Workplace interventions to prevent musculoskeletal disorders: a systematic review of randomized trials

Santos, Patricia Giselle de Araújo e Silva; Martinez-Silveira, Martha Silvia; Fernandes, Rita de Cássia Pereira

doi:10.1590/2317-6369/33622en2024v49e12

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Revista Brasileira de Saúde Ocupacional

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Review article • Rev. bras. saúde ocup. 49 • 2024 • https://doi.org/10.1590/2317-6369/33622en2024v49e12 copy

Workplace interventions to prevent musculoskeletal disorders: a systematic review of randomized trials

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

to investigate the effects of workplace interventions aiming to prevent musculoskeletal disorders.

Methods:

systematic review that included randomized, individual or community trials, which investigated the effects of workplace interventions aiming to prevent musculoskeletal disorders, reported in articles published between 2015 and 2020 and indexed in the following databases: Lilacs, Medline/Pubmed, PEDro, and Web of Science. Studies were categorized according to the type of intervention and evaluated in terms of methodological quality.

Results:

of all 58 studies selected, 15 satisfactorily met the quality criteria, addressing different types of physical exercise and/or cognitive-behavioral approaches, applied alone or in combination. No study addressed organizational interventions. Despite the heterogeneity of interventions and outcomes, physical exercises performed in the workplace led to reduction in musculoskeletal pain, use of analgesics, and absence from work due to musculoskeletal disorders; however, combined with behavioral interventions, they did not show the expected results. The results with participatory ergonomics confirmed the critical role of workers in performing interventions in the workplace.

Conclusion:

despite the benefits observed, the studies reviewed did not produce consolidated evidence about the most effective interventions to prevent musculoskeletal disorders among workers.

Keywords:
musculoskeletal disorders; cumulative trauma disorders; prevention of diseases; occupational health; systematic review

