one study, McLean 2001, into a meta‐analysis as the authors reported no measure of variance and this could not be calculated from the information provided.

We found very low‐quality evidence, based on two studies (Galinsky 2000; Galinsky 2007), that supplementary breaks significantly reduced the scores for neck discomfort (MD −0.25; 95% CI −0.40 to −0.11; Analysis 8.1) and right shoulder or upper arm discomfort (MD −0.33; 95% CI −0.46 to −0.19; Analysis 8.2) when compared with conventional breaks.

2.1.3 Outcome: severity/intensity of forearm or wrist or hand discomfort at two‐month follow‐up

We found very low‐quality evidence, based on two studies (Galinsky 2000; Galinsky 2007), that supplementary breaks significantly reduced right forearm or wrist or hand discomfort scores when compared with conventional breaks (MD −0.18; 95% CI −0.29 to −0.08; Analysis 8.3).

2,1,4 Outcome: work‐related function

Data is not available for this outcome measure.

2.1.5 Outcome: change in productivity (secondary outcome)

Two studies reported no significant difference in productivity between supplementary breaks and conventional breaks (Galinsky 2000; McLean 2001). In Galinsky 2000, there is no significant difference between the two groups in productivity as measured by the mean number of keystrokes per hour and mean number of documents entered. In McLean 2001, there is no difference between the groups in productivity measured as the number of words typed.

2.2 Biofeedback mouse for regulating breaks versus no intervention
2.2.1 Outcome: Incidence or prevalence of musculoskeletal disorders (MSDs)

Data is not available for this outcome measure.

2.2.2 Outcome: severity/intensity of shoulder pain at 25‐week follow‐up

We found low‐quality evidence, based on one study (King 2013), that there is no difference in shoulder pain intensity scores when using a vibrating mouse versus no intervention (MD −0.79; 95% CI −2.57 to 0.99; Analysis 9.1).

2.2.3 Outcome: severity/intensity of upper extremity pain at 25‐week follow‐up

We found low‐quality evidence, based on one study (King 2013), that there is no difference in upper extremity pain intensity scores when using a vibrating mouse versus no intervention (MD −1.64; 95% CI −6.85 to 3.57; Analysis 9.2).

2,2,4 Outcome: work‐related function

Data is not available for this outcome measure.

2.2.3 Outcome: compliance with intervention (secondary outcome)

In one study (King 2013), the intervention group had a relatively higher use of the mouse compared to total computer use, however the results were not significant (MD 14.80%; 95% CI ‐6.27 to 35.87; Analysis 9.3).

3. Cognitive ergonomic interventions

We found no studies that specifically addressed the cognitive domain.

4. Training interventions

4.1 Participatory ergonomic training intervention versus no intervention
4.1.1 Outcome: Incidence of musculoskeletal disorders (MSDs)

Data is not available for this outcome measure.

4.1.2 Outcome: prevalence of neck/shoulder musculoskeletal symptoms (by questionnaire) at six‐month follow‐up

We found very low‐quality evidence, based on two studies (Baydur 2016; Brisson 1999), that an ergonomic training intervention produced no considerable change in shoulder pain compared with no intervention (RR 0.76; 95% CI 0.47 to 1.21; Analysis 10.1). Data from one study, Brisson 1999, on neck or shoulder pain, were was used twice for analysis of shoulder and neck symptoms separately. The two studies showed heterogeneity, which ranged from 40% to 68%, which may be explained by differences in duration of study (the study by Baydur and colleagues was 13 months in duration and that of Brisson and colleagues was only six months).

4.1.3 Outcome: prevalence of neck musculoskeletal symptoms (by questionnaire) at six‐month follow‐up

We found very low‐quality evidence, based on two studies (Baydur 2016; Brisson 1999), that an ergonomic training intervention produced no change in neck pain when compared with no intervention (RR 0.82; 95% CI 0.58 to 1.17; Analysis 10.2). For the study by Brisson 1999, we used the same data as those used in Analysis 8.1 and Analysis 8.2, as the study reported only the prevalence of neck and shoulder pain together and did not report them as a separate entity.

4.1.4 Outcome: prevalence of wrist/hand musculoskeletal symptoms (by questionnaire) at six‐month follow‐up

We found very low‐quality evidence, based on two studies (Baydur 2016; Brisson 1999), that an ergonomic training intervention produces no change in wrist or hand pain when compared with no intervention (RR 0.63; 95% CI 0.36 to 1.09; Analysis 10.3).

4.1.5 Outcome: prevalence of neck or shoulder pain (by medical examination) at six‐month follow‐up

We found very low‐quality evidence, based on one study (Brisson 1999), that an ergonomic training intervention produced no change in neck or shoulder pain when compared with no intervention (RR 1.12; 95% CI 0.60 to 2.09; Analysis 10.4).

4.1.6 Outcome: prevalence of hand/wrist pain (by medical examination) at six‐month follow‐up

We found very low‐quality evidence, based on one study (Brisson 1999), that an ergonomic training intervention produced no change in wrist or hand pain when compared with no intervention (RR 1.73; 95% CI 0.47 to 6.37; Analysis 10.5).

4.1.7 Outcome: prevalence of disability of shoulder at six‐month follow‐up

We found very low‐quality evidence, based on one study (Baydur 2016), that an ergonomic training intervention reduced disability of the shoulder based on the Quick DASH symptom severity score (OR 0.93; 95% CI 0.85 to 1.02) and Quick DASH work module score (OR 0.90; 95% CI 0.82 to 1.00) when compared with no intervention. The information for outcome 4.17 and 4.18 were obtained directly from the Baydur 2016 report, as the raw scores for disability and Quick DASH measure were not reported.

4.1.8 Outcome: prevalence of disability of neck at six‐month follow‐up

We found very low‐quality evidence, based on one study (Baydur 2016), that an ergonomic training intervention reduced disability of the neck, measured with the Northwick Part Neck Pain Score, when compared with no intervention (OR 0.90; 95% CI 0.82 to 0.98).

4.1.9 Outcome: compliance with intervention (secondary outcome)

We found very low‐quality evidence, based on one study (Brisson 1999), that compliance with the intervention was higher in participants under 40 years of age compared to participants over 40 years of age. The information was obtained directly from the Brisson 1999 report.

4.2 Participatory education intervention versus traditional education
4.2.1 Outcome: Incidence or prevalence of musculoskeletal disorders (MSDs)

Data is not available for this outcome measure.

4.2.2 Outcome: severity/intensity of upper body discomfortat 12‐month follow‐up

We could not combine results data from two studies — Bohr 2000 and Bohr 2002 — in a meta‐analysis as they did not report a measure of variance and it could not be calculated from the information provided. The authors only presented composite scores of pain or discomfort for the control, traditional and participatory education (Bohr 2000), and composite scores of pain or discomfort for the traditional and participatory education (Bohr 2002), at baseline and at 12‐month follow‐up.

4,2,3 Outcome: work‐related function

Data is not available for this outcome measure.

4.2.4 Outcome: compliance with intervention (secondary outcome)

We found very low‐quality evidence, based on the same two studies (Bohr 2000; Bohr 2002), that there were no significant differences between participatory education, traditional education and no intervention in terms of work area configuration, worker postures, or overall observation scores.

4.3 Active ergonomic training versus no intervention
4.3.1 Outcome: Incidence or prevalence of musculoskeletal disorders (MSDs)

Data is not available for this outcome measure.

4.3.2 Outcome: severity or intensity of upper extremity symptoms at three‐week follow‐up

We found very low‐quality evidence, based on one study (Greene 2005), that active ergonomic training produced no significant difference in upper extremity symptom intensity scale (0, mild pain to 4, worst ever) when compared with no intervention (MD 0.08; 95% CI −0.22 to 0.38; Analysis 10.6).

4.3.3 Outcome: frequency of upper extremity symptoms at three‐week follow‐up

We found very low‐quality evidence, based on one study (Greene 2005), that active ergonomic training produced no significant difference in upper extremity symptom frequency scale (1, once per week to 4, daily in the past week) when compared with no intervention (MD −0.03; 95% CI −0.45 to 0.39; Analysis 10.7).

4.3.4 Outcome: duration of upper extremity symptoms at three‐week follow‐up

We found very low‐quality evidence, based on one study (Greene 2005), that active ergonomic training produced no significant difference in upper extremity symptom duration scale (1, less than 1 hour to 4, more than 3 days to 1 week) when compared with no intervention (MD 0.13; 95% CI −0.25 to 0.51; Analysis 10.8).

4,3,5 Outcome: work‐related function

Data is not available for this outcome measure.

5. Multifaceted ergonomic interventions

5.1 Combined physical and organisational ergonomic intervention (work injury prevention program) versus no intervention
5.1.1 Outcome: Incidence or prevalence of musculoskeletal disorders (MSDs)

Data is not available for this outcome measure.

5.1.2 Outcome: severity or intensity of neck musculoskeletal symptoms at 16‐week follow‐up

We found very low‐quality evidence, based on one study (Gatty 2004), that a combined physical and organisational ergonomic intervention produced no significant difference in frequency of neck ache or pain when compared with no intervention (MD −1.20; 95% CI −2.77 to 0.37; Analysis 11.1).

5.1.3 Outcome: severity or intensity of shoulder musculoskeletal symptoms at 16‐week follow‐up

We found very low‐quality evidence, based on one study (Gatty 2004), that a combined physical and organisational ergonomic intervention produced no significant difference in frequency of shoulder ache or pain when compared with no intervention (MD −1.10; 95% CI −2.65 to 0.45; Analysis 11.2).

5.1.4 Outcome: severity or intensity of wrist or hand musculoskeletal symptoms at 16‐week follow‐up

We found very low‐quality evidence, based on one study (Gatty 2004), that a combined physical and organisational ergonomic intervention produced no significant difference in frequency of wrist or hand ache or pain when compared with no intervention (MD −1.00; 95% CI −2.52 to 0.52; Analysis 11.3).

5,1,5 Outcome: work‐related function

Data is not available for this outcome measure.

5.1.6 Outcome: compliance with intervention (secondary outcome)

One study, Gatty 2004, assessed the participants' self‐reported compliance with the intervention using a scale from one (never) to four (always). The study reported that compliance in the intervention group was high at the end of the study, with the greatest level of compliance obtained for ergonomic equipment (mean 3.5 (SD 0.55), followed by the performance of modified job duties (mean 2.8 (SD 0.41), and the performance of issued stretches or breaks (mean 2.5 (SD 1.05).

Discussion

Summary of main results

This systematic review identified 15 randomised controlled trials (RCTs) evaluating the effectiveness of workplace ergonomic interventions for the prevention of work‐related musculoskeletal disorders of the upper limb or neck, or both, among office workers.

For physical ergonomic interventions, we found three interventions consisting of a form of arm support, one of alternative computer mouse design, one of alternative workstation design and one of sit‐stand desk (summary of findings Table for the main comparison; summary of findings Table 3; summary of findings Table 2; summary of findings Table 5; summary of findings Table 4; summary of findings Table 6). All six interventions were evaluated with, on average, three outcomes. Only one of the 20 intervention‐outcome combinations produced a statistically significant result; this was for the comparison of an arm support with an alternative computer mouse versus an alternative mouse alone. We rated the quality of this evidence as moderate. However, the other comparisons that compared only arm‐support or only an alternative mouse did not yield beneficial results. Therefore, based on the moderate‐ to very low‐quality evidence available, we conclude that there is no considerable effect of physical ergonomic changes on upper limb symptoms.

For organisational ergonomic interventions, there is very low‐quality evidence, based on two studies, that supplementary breaks may reduce discomfort of the neck and right shoulder, upper limb, forearm, wrist or hand (summary of findings Table 7).

There were no studies on cognitive interventions.

For training interventions, there is low‐ to very low‐quality evidence from five studies that evaluated participatory and active training interventions; this evidence indicated that these interventions may or may not prevent work‐related upper limb or neck musculoskeletal disorders (MSDs), or both (summary of findings Table 8; summary of findings Table 9).

For multifaceted interventions there is one study (very low‐quality evidence) that did not show an effect on any of the six upper limb pain outcomes.

Seven studies assessed compliance with the intervention (Bohr 2002; Bohr 2000; Brisson 1999; Gatty 2004, Gerr 2005, Graves 2015; King 2013). Overall these studies found compliance to ergonomic interventions to be low, but two studies noted high compliance (Gatty 2004; Graves 2015).

Overall completeness and applicability of evidence

We found evidence for all classes of ergonomic interventions designed to reduce pain and discomfort in the upper limb and neck except for cognitive ergonomic interventions. Cognitive ergonomic interventions would not be the most applied for preventing musculoskeletal pain. Physical workplace changes, such as arm support and differently designed mouses, would be the most applied interventions. We also found studies about organisational interventions, such as breaks, which would be an intuitive way of decreasing the workload and thus preventing pain. There were also studies about training workers, with the aim that this will lead to better ergonomic conditions and thus to less musculoskeletal pain or discomfort. These studies applied the important concept of participation of the workers in the intervention process. Therefore, we believe that we have covered a range of interventions that are currently applied in practice.

Although we included 15 RCTs overall, the number of studies for each individual intervention was small, with a maximum of two studies per meta‐analysis. A wide range of outcomes was used to evaluate the interventions but this also dispersed the evidence across different intervention‐outcome combinations that we considered too different to be combined. The small sample sizes included in these intervention‐outcome combinations may also have led to a lack of power to detect small differences in outcomes.

There were studies among men and women and among different age groups. However, some studies included only workers that had to enter data as their job, or only call‐centre workers. Thus the evidence might not always be applicable to all types of office workers.

Most studies were more than ten years old and there were only four studies conducted after the year 2010. This might indicate that the interventions are not up‐to‐date given that current office equipment is considerably different from that used 10 to 20 years ago. Where the majority was stationary sitting workstations with a desktop or laptop computers, as compared to mobile office, sit‐stand workstations, and the use of tablets and smart phones for office work currently.

Studies from low‐ and middle‐income countries were missing.

Quality of the evidence

We assessed the quality of evidence for each subtype regardless of whether it was included in meta‐analyses. We assessed the quality of evidence per outcome using the GRADEpro GDT software (GRADEpro GDT).