Authors, year, country	Study type	Type of intervention	Characteristics of intervention	Follow-up	Population	Result/outcome
Multidimensional interventions
Rasmussen et al., 2015 ⁽¹⁰10. Rasmussen CDN, Holtermann A, Bay H, Søgaard K, Birk Jørgensen M. A multifaceted workplace intervention for low back pain in nurses' aides: a pragmatic stepped wedge cluster randomised controlled trial. PAIN. 2015;156(9):1786-94., Denmark	Cluster	1) Physical exercises	Participatory ergonomics (prevent effort and pain)	3 months	Nursing and kitchen assistants, and cleaning staff, as well as caretakers (workers employed in elderly care in nursing homes or home care)	The analyses produced significantly reduced the number of days of low back pain, pain intensity, and discomfort after the intervention when compared to the control group.
					This study assessed four groups, each doing an activity at different times.
					594 participants
			1) Physical training (introduce different types of physical exercises to present different types of physical activities: 1) body awareness and body postures; 2) strength and coordination training; 3) general physical activity.		21 clusters divided into four groups
		2) Cognitive-behavioral therapy			Study population assessed = 586
					- Group 1: 5 clusters/12 teams, n = 126 participants;	A multidimensional workplace intervention consisting of physical training and CBT effectively reduced the number of days of low back pain, pain intensity, and discomfort among workers in workplaces with elderly people.
			2) Cognitive-behavioral training (CBT): workshops focused on changing maladaptive pain behaviors and cognitive processes.		- Group 2: 5 clusters/14 teams, n = 146 participants;
					- Group 3: 5 clusters/13 teams, n = 158 participants;
					- Group 4: 6 clusters/15 teams, n = 164 participants
Jay et al., 2015 ⁽¹¹11. Jay K, Brandt M, Hansen K, Sundstrup E, Jakobsen MD, Schraefel MC, et al. Effect of individually tailored biopsychosocial workplace interventions on chronic musculoskeletal pain and stress among laboratory technicians: randomized controlled trial. Pain Physician. 2015;18:459-71., Denmark	Individual RCT	1) Physical exercises	The experimental intervention treatment (PCMT group) consisted of four main elements:	10 weeks	Workers of a large pharmaceutical company	- Pain reduction in the PCMT and control groups: 52% and 15%, respectively;
		2) Cognitive-behavioral training	1) Individualized motor control training.		Control group (n = 56): an email was sent to people encouraging them to participate in existing initiatives, such as weekly training with elastic bands and active breaks.	- Significant associations for change in pain with the number of physical-cognitive training sessions per week and number of mindfulness sessions.
		2) Cognitive-behavioral training	2) Individualized resistance and specific training for the area affected by pain.			- Significant reduction in musculoskeletal pain when compared to the control group after the intervention.
		- Mindfulness	3) Cognitive training and behavior change education, emphasizing specific individual concerns about pain and movement.		Intervention group - PCMT (n = 56): Group-based mindfulness training; 20-minute physical training with flexible schedules; guided mindfulness	- The authors hoped to reduce pain through the influence of stress, because if stress decreases, pain decreases too, and vice versa; however, while mindfulness can help reduce pain, dose-response analysis showed an opposite effect.
		- Mindfulness	4) Mindfulness.			- Participation in mindfulness sessions increased the perception of pain at each session attended.
Stevens et al., 2019 ⁽¹²12. Stevens ML, Boyle E, Hartvigsen J, Mansell G, Søgaard K, JørgensenMB, et al. Mechanisms for reducing low back pain: a mediation analysis of a multifaceted intervention in workers in elderly care. Int Arch Occup Environ Health. 2019;92:49-58. Disponível em: https://doi.org/10.1007/s00420-018-1350-3 https://doi.org/10.1007/s00420-018-1350-... , Denmark	Cluster	1) Physical exercises	Participatory ergonomics training: two 3-hour workshops and two 1-hour assessment sessions focused on reducing physical effort at work, changing work tasks perceived as physically demanding.	3 months	Elderly care workers	Effects of the intervention to reduce fear avoidance by increasing the use of assistive devices, but not on perception of muscle strength or physical effort.
		1) Physical exercises	1) Physical exercise program: 12 weekly 1-hour sessions (various types of physical activity).		N = 420
		2) Cognitive-behavioral training	2) Cognitive-behavioral training program: 2 three-hour workshops focused on the use of cognitive processes to change maladaptive pain behaviors.		Control group: did not perform any activity.	The intervention reduced beliefs about avoiding fear and increased the use of assistive devices at work, but it did not lead to changes in low back pain patterns (number of days with low back pain, pain intensity, and days with some discomfort).
		2) Cognitive-behavioral training			Intervention group: performed proposed activities.
Becker et al., 2017 ⁽¹³13. Becker A, Angerer P, Müller A. The prevention of musculoskeletal complaints: a randomized controlled trial on additional effects of a work-related psychosocial coaching intervention compared to physiotherapy alone. Int Arch Occup Environ Health. 2017;90(4):357-71. Disponível em: https://doi.org/10.1007/s00420-017-1202-6 https://doi.org/10.1007/s00420-017-1202-... . Germany	Individual RCT	1) Physical therapy	1) Physical therapy	10 weeks	Nurses from five hospitals located in the Paderborn region, in Germany	Significant improvement was observed in both groups over time.
		1) Physical therapy	The standard treatment for musculoskeletal complaints is guided monitored movement therapy. In addition, an appreciation for posture and proprioceptive movements must be developed to reduce fear of movement.		Control group (34): received only the exercises from the physical therapy program.	Tendency of more pain due to the maximum degree of movement in the intervention group.
		2) Coaching	Preventive physical therapy was performed at five physical therapy practice sites.			The result of the time × group interaction showed that combined intervention of physical therapy and coaching, when compared to physical therapy alone, helps improve current mobility.
			2) Coaching		Intervention group (34): received physical therapy exercises and psychosocial coaching intervention.	Combined intervention of physical therapy and coaching, when compared to physical therapy alone, reduced the level of pain in daily movements at the first follow-up.
			Coaching focuses on a private consultation with qualified personnel and management of individual development issues at work.
Becker et al., 2020 ⁽¹⁴14. Becker A, Angerer P, Weber J, Müller A. The prevention of musculoskeletal complaints: long-term effect of a work-related psychosocial coaching intervention compared to physiotherapy alone - a randomized controlled trial. Int Arch Occup Environ Health. 2020;93:877-89. Disponível em: https://doi.org/10.1007/s00420-020-01538-1 https://doi.org/10.1007/s00420-020-01538... , Germany	Individual RCT	1) Physical therapy	Both groups received physical therapy exercises over a 10-week period (focused on individual functional status and job-specific physical demands; 10 × 45 min.). In addition, the intervention group received work-related psychosocial coaching during this period. This psychosocial coaching intervention consisted of 1 × 120 minutes of introduction to the theoretical model of selection, optimization, and compensation.	10 weeks	Nurses	A significant effect of the intervention was observed on maximal spinal motion restriction for imputed data sets only, which means a higher decrease in disability in the IG than in the CG at the third follow-up. No other significant effect of the intervention was observed.