There is moderate‐ to low‐quality evidence on the effectiveness of physical ergonomic interventions and low‐ to very‐low‐quality evidence on the effectiveness of organisational ergonomic interventions and on organisational combined with physical ergonomic interventions. We downgraded our assessments of the quality of evidence produced by the included studies because of small sample sizes, risk of bias, lack of blinding and use of subjective outcome measures (detection bias), lack of information on sequence generation (selection bias), and lack of information on allocation concealment (selection bias). The main quality concerns were small sample sizes and use of subjective outcome measures (detection bias), which occurred for all the interventions.

Although all the included studies were RCTs, the majority of the studies did not report the methods for random sequence generation and allocation concealment. This has led us to the downgrade the quality of evidence because of the possibility of selection bias. Future studies should be clear about how they generated a random sequence and how they concealed allocation.

Potential biases in the review process

The process of study selection, data extraction, and assessment of risk of bias of included studies was performed by two independent review authors and we resolved disagreements through discussion and consensus. We minimised selection bias in our search by screening references of identified studies and systematic reviews, by contacting experts in the research field, and by not restricting our search strategy by language or publication date. Even though our search strategy was comprehensive, there is always a risk that relevant studies may not have been identified in the review process.

We were unable to assess the risk of publication bias adequately as there was a very limited number of studies assessing similar interventions and outcomes. We avoided duplicate publication bias by using study data only once. However, we found two reports from the same author (Bohr 2000; Bohr 2002), which may be reporting on the same population. We wrote to the author for clarification, however we did not receive a response. In our included studies, there were two studies that were each reported twice. We combined the results from the two reports and only used the data that were appropriate for this review (Gatty 2004). We were able to obtain missing data for four studies (Baydur 2016; Brisson 1999;Galinsky 2000;Galinsky 2007).

We had considerable difficulty in classifying the interventions and we might have been too restrictive in combining studies. However, we believe that the broad categories of ergonomic interventions that we made have resulted in a meaningful categorisation. Thus we believe it is possible to get at least an impression of the effectiveness of interventions in the various categories.

Due to the strict inclusion criteria used in this review, we excluded 13 studies due to the high prevalence of MSDs at baseline. Some of those studies may be able to provide additional evidence on the effectiveness of the intervention. However, given the lesser‐quality study design, this would probably not lead to an increase in the confidence of the results

This review included only RCTs since methodologically weaker designs can easily lead to bias. In the field of occupational health, randomisation is sometimes difficult to perform. From the 'Risk of bias' tables it can be noted that there were a high number of studies with a classification of ‘unclear’ in the sequence generation and allocation concealment domains. This indicates that the primary publication did not supply enough information to assess these biases. We did not seek further information from the authors for reasons of simplicity and lack of resources in conducting the review. Instead, we chose to complete the 'Risk of bias' assessment based on information provided in the published reports.

Agreements and disagreements with other studies or reviews

The findings of this review differ from those of three earlier systematic reviews (Boocock 2007; Kennedy 2010; Van Eerd 2016). Our review focuses on prevention of MSDs, and unlike previous reviews, we excluded studies where more than 25% of the participants had MSDs of the upper limb or neck. Moreover, the three other systematic reviews, Boocock 2007, Kennedy 2010, and Van Eerd 2016, classified interventions differently and also included study designs other than RCTs. Because of their less rigorous inclusion criteria, one review included 31 studies (Boocock 2007), one included 36 studies (Kennedy 2010), and one included 61 studies (Van Eerd 2016). Moreover, the other three reviews did not perform meta‐analyses and included populations other than office workers.

The systematic reviews by Boocock 2007, Kennedy 2010 and Van Eerd 2016 used similar methods to assess the study quality and level of evidence of the included studies. In Boocock 2007, the researchers used the modified version of the Cochrane Musculoskeletal Injuries Group scoring system, in conjunction with the generic appraisal tool for epidemiology (GATE) tool, to provide an overall score for each study from 0 to 26 and to classify each study as low (less than 10), medium (10 to 18) or high quality (19 or more). The quality of evidence was then classified as strong, moderate, some or insufficient evidence based on consistency of the quality scores. Kennedy 2010, and Van Eerd 2016, used the same methods, which involved assessing the quality of the included studies using 16 quality criteria. Each study received a quality ranking score by dividing the weighted score by 41 and then multiplying by 100. The studies were then categorised as high (more than 85%), medium (50% to 85%) or low (less than 50%) quality. The quality of evidence was then categorised as strong, moderate, limited, mixed and insufficient based on quality of the study, number of studies, and consistency of findings (Kennedy 2010; Van Eerd 2016).

In Boocock 2007, they concluded that there is some evidence to support the use of mechanical and modifier interventions for preventing and managing neck or upper extremity musculoskeletal conditions. They found moderate evidence that mouse and keyboard design can lead to positive health benefits in visual display unit workers with neck or upper extremity musculoskeletal conditions.

In Kennedy 2010, the researchers found moderate evidence for arm supports and limited evidence for ergonomic training plus workstation adjustments, new chairs, and rest breaks having beneficial effects on upper‐extremity MSD outcomes. In Van Eerd 2016, they found moderate evidence for mouse‐use feedback and forearm supports, job stress management training, and office workstation adjustment having beneficial effects on MSDs and symptoms. Kennedy 2010 and Van Eerd 2016 included in their evidence for arm support the studies of Lintula 2001, Rempel 2006, and Conlon 2008. These were also included in our study. However, Kennedy and colleagues (Kennedy 2010), and Van Eerd and colleagues (Van Eerd 2016), did not perform a meta‐analysis although the data were comparable, and thus the capacity of these reviews to report a quantitative assessment is limited.

PRISMA study flow diagram
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Figure 1

PRISMA study flow diagram

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'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies.
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Figure 2

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

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'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study.
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Figure 3

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

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Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 1 Neck/shoulder discomfort score at 12‐month follow‐up.
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Analysis 1.1

Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 1 Neck/shoulder discomfort score at 12‐month follow‐up.

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Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 2 Incidence of neck/shoulder disorder at 12‐month follow‐up.
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Analysis 1.2

Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 2 Incidence of neck/shoulder disorder at 12‐month follow‐up.

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Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 3 Right upper extremity discomfort score at 12‐month follow‐up.
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Analysis 1.3

Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 3 Right upper extremity discomfort score at 12‐month follow‐up.

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Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 4 Incidence of right upper limb disorder at 12‐month follow‐up.
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Analysis 1.4

Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 4 Incidence of right upper limb disorder at 12‐month follow‐up.

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Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 5 Incidence of upper body disorders (neck, shoulder, and upper limb) at 12‐month follow‐up.
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Analysis 1.5

Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 5 Incidence of upper body disorders (neck, shoulder, and upper limb) at 12‐month follow‐up.

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Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 6 Change in percentage of work time.
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Analysis 1.6

Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 6 Change in percentage of work time.

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Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 7 Change in average time to completely process a call.
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Analysis 1.7

Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 7 Change in average time to completely process a call.

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Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 8 Change in calls per hour.
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Analysis 1.8

Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 8 Change in calls per hour.

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Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 9 Subject perceived improvement.
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Analysis 1.9

Comparison 1 An arm support together with an alternative mouse versus a conventional mouse alone, Outcome 9 Subject perceived improvement.