		2) Coaching			Control group (n = 31): received physical therapy only.
		2) Coaching			Intervention group (n = 32): received physical therapy and coaching sessions.
Individual interventions
Pereira et al., 2019 ⁽¹⁵15. Pereira M, Comans T, Sjøgaard G, Straker L, Melloh M, O'Leary S, et al. The impact of workplace ergonomics and neck-specific exercise versus ergonomics and health promotion interventions on office worker productivity: A cluster-randomized trial. Scand J Work Environ Health. 2019;45(1):42-52. Disponível em: https://doi.org/10.5271/sjweh.3760 https://doi.org/10.5271/sjweh.3760... , Australia	Cluster	1) Ergonomic guidance	Group 1) EET -> Workplace ergonomics and specific physical training for the neck: exercise at work in groups for 20 minutes, three times a week.	12 weeks	Office workers	At the end of the program, EET participants with neck pain had lower absenteeism over 12 months when compared to participants in the EHP group.
		1) Ergonomic guidance			There was no control group, the study had two groups with different activities for compariso.
		2) Physical exercises	Group 2) EHT -> Workplace ergonomics and health promotion information: received a weekly series of health promotion seminars, each lasting one hour for 12 weeks.		EET -> Workplace ergonomics and specific physical training for the neck: exercise at work in groups for 20 minutes, three times a week.
		2) Physical exercises			EHT -> Workplace ergonomics and health promotion information: received a weekly series of health promotion seminars, each lasting one hour for 12 weeks. 12 weeks.
Akyurek et al., 2020 ⁽¹⁶16. Akyurek G, Avci N, Ekici G. The effects of "Workplace Health Promotion Program" in nurses: A randomized controlled trial and one-year follow-up. Health Care for Women International. 2020;43(9):980-96. Disponível em: https://doi.org/10.1080/07399332.2020.1800013 https://doi.org/10.1080/07399332.2020.18... , Türkiye	Individual RCT	1) Physical exercises	Workplace Health Promotion Programs (WHPP):	5 weeks	Nurses	The authors reported in the results that, after the WHPP, the intervention group had a significant
			1) Physical exercises:		Nurses
			- Progressive muscle relaxation (PMR).		Control group (n = 15): rested in a room with reading materials, but without other activities. Individuals were instructed not to change their activities or forms of relaxation for one year.
		2) Ergonomic guidance	- Postural exercises (specific strengthening and stretching).			improvement in pain, fatigue, stress, coping skills, and quality of professional life immediately after the end of the program, when compared to baseline data. The results (improvements) were maintained after one year.
			- Breathing exercises.		Intervention group (n = 15): performed the entire proposed activity twice a week.
			2) Ergonomic guidance (postural guidance, chair position, among others).
Jakobsen et al., 2015 ⁽¹⁷17. Jakobsen MD, Sundstrup E, Brandt M, Jay K, Aagaard P, Andersen LL. Effect of workplace- versus home-based physical exercise on musculoskeletal pain among healthcare workers: a cluster randomized controlled trial. Scand J Work Environ Health. 2015;41(2):153-63. Disponível em: https://doi.org/10.5271/sjweh.3479 https://doi.org/10.5271/sjweh.3479... , Denmark	Cluster	Physical exercises	Any physical exercise at work or at home.	10 weeks	Healthcare professionals from three Danish hospitals.	- Pain intensity decreased in the WORK group.
			Any physical exercise at work or at home.		Control group (physical exercise at home - HOME)	- Pain intensity decreased in the WORK group.
			- Both groups were encouraged to do the exercise for 5 to 10 minutes every week for 10 weeks.		- Participants received a bag with exercise equipment.	- Muscle strength (lumbar spine) increased in the WORK group.
					- Folders explaining the exercises.
			Both groups:		Intervention group (physical exercise in the workplace - WORK)	- Higher reduction in the use of analgesics in the WORK group.
			Both groups:		- Supervised high-intensity strength training with Thera-Band elastic bands and kettlebells during working hours at the hospital.
			- Ergonomic training and education on patient transfer and use of assistive devices.		- 10 exercises.	- The study showed a significant decrease in the intensity of musculoskeletal pain, an increase in muscle strength, and a reduction in the use of analgesics among healthcare workers in response to exercise for 10 weeks in the workplace when compared to exercise performed at home.
					- 5 coaching sessions of 30 to 45 minutes to motivate participants to practice exercise.
					- One of the objectives of coaching was to encourage participation in the intervention - whether physical exercise or coaching sessions (stimulate other colleagues).
Jakobsen, et al., 2017 ⁽¹⁸18. Jakobsen MD, Sundstrup E, Brandt M, Andersen LL. Factors affecting pain relief in response to physical exercise interventions among healthcare workers. Scand J Med Sci Sports. 2017;27:1854-63. Disponível em: https://doi.org/10.1111/sms.12802 https://doi.org/10.1111/sms.12802... , Denmark	Cluster	Physical exercises	Any physical exercise at work or at home, both groups were encouraged to exercise for 5 to 10 minutes per week.	10 weeks	Healthcare professionals from three Danish hospitals.	The authors identified that a higher adherence to training also led to better results.
			Both groups: - Ergonomic training and guidance on patient transfer and use of assistive devices.		Control group (n = 89, 9 clusters) (physical exercise at home - HOME).	However, the study showed that even when the analysis was adjusted for training adherence (among other parameters), performing physical exercise, and receiving motivational coaching in the workplace more effectively reduced musculoskeletal pain intensity in low back, neck, and shoulders when compared to performing exercise at home.
					Intervention group (n = 111, 9 clusters) (physical exercise in the workplace - WORK).
Jakobsen et al., 2018 ⁽¹⁹19. Jakobsen MD, Sundstrup E, Brandt M, Andersen LL. Effect of physical exercise on musculoskeletal pain in multiple body regions among healthcare workers: Secondary analysis of a cluster randomized controlled trial. Musculoskelet Sci Pract. 2018;34:89-96. Disponível em: https://doi.org/10.1016/j.msksp.2018.01.006 https://doi.org/10.1016/j.msksp.2018.01.... , Denmark	Cluster	Physical exercises	Intervention: physical exercise at work or at home (5 to 10 minutes).	10 weeks	Healthcare professionals from three hospitals	According to the study authors, although adherence was higher in the group that performed the intervention in the workplace, in the analyses, adjustments were made for training adherence and the WORK group presented better results.
			*Groups:
			# WORK
			- Supervised strength training.		Control group (9 clusters, n = 89): was part of the HOME group and performed the exercises at home.
			- 2 to 20 workers per session.