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Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 1 Right upper‐limb strain scale at 6‐week follow‐up.
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Analysis 2.1

Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 1 Right upper‐limb strain scale at 6‐week follow‐up.

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Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 2 Neck/shoulder discomfort score.
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Analysis 2.2

Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 2 Neck/shoulder discomfort score.

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Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 3 Incidence of neck/shoulder disorder.
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Analysis 2.3

Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 3 Incidence of neck/shoulder disorder.

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Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 4 Right upper extremity discomfort score.
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Analysis 2.4

Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 4 Right upper extremity discomfort score.

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Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 5 Incidence of right upper extremity disorders.
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Analysis 2.5

Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 5 Incidence of right upper extremity disorders.

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Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 6 Incidence of upper body disorders (neck, shoulder and upper limb).
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Analysis 2.6

Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 6 Incidence of upper body disorders (neck, shoulder and upper limb).

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Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 7 Change in percentage of work time.
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Analysis 2.7

Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 7 Change in percentage of work time.

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Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 8 Change in average time to completely process a call.
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Analysis 2.8

Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 8 Change in average time to completely process a call.

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Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 9 Change in calls per hour.
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Analysis 2.9

Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 9 Change in calls per hour.

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Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 10 Subject perceived improvement.
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Analysis 2.10

Comparison 2 An arm support together with a conventional mouse versus a conventional mouse alone, Outcome 10 Subject perceived improvement.

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Comparison 3 Arm support for both arms versus no arm support, Outcome 1 Right upper‐limb strain scale at 6‐week follow‐up.
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Analysis 3.1

Comparison 3 Arm support for both arms versus no arm support, Outcome 1 Right upper‐limb strain scale at 6‐week follow‐up.

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Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 1 Neck/shoulder discomfort score.
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Analysis 4.1

Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 1 Neck/shoulder discomfort score.

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Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 2 Incidence of neck/shoulder disorder.
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Analysis 4.2

Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 2 Incidence of neck/shoulder disorder.

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Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 3 Incidence of right upper extremity disorder.
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Analysis 4.3

Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 3 Incidence of right upper extremity disorder.

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Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 4 Right upper extremity discomfort score.
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Analysis 4.4

Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 4 Right upper extremity discomfort score.

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Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 5 Incidence of upper body disorder (neck, shoulder, and upper extremity).
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Analysis 4.5

Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 5 Incidence of upper body disorder (neck, shoulder, and upper extremity).

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Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 6 Change in percentage of work time.
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Analysis 4.6

Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 6 Change in percentage of work time.

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Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 7 Change in average time to completely process a call.
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Analysis 4.7

Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 7 Change in average time to completely process a call.

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Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 8 Change in calls per hour.
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Analysis 4.8

Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 8 Change in calls per hour.

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Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 9 Subject perceived improvement.
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Analysis 4.9

Comparison 4 An alternative mouse alone versus a conventional mouse alone, Outcome 9 Subject perceived improvement.

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Comparison 5 An alternative workstation adjustment versus no adjustment, Outcome 1 Incidence of neck and shoulder pain.
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Analysis 5.1

Comparison 5 An alternative workstation adjustment versus no adjustment, Outcome 1 Incidence of neck and shoulder pain.

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Comparison 5 An alternative workstation adjustment versus no adjustment, Outcome 2 Incidence of arm and hand pain.
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Analysis 5.2

Comparison 5 An alternative workstation adjustment versus no adjustment, Outcome 2 Incidence of arm and hand pain.

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Comparison 6 Workstation adjustment according to OSHA/NIOSH recommendation compared to no workstation adjustment, Outcome 1 Incidence of neck and shoulder pain.
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Analysis 6.1

Comparison 6 Workstation adjustment according to OSHA/NIOSH recommendation compared to no workstation adjustment, Outcome 1 Incidence of neck and shoulder pain.

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Comparison 6 Workstation adjustment according to OSHA/NIOSH recommendation compared to no workstation adjustment, Outcome 2 Incidence of arm and hand pain.
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Analysis 6.2

Comparison 6 Workstation adjustment according to OSHA/NIOSH recommendation compared to no workstation adjustment, Outcome 2 Incidence of arm and hand pain.

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Comparison 7 Sit‐stand workstation versus normal workstation, Outcome 1 Intensity of neck and shoulder discomfort and pain.
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Analysis 7.1

Comparison 7 Sit‐stand workstation versus normal workstation, Outcome 1 Intensity of neck and shoulder discomfort and pain.

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Comparison 7 Sit‐stand workstation versus normal workstation, Outcome 2 Sitting time at 8‐week.
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Analysis 7.2

Comparison 7 Sit‐stand workstation versus normal workstation, Outcome 2 Sitting time at 8‐week.

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Comparison 8 Supplementary breaks versus normal breaks, Outcome 1 After shift discomfort rating for neck (4‐8 weeks).
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Analysis 8.1

Comparison 8 Supplementary breaks versus normal breaks, Outcome 1 After shift discomfort rating for neck (4‐8 weeks).

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Comparison 8 Supplementary breaks versus normal breaks, Outcome 2 After shift discomfort rating for right shoulder or upper arm (4‐8 weeks).
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Analysis 8.2

Comparison 8 Supplementary breaks versus normal breaks, Outcome 2 After shift discomfort rating for right shoulder or upper arm (4‐8 weeks).

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Comparison 8 Supplementary breaks versus normal breaks, Outcome 3 After shift discomfort rating for right forearm or wrist or hand (4‐8 weeks).
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Analysis 8.3

Comparison 8 Supplementary breaks versus normal breaks, Outcome 3 After shift discomfort rating for right forearm or wrist or hand (4‐8 weeks).

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Comparison 9 Biofeedback (vibration) to reduce hand idle time on mouse versus no intervention, Outcome 1 Shoulder Pain Intensity.
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Analysis 9.1

Comparison 9 Biofeedback (vibration) to reduce hand idle time on mouse versus no intervention, Outcome 1 Shoulder Pain Intensity.

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Comparison 9 Biofeedback (vibration) to reduce hand idle time on mouse versus no intervention, Outcome 2 Upper Extremity Pain Intensity.
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Analysis 9.2

Comparison 9 Biofeedback (vibration) to reduce hand idle time on mouse versus no intervention, Outcome 2 Upper Extremity Pain Intensity.

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Comparison 9 Biofeedback (vibration) to reduce hand idle time on mouse versus no intervention, Outcome 3 Relative Mouse Use over Total Computer Use.
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Analysis 9.3

Comparison 9 Biofeedback (vibration) to reduce hand idle time on mouse versus no intervention, Outcome 3 Relative Mouse Use over Total Computer Use.

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Comparison 10 Ergonomic training versus no intervention, Outcome 1 Prevalence of Neck Musculoskeletal symptoms (by questionnaire) at 6‐month follow‐up.
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Analysis 10.1

Comparison 10 Ergonomic training versus no intervention, Outcome 1 Prevalence of Neck Musculoskeletal symptoms (by questionnaire) at 6‐month follow‐up.

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Comparison 10 Ergonomic training versus no intervention, Outcome 2 Prevalence of shoulder musculoskeletal symptoms (by questionnaire) at 6‐month follow‐up.
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Analysis 10.2

Comparison 10 Ergonomic training versus no intervention, Outcome 2 Prevalence of shoulder musculoskeletal symptoms (by questionnaire) at 6‐month follow‐up.