			- 4 to 6 exercises (from pre-established exercises).			*The coaching sessions, with motivation to participate in the program, may have impacted the results.
			- The group that exercised at work (WORK) also participated in 5 motivational training sessions of 30 to 45 minutes in a group of 5 to 12 participants.		Intervention group (9 clusters, n = 111): was part of the WORK group and participated in the proposed activities.
			# HOME
			- Participants were instructed to exercise for 10 minutes, five times a week, and perform 4 exercises (out of 10 proposed exercises).
			- The group at home (HOME) performed the activities during leisure time.
Korshøj et al., 2018 ⁽²⁰20. Korshøj M, Jørgensen MB, Lidegaard M, Mortensen OS, Krustrup P, Holtermann A, Søgaard K. Decrease in musculoskeletal pain after 4 and 12 months of an aerobic exercise intervention: a worksite RCT among cleaners. Scand J Public Health. 2018;46(8):846-53. Disponível em: https://doi.org/10.1177/1403494817717833 https://doi.org/10.1177/1403494817717833... , Denmark	Cluster	Physical exercises	First phase of the intervention:	12 weeks	Cleaning companies in the suburban area of Copenhagen, Denmark, recruited by contact.	- 4 months: no significant changes, except in the hip;
			Control group (reference): 2 classes/lectures of 2 hours/class.
			Intervention group: 2 × 30 min. --> 32 sessions (16 hours).
			Second phase of the intervention:
			Control group (reference): 3 classes/lectures of 2 hours/class.		Control group (reference) (20 clusters, n = 59): lectures with guidance about healthy lifestyle.	- 12 months: significant changes in shoulders, arms, wrists, and trends in knees, feet, and ankles;
			Intervention group: exercise group: 2 × 30 min. --> 52 sessions (26 hours).
			In the second phase, exercise supervision of the intervention group gradually decreased, as follows:
			- period from baseline up to 4 weeks: 6 supervised sessions,
			- period from 4 to 8 weeks: 5 supervised sessions,		Intervention group (20 clusters, n = 57): physical activity (at or near the location, during working hours).	- the study showed significant results in upper limbs; however, it showed worsening in lower limbs.
			- period from 8 to 12 weeks: 4 supervised sessions,
			- period from 12 to 16 weeks: 2 supervised sessions,
			- period from 16 to 20 weeks: 1 supervised session.
			Participation was recorded only when the instructor was present.
Moreira et al., 2020 ⁽²¹21. Moreira RFC, Moriguchi CS, Carnaz L, Foltran FA, Silva LCCB, Coury HJCG. Effects of a workplace exercise program on physical capacity and lower back symptoms in hospital nursing assistants: a randomized controlled trial. Int Arch Occup Environ Health. 2020;94:275-84. Disponível em: https://doi.org/10.1007/s00420-020-01572-z https://doi.org/10.1007/s00420-020-01572... , Brazil	Individual RCT	Physical exercises	Intervention: therapeutic exercise program twice a week for 12 weeks, each session of 30 minutes.	12 weeks	Active nursing assistants at a general hospital in Brazil.	Results of low back pain: positive, pain relief (measurements before and after the intervention), although it is not possible to predict long-term effects.
					Control group (n = 44): did not receive any intervention, only after the end of the analyses.
					Intervention group (n = 46): received proposed intervention.
Doda et al., 2015 ⁽²²22. Doda D, Rothmore P, Pisaniello D, Briggs N, Stewart S, Mahmood M, Hiller JE. Relative benefit of a stage of change approach for the prevention of musculoskeletal pain and discomfort: a cluster randomised trial. Occup Environ Med. 2015;72(11):784-79. Disponível em: https://doi.org/10.1136/oemed-2015-102916 https://doi.org/10.1136/oemed-2015-10291... , Australia	Cluster	Behavioral approach (SOC - Stages of Change model)	Interventions addressed various types of recommendations to control MSD, including redesign of tools, workstations, work processes, purchase of new equipment, job rotation, workplace inspection programs, manual handling training, and exercises.	12 weeks	29 work groups from 23 medium-sized companies (20 to 200 employees) and large companies (more than 200 employees)	Interventions adapted according to the SOC model showed relative benefit, particularly for low back pain and discomfort.
			- In total, 25 interventions (13 standardized and 12 customized) were monitored in 21 companies from eight industrial sectors. The interventions were implemented by the manager for workers. The ergonomist monitored the interventions every three months, through a telephone call to the manager.		Group of personalized interventions based on the SOC model (15 groups from 14 companies, n = 109) and group of standardized interventions (14 groups from 12 companies, n = 133).
			The main focus of the study question was not the effect of the intervention at the individual level.
Viester et al., 2015 ⁽²³23. Viester L, Verhagen EALM, Bongers PM, van der Beek AJ. The effect of a health promotion intervention for construction workers on work-related outcomes: results from a randomized controlled trial. Int Arch Occup Environ Health. 2015;88(6):789-98. Disponível em: https://doi.org/10.1007/s00420-014-1007-9 https://doi.org/10.1007/s00420-014-1007-... , The Netherlands	Individual RCT	Behavioral approach	- Lifestyle coaching program	12 weeks	Workers of a large construction company.	The prevalence of musculoskeletal symptoms decreased; however, the reduction was not statistically significant.
			- Personalized lifestyle information, lifestyle coaching sessions, exercise instructions, and the VIP (vitality in practice) under construction with Toolbox.		Control group (n = 152): received usual care, without any other intervention.
			- Participants received a ‘personal energy plan’ form to write goals and action plans.		Intervention group (n = 162): performed proposed intervention.
Danquah et al., 2017 ⁽²⁴24. Danquah IH, Kloster S, Holtermann A, Aadahl M, Tolstrup JS. Effects on musculoskeletal pain from "Take a Stand!" - a cluster-randomized controlled trial reducing sitting time among office workers. Scand J Work Environ Health. 2017;43(4):350-57. Disponível em: https://doi.org/10.5271/sjweh.3639 https://doi.org/10.5271/sjweh.3639... , Denmark/Greenland	Cluster	Behavioral approach	The Take a Stand! intervention included five elements: (1) appointment of local ambassadors, management and support; (2) environmental changes; (3) a lecture; (4) a workshop aiming to ensure local adaptation of the individual at office and workplace level; and (5) emails and text messages. The intervention focused on four strategies to reduce sitting time: use of a desk with support for sitting, taking breaks for extended periods, standing up, adoption of walking meetings, and setting common office-level goals.	3 months	Office workers	When comparing the intervention and control groups after 1 and 3 months, taking into account baseline levels, a small reduction was observed in total pain score.
					Control group (9 offices, n = 144): instructed to maintain their usual activities.	After 3 months, the prevalence of neck-shoulder pain was slightly reduced in the intervention group when compared to the control group, but for back and extremity pain, no change was found (exploratory analyses). For total pain score, a small reduction was observed in the intervention group when compared to the control group at 1- and 3-month follow-up.
					Intervention group (10 offices, n = 173): followed the proposed intervention program.

Authors, year, country	Study type	Study objective	Measurement instruments	Effect/impact/association measures OR, RR, mean difference	Study limitations
Multidimensional interventions
Rasmussen et al., 2015 ⁽¹⁰10. Rasmussen CDN, Holtermann A, Bay H, Søgaard K, Birk Jørgensen M. A multifaceted workplace intervention for low back pain in nurses' aides: a pragmatic stepped wedge cluster randomised controlled trial. PAIN. 2015;156(9):1786-94., Denmark	Cluster	Test the effectiveness of a 3-month multidimensional intervention consisting of participatory ergonomics, physical exercises, and cognitive behavioral therapy for low back pain in the workplace with nursing assistants.	Numerical scale (0-10)	Linear regression models estimated the intervention effect. Beta coefficients and 95% confidence interval (CI) were calculated.	- Difference in dropout between the 4 groups, with higher dropout in groups that started the intervention at a later time. It may cause a small selection bias toward a healthier population being analyzed.
			Oswestry Disability Questionnaire	After the intervention, reduction was observed in parameters, as follows:	- Due to the specific population analyzed in this study, the results cannot be generalized to other occupational groups.
			Oswestry Disability Questionnaire	- 0.8 day reduction in low back pain;	- Low participation rate (50%).
			Roland Morris Questionnaire	- 0.4 point pain intensity and reduction of discomfort, with	- It was not possible to evaluate the effects of every component of the intervention separately.
			Roland Morris Questionnaire	-0.5 day reduction in discomfort in the intervention group.
Jay et al., 2015 ⁽¹¹11. Jay K, Brandt M, Hansen K, Sundstrup E, Jakobsen MD, Schraefel MC, et al. Effect of individually tailored biopsychosocial workplace interventions on chronic musculoskeletal pain and stress among laboratory technicians: randomized controlled trial. Pain Physician. 2015;18:459-71., Denmark	Individual RCT	Investigate the effect of a workplace intervention - with individually adapted physical and cognitive elements - on pain intensity and stress level among laboratory technicians with chronic musculoskeletal pain.	Nordic Musculoskeletal Questionnaire (NMQ)	Beta coefficients from the models showed the punctual measure of change, with accuracy estimated with 95% CI.	- Inability to blind participants.
			Visual Analogue Scale (VAS)	The models evaluated the pain reduction effect.	- Self-reported results may be influenced.
			Visual Analogue Scale (VAS)	Significant effects of the intervention on “fear avoidance” and use of safety devices: β < 1.0 (CI < 1.0) after the intervention.	- Self-reported results may be influenced.
Stevens et al., 2019 ⁽¹²12. Stevens ML, Boyle E, Hartvigsen J, Mansell G, Søgaard K, JørgensenMB, et al. Mechanisms for reducing low back pain: a mediation analysis of a multifaceted intervention in workers in elderly care. Int Arch Occup Environ Health. 2019;92:49-58. Disponível em: https://doi.org/10.1007/s00420-018-1350-3 https://doi.org/10.1007/s00420-018-1350-... , Denmark	Cluster	Investigate whether a workplace intervention would cause significant change in proposed mediators, which would, in turn, cause a significant change in low back pain outcomes.	Örebro Musculoskeletal Pain Questionnaire (OMPQ)	No effect of interventions on low back pain outcomes.	- Tools used to measure potential mediators may not have been ideal.
					- Use of a self-reported measurement of muscle strength.
					- Variables may be related. These interrelations have to be tested in future studies which would include multiple measurements of each variable.
Becker et al., 2017 ⁽¹³13. Becker A, Angerer P, Müller A. The prevention of musculoskeletal complaints: a randomized controlled trial on additional effects of a work-related psychosocial coaching intervention compared to physiotherapy alone. Int Arch Occup Environ Health. 2017;90(4):357-71. Disponível em: https://doi.org/10.1007/s00420-017-1202-6 https://doi.org/10.1007/s00420-017-1202-... , Germany	Individual RCT	Determine whether an additional psychosocial coaching intervention focused on dealing with psychosocial work stressors is superior to physical therapy techniques alone as a standard intervention to reduce musculoskeletal complaints..	Nordic Musculoskeletal Questionnaire (NMQ);	Mean difference between groups was the effect measure:	- The initially desired number of participants was not reached (95 instead of 110 participants).
			Nordic Musculoskeletal Questionnaire (NMQ);	NMQ (restriction of daily activities, last three months, 0-9 scale)	- ANOVA was used, but the authors reported that it did not fully meet the criteria for an intention-to-treat analysis.
			Visual Analogue Scale (VAS);	- IG: t1 = 1.09 (1.86) / t7 = 0.55 (1.37) / t8 = 0.59 (1.62)	- Result based on self-reported data (possible Hawthorne effect - minimized effect due to physical examinations performed by physical therapists, who were not aware of study conditions).
				- CG: t1 = 1.22 (1.7) / t7 = 0.48 (1.00) / t8 = 0.40 (1.00)
				time effect F: t1-t7 = 14,393 (p < 0.05) / t1-t8 = 8,935 (p < 0.05)	- The effects of the intervention can be attributed to the combined intervention only (coaching plus physical therapy), and not to coaching alone.
			West Haven-Yale Multidimensional Pain Inventory (WHYMPI).	t1 = time 1
				t7 = time 7	- Extrapolation of results to other occupational groups was not clarified.
				t8 = time 8
Becker et al., 2020 ⁽¹⁴14. Becker A, Angerer P, Weber J, Müller A. The prevention of musculoskeletal complaints: long-term effect of a work-related psychosocial coaching intervention compared to physiotherapy alone - a randomized controlled trial. Int Arch Occup Environ Health. 2020;93:877-89. Disponível em: https://doi.org/10.1007/s00420-020-01538-1 https://doi.org/10.1007/s00420-020-01538... , Germany	Individual RCT	Determine the long-term effects on non-specific musculoskeletal complaints of an intervention that combined physical therapy and coaching compared to physical therapy alone. The coaching intervention focused on enabling better strategies to deal with work stressors.	West Haven-Yale Multidimensional Pain Inventory (WHYMPI);	Mean difference between groups was the effect measure. The results showed reduced effect, with good accuracy measured at the 95% CI.	- A statistically significant long-term effect of the combined intervention was observed only on one of the four primary outcome indicators.