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Comparison 10 Ergonomic training versus no intervention, Outcome 3 Prevalence of hand/wrist musculoskeletal symptoms (by questionnaire) at 6‐month follow‐up at 6‐month follow‐up.
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Analysis 10.3

Comparison 10 Ergonomic training versus no intervention, Outcome 3 Prevalence of hand/wrist musculoskeletal symptoms (by questionnaire) at 6‐month follow‐up at 6‐month follow‐up.

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Comparison 10 Ergonomic training versus no intervention, Outcome 4 Prevalence of neck/shoulder MSD (by medical examination) at 6‐month follow‐up.
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Analysis 10.4

Comparison 10 Ergonomic training versus no intervention, Outcome 4 Prevalence of neck/shoulder MSD (by medical examination) at 6‐month follow‐up.

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Comparison 10 Ergonomic training versus no intervention, Outcome 5 Prevalence of hand/wrist MSD (by medical examination) at 6‐month follow‐up.
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Analysis 10.5

Comparison 10 Ergonomic training versus no intervention, Outcome 5 Prevalence of hand/wrist MSD (by medical examination) at 6‐month follow‐up.

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Comparison 10 Ergonomic training versus no intervention, Outcome 6 Intensity of upper extremity pain at 3‐week follow‐up.
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Analysis 10.6

Comparison 10 Ergonomic training versus no intervention, Outcome 6 Intensity of upper extremity pain at 3‐week follow‐up.

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Comparison 10 Ergonomic training versus no intervention, Outcome 7 Frequency of upper extremity pain at 3‐week follow‐up.
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Analysis 10.7

Comparison 10 Ergonomic training versus no intervention, Outcome 7 Frequency of upper extremity pain at 3‐week follow‐up.

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Comparison 10 Ergonomic training versus no intervention, Outcome 8 Duration of upper extremity pain at 3‐week follow‐up.
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Analysis 10.8

Comparison 10 Ergonomic training versus no intervention, Outcome 8 Duration of upper extremity pain at 3‐week follow‐up.

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Comparison 11 Work injury prevention programme versus no intervention, Outcome 1 Frequency of neck ache or pain.
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Analysis 11.1

Comparison 11 Work injury prevention programme versus no intervention, Outcome 1 Frequency of neck ache or pain.

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Comparison 11 Work injury prevention programme versus no intervention, Outcome 2 Frequency of shoulder ache or pain.
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Analysis 11.2

Comparison 11 Work injury prevention programme versus no intervention, Outcome 2 Frequency of shoulder ache or pain.

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Comparison 11 Work injury prevention programme versus no intervention, Outcome 3 Frequency of wrist/hand ache or pain.
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Analysis 11.3

Comparison 11 Work injury prevention programme versus no intervention, Outcome 3 Frequency of wrist/hand ache or pain.

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Comparison 11 Work injury prevention programme versus no intervention, Outcome 4 Intensity of neck ache or pain.
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Analysis 11.4

Comparison 11 Work injury prevention programme versus no intervention, Outcome 4 Intensity of neck ache or pain.

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Comparison 11 Work injury prevention programme versus no intervention, Outcome 5 Intensity of shoulder ache or pain.
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Analysis 11.5

Comparison 11 Work injury prevention programme versus no intervention, Outcome 5 Intensity of shoulder ache or pain.

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Comparison 11 Work injury prevention programme versus no intervention, Outcome 6 Intensity of wrist/hand ache or pain.
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Analysis 11.6

Comparison 11 Work injury prevention programme versus no intervention, Outcome 6 Intensity of wrist/hand ache or pain.

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Summary of findings for the main comparison. Arm support combined with alternative mouse versus conventional mouse alone

Patient or population: office workers
Settings: office environment using visual display units (> 20 h/week)
Intervention: an arm support combined with an alternative computer mouse
Comparison: conventional mouse alone (with no arm support)

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Conventional mouse alone

Arm support with alternative mouse

Incidence of upper body disorders (neck, shoulder, and upper extremity)
Questionnaire followed by medical examination
Follow‐up: 12 months

333 per 1000

220 per 1000
(140 to 347)

RR 0.66
(0.42 to 1.04)

191
(2 studies)

⊕⊕⊕⊝
moderate1

Incidence of neck or shoulder disorder
Questionnaire followed by medical examination
Follow‐up: 12 months

232 per 1000

120 per 1000
(63 to 229)

RR 0.52
(0.27 to 0.99)

186
(2 studies)

⊕⊕⊕⊝
moderate1

Incidence of right upper extremity disorder
Questionnaire followed by medical examination
Follow‐up: 12 months

174 per 1000

127 per 1000
(56 to 289)

RR 0.73
(0.32 to 1.66)

181
(2 studies)

⊕⊕⊕⊝
moderate1

Neck or shoulder discomfort score
Questionnaire
Follow‐up: 12 months

The mean neck or shoulder discomfort score in the intervention groups was
0.41 standard deviations lower
(0.69 to 0.12 lower) 4

194
(2 studies)

⊕⊕⊝⊝
low2,3

SMD −0.41 (−0.69 to −0.12) clinically meaningful difference

Right upper extremity discomfort score
Questionnaire
Follow‐up: 12 months

The mean right upper extremity discomfort score in the intervention groups was
0.34 standard deviations lower
(0.63 to 0.06 lower)4

194
(2 studies)

⊕⊕⊝⊝
low2,3

SMD −0.34 (−0.63 to −0.06) clinically meaningful difference

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio; VDU: visual display unit;SMD: standardised mean difference

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because the total number of participants is less than 300 (small sample size for a categorical variable).
2 Downgraded one level because total number of participants is less than 400 (small sample size for a continuous variable).
3 Downgraded one level because of study limitations (measure of outcome was based on subjective symptoms (detection bias)).
4 Lower discomfort score indicates beneficial effects.

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Summary of findings for the main comparison. Arm support combined with alternative mouse versus conventional mouse alone
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Summary of findings 2. Arm support with conventional mouse versus conventional mouse alone

Patient or population: office workers
Settings: VDU users (more than 20 hours per week)
Intervention: arm support board (with conventional computer mouse)
Comparison: no arm support board (with conventional mouse)

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

No arm support board (with conventional mouse)

Arm support board (with conventional mouse)

Incidence of upper body disorders
Questionnaire followed by medical examination
Follow‐up: 12 months

333 per 1000

290 per 1000
(140 to 600)

RR 0.87
(0.42 to 1.80)

191
(2 studies)

⊕⊕⊝⊝
low1,2

Incidence of neck or shoulder disorder
Questionnaire followed by medical examination
Follow‐up: 12 months

232 per 1000

211 per 1000
(28 to 1000)

RR 0.91
(0.12 to 6.98)

186
(2 studies)

⊕⊕⊝⊝
low1,2

Incidence of right upper extremity disorders
Questionnaire followed by medical examination
Follow‐up: 12 months

185 per 1000

195 per 1000
(116 to 308)

OR 1.07
(0.58 to 1.96)

178
(2 studies)

⊕⊕⊕⊝
moderate2

Neck or shoulder discomfort score
Questionnaire
Follow‐up: 12 months

The mean neck or shoulder discomfort score in the intervention groups was
0.02 standard deviations higher
(0.26 lower to 0.3 higher) 5