	Individual RCT		Nordic Musculoskeletal Questionnaire (NMQ).	NMQ (restriction of daily activities, last three months, 0-9 scale): 0.22 (-0.44; 0.87).	- High number of dropouts, risk of biased results, and limited power to detect the effects of the intervention.
Individual interventions
Pereira et al., 2019 ⁽¹⁵15. Pereira M, Comans T, Sjøgaard G, Straker L, Melloh M, O'Leary S, et al. The impact of workplace ergonomics and neck-specific exercise versus ergonomics and health promotion interventions on office worker productivity: A cluster-randomized trial. Scand J Work Environ Health. 2019;45(1):42-52. Disponível em: https://doi.org/10.5271/sjweh.3760 https://doi.org/10.5271/sjweh.3760... , Australia	Cluster	Compare the immediate and long-term impact of workplace ergonomics and neck-specific exercises versus ergonomics and information of health promotion regarding health-related productivity in a general population of office workers and workers with neck pain.	World Health Organization Health and Work Questionnaire	Multiple linear regression was conducted in hierarchical or multilevel models.	- The 12-month follow-up rate was 49.5%, lower than expected.
					- The human capital approach was used to quantify the monetary amount of lost productivity, which may be an overestimate compared to the attrition cost approach.
				Beta coefficients allowed authors to compare the groups submitted to two interventions and estimate changes that occurred at 12 months compared to the baseline for each group in terms of loss of productivity, absenteeism, and presenteeism.	- The presenteeism measurement used in the study, which is not health-specific and is an overview of reduced work performance.
					- Use of a self-reported measurement.
Akyurek et al., 2020 ⁽¹⁶16. Akyurek G, Avci N, Ekici G. The effects of "Workplace Health Promotion Program" in nurses: A randomized controlled trial and one-year follow-up. Health Care for Women International. 2020;43(9):980-96. Disponível em: https://doi.org/10.1080/07399332.2020.1800013 https://doi.org/10.1080/07399332.2020.18... , Türkiye	Individual RCT	Investigate the effects of Workplace Health Promotion Programs (WHPP) on pain, fatigue, stress, professional quality of life (Pro-QOL), and coping skills for nurses working in healthcare settings.	Visual Analogue Scale (VAS)	Comparison of intervention and control groups to assess pain, fatigue, stress, coping skills, and professional quality of life scores at the beginning and at the end of treatment, and at 1-year follow-up.	- Small sample.
	Individual RCT		Visual Analogue Scale (VAS)	The results showed no difference in effect after follow-up (Z test and p value).	- Potential physiological and/or psychological mechanisms that may be responsible for reducing pain, fatigue, and stress and improving quality of life should be analyzed in future studies.
Jakobsen et al., 2015 ⁽¹⁷17. Jakobsen MD, Sundstrup E, Brandt M, Jay K, Aagaard P, Andersen LL. Effect of workplace- versus home-based physical exercise on musculoskeletal pain among healthcare workers: a cluster randomized controlled trial. Scand J Work Environ Health. 2015;41(2):153-63. Disponível em: https://doi.org/10.5271/sjweh.3479 https://doi.org/10.5271/sjweh.3479... , Denmark	Cluster	Investigate the effect of physical exercise in the workplace versus at home (WORK versus HOME) on musculoskeletal back and neck/shoulder pain among healthcare professionals.	Visual Analogue Scale (VAS);	Mean difference between groups at follow-up was the effect measure. The results showed reduced effect, with good accuracy measured at the 95% CI.	- Inability to blind participants and those responsible for the intervention.
	Cluster		Nordic Musculoskeletal Questionnaire (NMQ).		- Perceived pain can be influenced by outcome expectations (Hawthorne bias).
Jakobsen et al., 2017 ⁽¹⁸18. Jakobsen MD, Sundstrup E, Brandt M, Andersen LL. Factors affecting pain relief in response to physical exercise interventions among healthcare workers. Scand J Med Sci Sports. 2017;27:1854-63. Disponível em: https://doi.org/10.1111/sms.12802 https://doi.org/10.1111/sms.12802... , Denmark	Cluster	Investigate whether adherence to training, type of physical exercise intervention (at work or at home), pain state, frequency of patient handling, body mass index (BMI), age, and leisure activities affect the relief of musculoskeletal pain.	Visual Analogue Scale (VAS);	Mean difference between groups at follow-up was the effect measure. The results showed reduced effect, with good accuracy measured at the 95% CI.	- The authors did not stratify the randomization for pain/non-pain cases; therefore, the results should be interpreted with caution.
			Visual Analogue Scale (VAS);		- Follow-up questionnaire not validated; therefore, it should be interpreted with caution.
			Nordic Musculoskeletal Questionnaire (NMQ).		- Short-term follow-up.
					- Training intensity (individual muscle load) and training volume (number of sets and repetitions in every 10-minute session) were not quantified in this study, did not allow the authors to identify whether it was the potential difference in training volume, the training intensity or technical performance of the exercises that contributed to a better result after 10 weeks of workplace exercises when compared to home exercises.
					- Assessment of training adherence was measured retrospectively at follow-up.
Jakobsen et al., 2018 ⁽¹⁹19. Jakobsen MD, Sundstrup E, Brandt M, Andersen LL. Effect of physical exercise on musculoskeletal pain in multiple body regions among healthcare workers: Secondary analysis of a cluster randomized controlled trial. Musculoskelet Sci Pract. 2018;34:89-96. Disponível em: https://doi.org/10.1016/j.msksp.2018.01.006 https://doi.org/10.1016/j.msksp.2018.01.... , Denmark	Cluster	Assess the effect of physical exercise in the workplace versus at home on pressure pain threshold and musculoskeletal pain intensity in various regions of the body among healthcare workers.	Nordic Musculoskeletal Questionnaire (NMQ).	Changes in pain intensity and pressure pain threshold from baseline to 10-week follow-up. Values are differences in means (95% confidence interval).	- No significant increase was observed in absolute pain threshold after exercise in the workplace, which somehow confuses the relationship between pain perception and sensitivity.
				Neck: -0.3 (-0.8-0.1) / p-value = 0.133
				Shoulder: -0.5 (-0.9-0) / p-value = 0.034
				Upper back: -0.5 (-0.9-0.1) / p-value = 0.009
				Low back: -0.7 (-1.1-0.3) / p-value = 0.001
			Visual Analogue Scale (VAS);	Elbow: -0.1 (-0.3-0.2) / p-value = 0.711	One explanation for the absence of increase in pain threshold may be related to the variation of sessions, since the baseline test was performed at the end of summer, and the follow-up in December (in winter when the weather is cold).
				Wrist/hand: -0.4 (-0.7-0) / p-value = 0.057
				Hip: -0.4 (-0.8-0.1) / p-value = 0.020
				Knee: -0.1 (-0.4-0.3) / p-value = 0.676
				Foot: -0.6 (-0.9-0.2) / p-value = 0.002
Korshøj et al., 2018 ⁽²⁰20. Korshøj M, Jørgensen MB, Lidegaard M, Mortensen OS, Krustrup P, Holtermann A, Søgaard K. Decrease in musculoskeletal pain after 4 and 12 months of an aerobic exercise intervention: a worksite RCT among cleaners. Scand J Public Health. 2018;46(8):846-53. Disponível em: https://doi.org/10.1177/1403494817717833 https://doi.org/10.1177/1403494817717833... , Denmark	Cluster	Assess changes in the musculoskeletal system in the context of an aerobic exercise.	Nordic Musculoskeletal Questionnaire (NMQ).	Measurements of musculoskeletal pain intensity after four months.	- One study limitation refers to convenience sampling of only three companies in Copenhagen, Denmark, limiting the representativeness of the results for cleaning staff in general.
				Neck
				Mean difference = -0.40
				Standard error = 0.47
				95% CI = -1.33 to 0.53
				p = 0.40	- Possible selection bias for a population in unhealthier situations.
				Low back
				Mean difference = 0.11
				Standard error = 0.42
				95% CI = -0.73 to 0.94
				p = 0.80	- Loss to follow-up: 29% at 4-month follow-up and 35% at 12-month follow-up.
				Hip
				Mean difference = -0.61
				Standard error = 0.26
				IC 95% = 0.11 to 1.12
				p = 0.02
Moreira et al., 2020 ⁽²¹21. Moreira RFC, Moriguchi CS, Carnaz L, Foltran FA, Silva LCCB, Coury HJCG. Effects of a workplace exercise program on physical capacity and lower back symptoms in hospital nursing assistants: a randomized controlled trial. Int Arch Occup Environ Health. 2020;94:275-84. Disponível em: https://doi.org/10.1007/s00420-020-01572-z https://doi.org/10.1007/s00420-020-01572... , Brazil	Individual RCT	Assess the effectiveness of a therapeutic exercise program on muscle strength and low back symptoms among nursing assistants.	Nordic Musculoskeletal Questionnaire (NMQ).	Post-intervention low back symptoms:	- Short follow-up period. The authors suggest an adequate follow-up period in order to identify long-term effects of the therapeutic exercise program.
	Individual RCT		Nordic Musculoskeletal Questionnaire (NMQ).	The clinical examination identified a positive effect in the reference group, in 67.5% of the population, and in 93% of the intervention group, with p-value = 0.002 and OR (95% CI) = 6.25 (1.6; 24.1).
Doda et al., 2015 ⁽²²22. Doda D, Rothmore P, Pisaniello D, Briggs N, Stewart S, Mahmood M, Hiller JE. Relative benefit of a stage of change approach for the prevention of musculoskeletal pain and discomfort: a cluster randomised trial. Occup Environ Med. 2015;72(11):784-79. Disponível em: https://doi.org/10.1136/oemed-2015-102916 https://doi.org/10.1136/oemed-2015-10291... , Australia	Cluster	Report the differences between standard interventions (ergonomic) and a psychological approach (stage of change - SOC) for the prevention of work-related musculoskeletal pain and discomfort (MSPD).	A number of questionnaires about:	General effect of the intervention: RR less than 1.0, characterizing protection against MSD in any region and an increase in the protective capacity against the development of low back pain.	- Participant attrition rate from baseline to follow-up studies (40.1%).
			- demographic information;
			- MSD symptoms.
Viester et al., 2015 ⁽²³23. Viester L, Verhagen EALM, Bongers PM, van der Beek AJ. The effect of a health promotion intervention for construction workers on work-related outcomes: results from a randomized controlled trial. Int Arch Occup Environ Health. 2015;88(6):789-98. Disponível em: https://doi.org/10.1007/s00420-014-1007-9 https://doi.org/10.1007/s00420-014-1007-... , The Netherlands	Individual RCT	Evaluate whether the intervention program for blue-collar construction workers reduced musculoskeletal symptoms.	Dutch musculoskeletal questionnaire (DMQ)	Effect of the intervention with protection measured by RR < 1.0. The results showed punctual measurements (RR) for 6 and 12 months, with low accuracy of confidence intervals (1.0 < CI > 1.0).	- Power calculation was performed at the measured primary outcome of the study, i.e., body weight.
					- Results of measurements based on self-report.
					- The possibility of contamination was not completely ruled out.
Danquah et al., 2017 ⁽²⁴24. Danquah IH, Kloster S, Holtermann A, Aadahl M, Tolstrup JS. Effects on musculoskeletal pain from "Take a Stand!" - a cluster-randomized controlled trial reducing sitting time among office workers. Scand J Work Environ Health. 2017;43(4):350-57. Disponível em: https://doi.org/10.5271/sjweh.3639 https://doi.org/10.5271/sjweh.3639... , Denmark/Greenland	Cluster RCT	Assess the effects on musculoskeletal pain of a 3-month intervention to reduce sitting time.	MSD questionnaire developed by the authors.	Effect of the intervention with protection measured by RR < 1.0. The results showed punctual measurements (RR) for 6 and 12 months, with low accuracy of confidence intervals (1.0 < CI > 1.0).	- The pain measurement was not very precise, as it was measured in only three categories (no discomfort, small discomfort, strong discomfort).
	Cluster RCT		MSD questionnaire developed by the authors.		- Short intervention period may not have been enough.