195
(2 studies)

⊕⊕⊝⊝
low2,3

SMD 0.02 (−0.26 to 0.30) ‐ no significant difference

Right upper extremity discomfort score
Questionnaire
Follow‐up: median 12 months

The mean right upper extremity discomfort score in the intervention groups was
0.07 standard deviations lower
(0.35 lower to 0.22 higher) 5

195
(2 studies)

⊕⊕⊝⊝
low2,3

SMD −0.07 (−0.35 to 0.22) ‐ no significant difference

Right upper‐limb strain scale

Questionnaire

Follow‐up: 6 weeks

The mean right upper‐limb strain scale in the intervention groups was

3.00 lower

(34.47 lower to 28.47 higher) 5

14

(1 study)

⊕⊝⊝⊝
very low2,3,4

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; RR: Risk ratio; OR: Odds ratio; SMD: standardised mean difference; MD: mean difference

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because of high I² value (more than 50%), indicating heterogeneity.
2 Downgraded one level because of total number of participants less than 300 (small sample size for a categorical variable).
3 Downgraded one level because of limitations in studies (measure of outcome based on subjective symptoms (detection bias)).
4 Downgraded one level because of there is no information on sequence generation (selection bias).
5 Lower score indicates beneficial effects.

Figures and Tables -
Summary of findings 2. Arm support with conventional mouse versus conventional mouse alone
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Summary of findings 3. Alternative mouse alone versus conventional mouse alone

Patient or population: office workers
Settings: VDU users (more than 20 hours per week)
Intervention: alternative computer mouse alone (no arm support)
Comparison: conventional mouse alone (no arm support)

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Conventional mouse alone (no arm support)

Alternative mouse alone (no arm support)

Incidence of upper body disorder (neck, shoulder and upper extremity)
Questionnaire followed by medical examination
Follow‐up: 12 months

333 per 1000

263 per 1000
(173 to 403)

RR 0.79
(0.52 to 1.21)

190
(2 studies)

⊕⊕⊕⊝
moderate1

Incidence of neck or shoulderdisorder
Questionnaire followed by medical examination
Follow‐up: 12 months

232 per 1000

144 per 1000
(44 to 463)

RR 0.62
(0.19 to 2)

182
(2 studies)

⊕⊕⊝⊝
low1,2

Incidence of right upper extremity disorder
Questionnaire followed by medical examination
Follow‐up: 12 months

185 per 1000

168 per 1000
(89 to 318)

RR 0.91
(0.48 to 1.72)

182
(2 studies)

⊕⊕⊕⊝
moderate1

Neck or shoulder discomfort score
Questionnaire
Follow‐up: 12 months

The mean neck or shoulder discomfort score in the intervention groups was
0.04 standard deviations higher
(0.26 lower to 0.33 higher) 5

195
(2 studies)

⊕⊕⊝⊝
low3,4

SMD 0.04 (−0.26 to 0.33) ‐ no significant difference

Right upper extremity discomfort score
Questionnaire
Follow‐up: 12 months

The mean rt upper extremity discomfort score in the intervention groups was
0 standard deviations higher
(0.28 lower to 0.28 higher) 5

195
(2 studies)

⊕⊕⊝⊝
low3,4

SMD 0 (−0.28 to 0.28) ‐ no significant difference

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; RR: Risk ratio; SMD: standardised mean difference

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because total number of participants less than 300 (small sample size for a categorical variable).
2 Downgraded one level because high I² value (over 50%), indicating heterogeneity.
3 Downgraded one level because limitations in studies (measure of outcome based on subjective symptoms (detection bias)).
4 Downgraded one level because total number of participants less than 400 (small sample size for a continuous variable).
5 Lower discomfort score indicates beneficial effects.

Figures and Tables -
Summary of findings 3. Alternative mouse alone versus conventional mouse alone
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Summary of findings 4. Alternative workstation adjustment compared to no workstation adjustment

Patient or population: office workers
Settings: administrative work
Intervention: alternative workstation adjustment intervention
Comparison: no workstation adjustment

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

No workstation adjustment

Alternative workstation adjustment intervention

Neck or shoulder symptoms
Questionnaire
Follow‐up: 6 months

314 per 1000

248 per 1000

RR 1.08
(0.73 to 1.59)

254
(1 study)

⊕⊝⊝⊝
very low1,2,3

Arm or hand pain or discomfort
questionnaire
Follow‐up: 6 months

175 per 1000

210 per 1000

RR 0.83
(0.50 to 1.19)

245
(1 study)

⊕⊝⊝⊝
very low1,2,3

Intensity or severity of musculoskeletal pain

no data

no data

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; HR: Hazard ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because of limitations in studies (high risk of bias due to large dropout rate).
2 Downgraded one level because only one study available and thus inconsistency cannot be assessed.
3 Downgraded one level because total number of events (symptoms) is less than 300.

Figures and Tables -
Summary of findings 4. Alternative workstation adjustment compared to no workstation adjustment
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Summary of findings 5. Workstation adjustment according to OSHA/NIOSH recommendation compared to no workstation adjustment

Patient or population: office workers
Settings: office
Intervention: workstation adjustment according to Occupational Safety and Health Administration (OSHA)/Nastinal Institute of Occupational Safety and Health (NIOSH) recommendation
Comparison: no workstation adjustment

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

No workstation adjustment

Workstation adjustment according to OSHA/NIOSH recommendation

Neck or shoulder symptoms
questionnaire
Follow‐up: 6 months

295 per 1000

248 per 1000

RR 1.19
(0.79 to 1.79)

255
(1 study)

⊕⊝⊝⊝
very low1,2,3

Arm or hand symptoms
Ouestionnaire
Follow‐up: 6 month

192 per 1000

210 per 1000

RR 0.92
(0.56 to 1.50)

249
(1 study)

⊕⊝⊝⊝
very low1,2,3,

Intensity or severity of musculoskeletal pain

no data

no data

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; HR: Hazard ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because of high risk of bias due to high dropout rate.
2 Downgraded one level because of small sample size (only one study available and thus inconsistency cannot be assessed).
3 Downgraded one level because total number of events (symptoms) is less than 300.

Figures and Tables -
Summary of findings 5. Workstation adjustment according to OSHA/NIOSH recommendation compared to no workstation adjustment
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Summary of findings 6. Sit‐stand workstation versus normal workstation

Patient or population: office workers
Settings: office setting
Intervention: sit‐stand workstation versus normal workstation

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Normal workstation

Sit‐stand workstation

Incidence or prevalence of musculoskeletal disorders

no data

no data

Intensity of neck and shoulder discomfort and pain
Self‐reported questionnaire
Follow‐up: 8 weeks

The mean discomfort and pain score was 1.9

The mean intensity of neck and shoulder discomfort and pain in the intervention groups was
0.3 lower
(1.69 lower to 1.09 higher)5

46
(1 study)

⊕⊝⊝⊝
very low1,2,3,4

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because the allocation of participants to the intervention and control arm were not concealed.
2 Downgraded one level because of limitations in studies (measured of outcome was based on subjective symptoms (detection bias)).
3 Downgraded one level because of limitations in studies (lack of prognostic balance: male/female participants were not distributed equally between intervention and control group).
4 Downgraded one level because of small number of participants (less than 400) in analysis using continuous variables.
5 Lower discomfort score indicates beneficial effects.

Figures and Tables -
Summary of findings 6. Sit‐stand workstation versus normal workstation
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Summary of findings 7. Supplementary breaks versus normal breaks

Patient or population: office workers
Settings: office setting
Intervention: supplementary breaks versus normal breaks

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Normal breaks

Supplementary breaks

Incidence or prevalence of musculoskeletal disorders

no data

no data

After shift discomfort rating for neck (range 1 to 5)
Self‐reported questionnaire
Follow‐up: 4‐8 weeks

Mean discomfort rating was 1.55 4

The mean after shifts discomfort rating for neck (4‐8 weeks) in the intervention groups was
0.25 lower
(0.40 to 0.11 lower)5

186
(2 studies)

⊕⊝⊝⊝
very low1,2,3

After shift discomfort rating for right shoulder or upper arm
Self‐reported questionnaire
Follow‐up: 4‐8 weeks

Mean discomfort rating was 1.55 4

The mean after shifts discomfort ratings for right shoulder or upper arm (4‐8 weeks) in the intervention groups was
0.33 lower
(0.46 to 0.19 lower)5

186
(2 studies)

⊕⊝⊝⊝
very low1,2,3

After shift discomfort rating for right forearm or wrist or hand
Self‐reported questionnaire
Follow‐up: 4‐8 weeks

Mean discomfort rating was 1.45 4

The mean after shifts discomfort ratings for right forearm or wrist or hand (4‐8 weeks) in the intervention groups was
0.18 lower
(0.29 to 0.08 lower)5

186
(2 studies)

⊕⊝⊝⊝
very low1,2,3

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because of limitations in studies (possibility of carry‐over effects of cross‐over trials).
2 Downgraded one level because of limitations in studies (measured of outcome was based on subjective symptoms (detection bias)).
3 Downgraded one level because of small number of participants (less than 400) in analysis using continuous variables.
4 Taken from figure 1 in Galinsky 2007.
5 Lower discomfort rating indicates beneficial effect.

Figures and Tables -
Summary of findings 7. Supplementary breaks versus normal breaks
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Summary of findings 8. Ergonomic training programme for preventing work‐related musculoskeletal disorders of the upper limb and neck in adults

Patient or population: office workers
Settings: working 5 hours or more per week with a VDU
Intervention: ergonomic training programme versus no training programme

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Ergonomic training program

Prevalence of Neck Musculoskeletal symptoms

Questionnaire

Follow‐up: at 6‐month

196 per 1,000

149 per 1,000

(96 to 234)

RR 0.76

(0.47 to 1.21)

614
(2 studies)

⊕⊕⊝⊝
low1,2

Prevalence of shoulder musculoskeletal symptoms

Questionnaire

Follow‐up: 6‐10 month

181 per 1,000

150 per 1,000

(107 to 212)

RR 0.82

(0.59 to 1.17)

614
(2 RCTs)

⊕⊕⊝⊝
low1,2

Prevalence of hand or wrist musculoskeletal symptoms

Questionnaire

Follow‐up: 6‐10 month

75 per 1,000

47 per 1,000

(27 to 81)

RR 0.63

(0.36 to 1.09)

724
(2 studies)

⊕⊕⊝⊝
low1,2

Prevalence of neck or shoulder MSD

Medical examination

Follow‐up: 6‐month

77 per 1,000

86 per 1,000

(46 to 161)

RR 1.12

(0.60 to 2.09)

455
(1 study)

⊕⊕⊝⊝
low1,3

Prevalence of hand or wrist MSD

Medical examination

Follow‐up: 6‐month

14 per 1,000

24 per 1,000

(6 to 87)

RR 1.73

(0.47 to 6.37)

503
(1 study)

⊕⊕⊝⊝
low1,3

Intensity of upper extremity pain

Questionnaire

Follow‐up: 3‐week

The mean intensity of upper extremity pain was 0

MD 0.08 higher
(0.22 lower to 0.38 higher) 4

‐

82
(1 study)

⊕⊝⊝⊝
very low1,2,3

Frequency of upper extremity pain

Questionnaire

Follow‐up: 3‐week

The mean frequency of upper extremity pain was 0

MD 0.03 lower
(0.45 lower to 0.39 higher) 4

‐

82
(1 study)

⊕⊝⊝⊝
very low1,2,3

Duration of upper extremity pain

Questionnaire

Follow‐up: 3‐week

The mean duration of upper extremity pain was 0

MD 0.13 higher
(0.25 lower to 0.51 higher) 4

‐

82
(1 study)

⊕⊝⊝⊝
very low1,2,3

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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; RR: Risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because of limitations in studies (there is no information on sequence generation (selection bias)).
2 Downgraded one level because of limitations in studies (measured of outcome was based on subjective symptoms (detection bias)).
3 Downgraded one level because only one study available and thus inconsistency cannot be assessed.
4 Lower score indicates beneficial effect.

Figures and Tables -
Summary of findings 8. Ergonomic training programme for preventing work‐related musculoskeletal disorders of the upper limb and neck in adults
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Summary of findings 9. Biofeedback (vibration) to reduce hand idle time on mouse versus no intervention

Patient or population: office workers
Settings: working in the office environment with a computer for at least 4 h/day
Intervention: biofeedback (vibration) to reduce hand idle time on mouse versus no intervention

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Biofeedback (vibration) to reduce hand idle time on mouse versus no intervention

Incidence or prevalence of musculoskeletal disorders

no data

no data

Shoulder pain intensity
Questionnaire survey
Follow‐up: 25 weeks

The mean shoulder pain intensity in the control groups was 1.58

The mean shoulder pain intensity in the intervention groups was
0.79 lower
(2.57 lower to 0.99 higher)4

23
(1 study)

⊕⊕⊝⊝
low1,2,3

Upper extremity pain intensity
Self‐administered questionnaire
Follow‐up: 25 weeks

The mean upper extremity pain intensity in the control groups was 2.94

The mean upper extremity pain intensity in the intervention groups was
1.64 lower
(6.85 lower to 3.57 higher) 4

23
(1 study)

⊕⊕⊝⊝
low1,2,3

Work related function

no data

no data

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (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

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Downgraded one level because of limitations in studies (measure of outcome based on subjective symptoms (detection bias)).
2 Downgraded one level because of total number of participants less than 400 (small sample size for a continuous variable).
3 Downgraded one level because of imprecision (95% confidence interval includes no effect).
4 Lower score indicate beneficial effect.

Figures and Tables -
Summary of findings 9. Biofeedback (vibration) to reduce hand idle time on mouse versus no intervention
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Comparison 1. An arm support together with an alternative mouse versus a conventional mouse alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Neck/shoulder discomfort score at 12‐month follow‐up Show forest plot

2

194

Std. Mean Difference (IV, Random, 95% CI)

‐0.41 [‐0.69, ‐0.12]

2 Incidence of neck/shoulder disorder at 12‐month follow‐up Show forest plot

2

186

Risk Ratio (M‐H, Random, 95% CI)

0.52 [0.27, 0.99]

3 Right upper extremity discomfort score at 12‐month follow‐up Show forest plot

2

194

Std. Mean Difference (IV, Random, 95% CI)

‐0.34 [‐0.63, ‐0.06]

4 Incidence of right upper limb disorder at 12‐month follow‐up Show forest plot

2

181

Risk Ratio (M‐H, Random, 95% CI)

0.73 [0.32, 1.66]

5 Incidence of upper body disorders (neck, shoulder, and upper limb) at 12‐month follow‐up Show forest plot

2

191

Risk Ratio (M‐H, Random, 95% CI)

0.66 [0.42, 1.04]

6 Change in percentage of work time Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

7 Change in average time to completely process a call Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

8 Change in calls per hour Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

9 Subject perceived improvement Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected
Figures and Tables -
Comparison 1. An arm support together with an alternative mouse versus a conventional mouse alone
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Comparison 2. An arm support together with a conventional mouse versus a conventional mouse alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Right upper‐limb strain scale at 6‐week follow‐up Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2 Neck/shoulder discomfort score Show forest plot

2

195

Std. Mean Difference (IV, Random, 95% CI)

0.02 [‐0.26, 0.30]

3 Incidence of neck/shoulder disorder Show forest plot

2

186

Risk Ratio (M‐H, Random, 95% CI)

0.91 [0.12, 6.98]

4 Right upper extremity discomfort score Show forest plot

2

195

Std. Mean Difference (IV, Random, 95% CI)

‐0.07 [‐0.35, 0.22]

5 Incidence of right upper extremity disorders Show forest plot

2

178

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.58, 1.96]

6 Incidence of upper body disorders (neck, shoulder and upper limb) Show forest plot

2

191

Risk Ratio (M‐H, Random, 95% CI)

0.87 [0.42, 1.80]

7 Change in percentage of work time Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

8 Change in average time to completely process a call Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

9 Change in calls per hour Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

10 Subject perceived improvement Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected
Figures and Tables -
Comparison 2. An arm support together with a conventional mouse versus a conventional mouse alone
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Comparison 3. Arm support for both arms versus no arm support

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Right upper‐limb strain scale at 6‐week follow‐up Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected
Figures and Tables -
Comparison 3. Arm support for both arms versus no arm support
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Comparison 4. An alternative mouse alone versus a conventional mouse alone

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Neck/shoulder discomfort score Show forest plot

2

195

Std. Mean Difference (IV, Random, 95% CI)

0.04 [‐0.26, 0.33]

2 Incidence of neck/shoulder disorder Show forest plot

2

182

Risk Ratio (M‐H, Random, 95% CI)

0.62 [0.19, 2.00]

3 Incidence of right upper extremity disorder Show forest plot

2

182

Risk Ratio (M‐H, Random, 95% CI)

0.91 [0.48, 1.72]

4 Right upper extremity discomfort score Show forest plot

2

195

Std. Mean Difference (IV, Random, 95% CI)

0.00 [‐0.28, 0.28]

5 Incidence of upper body disorder (neck, shoulder, and upper extremity) Show forest plot

2

190

Risk Ratio (M‐H, Random, 95% CI)

0.79 [0.52, 1.21]

6 Change in percentage of work time Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

7 Change in average time to completely process a call Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

8 Change in calls per hour Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

9 Subject perceived improvement Show forest plot

1

Odds Ratio (M‐H, Fixed, 95% CI)

Totals not selected
Figures and Tables -
Comparison 4. An alternative mouse alone versus a conventional mouse alone
Navigate to table in Review
Comparison 5. An alternative workstation adjustment versus no adjustment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Incidence of neck and shoulder pain Show forest plot

1

234

Risk Ratio (M‐H, Fixed, 95% CI)

1.08 [0.73, 1.59]

2 Incidence of arm and hand pain Show forest plot

1

245

Risk Ratio (M‐H, Fixed, 95% CI)

0.83 [0.50, 1.39]
Figures and Tables -
Comparison 5. An alternative workstation adjustment versus no adjustment
Navigate to table in Review
Comparison 6. Workstation adjustment according to OSHA/NIOSH recommendation compared to no workstation adjustment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Incidence of neck and shoulder pain Show forest plot

1

255

Risk Ratio (M‐H, Fixed, 95% CI)

1.19 [0.79, 1.78]

2 Incidence of arm and hand pain Show forest plot

1

249

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.56, 1.50]
Figures and Tables -
Comparison 6. Workstation adjustment according to OSHA/NIOSH recommendation compared to no workstation adjustment
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Comparison 7. Sit‐stand workstation versus normal workstation

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Intensity of neck and shoulder discomfort and pain Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2 Sitting time at 8‐week Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected
Figures and Tables -
Comparison 7. Sit‐stand workstation versus normal workstation
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Comparison 8. Supplementary breaks versus normal breaks

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 After shift discomfort rating for neck (4‐8 weeks) Show forest plot

2

186

Mean Difference (Random, 95% CI)

‐0.25 [‐0.40, ‐0.11]

2 After shift discomfort rating for right shoulder or upper arm (4‐8 weeks) Show forest plot

2

186

Mean Difference (Random, 95% CI)

‐0.33 [‐0.46, ‐0.19]

3 After shift discomfort rating for right forearm or wrist or hand (4‐8 weeks) Show forest plot

2

186

Mean Difference (Random, 95% CI)

‐0.19 [‐0.29, ‐0.08]
Figures and Tables -
Comparison 8. Supplementary breaks versus normal breaks
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Comparison 9. Biofeedback (vibration) to reduce hand idle time on mouse versus no intervention

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Shoulder Pain Intensity Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2 Upper Extremity Pain Intensity Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3 Relative Mouse Use over Total Computer Use Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected
Figures and Tables -
Comparison 9. Biofeedback (vibration) to reduce hand idle time on mouse versus no intervention
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Comparison 10. Ergonomic training versus no intervention

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Prevalence of Neck Musculoskeletal symptoms (by questionnaire) at 6‐month follow‐up Show forest plot

2

610

Risk Ratio (M‐H, Random, 95% CI)

0.76 [0.47, 1.21]

2 Prevalence of shoulder musculoskeletal symptoms (by questionnaire) at 6‐month follow‐up Show forest plot

2

610

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.58, 1.17]

3 Prevalence of hand/wrist musculoskeletal symptoms (by questionnaire) at 6‐month follow‐up at 6‐month follow‐up Show forest plot

2

724

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.36, 1.09]

4 Prevalence of neck/shoulder MSD (by medical examination) at 6‐month follow‐up Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

5 Prevalence of hand/wrist MSD (by medical examination) at 6‐month follow‐up Show forest plot

1

Risk Ratio (M‐H, Random, 95% CI)

Totals not selected

6 Intensity of upper extremity pain at 3‐week follow‐up Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

7 Frequency of upper extremity pain at 3‐week follow‐up Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

8 Duration of upper extremity pain at 3‐week follow‐up Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected
Figures and Tables -
Comparison 10. Ergonomic training versus no intervention
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Comparison 11. Work injury prevention programme versus no intervention

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Frequency of neck ache or pain Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

2 Frequency of shoulder ache or pain Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3 Frequency of wrist/hand ache or pain Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4 Intensity of neck ache or pain Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

5 Intensity of shoulder ache or pain Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

6 Intensity of wrist/hand ache or pain Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected
Figures and Tables -
Comparison 11. Work injury prevention programme versus no intervention
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