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Pubmed/Medline	#1	“musculoskeletal diseases”[MeSH] OR “Back pain” OR “low back pain” OR Backpain[TIAB] OR backache[TIAB] OR “back ache” OR Neckache OR Cervicalgia* OR Cervicodynia* OR “Cervical Pain” OR “Musculoskeletal Pain”[TIAB] OR “Cumulative Trauma” OR “Repetition Strain Injur” OR “Repetitive Motion Disorder” OR “Overuse Syndrome” OR “Carpal Tunnel” OR “Iliotibial Band Syndrome” OR “Ulnar Nerve Compression” OR “Cubital Tunnel Syndrome” OR “musculoskeletal disease” OR “musculoskeletal disorder” OR Tendinopath OR Tendinos* OR Tendinit* OR Tendonit* OR Tendonopath* OR Epicondylit* OR ((Leg[TIAB] OR knee[TIAB] OR foot[TIAB] OR feet[TIAB] OR neck[TIAB] OR arm[TIAB] OR arms[TIAB] OR finger[TIAB] OR hand[TIAB] OR shoulder[TIAB] OR wrist[TIAB]) AND (pain[TIAB] OR injur[TIAB] OR ache[TIAB])) AND (occupation[tiab] OR work[tiab] OR Employ[tiab] OR job[tiab] OR jobs[tiab] OR work[Mesh:NoExp] OR employment[Mesh:NoExp] OR workplace[Mesh:NoExp] OR occupations[Mesh:NoExp]) AND (“Occupational diseases”[MESH] OR “Occupational disease”)
	#2	(work[tiab] OR workplace[tiab] OR work-place[tiab] OR workload[tiab] OR Work[Mesh:NoExp] OR “employment”[Mesh:NoExp] OR Employ[TIAB] OR Job[TIAB] OR jobs[TIAB] OR Occupation[TIAB] OR Worksite*[TIAB] OR “working conditions” OR Workload[TIAB])
	#3	(interven[tiab] OR strateg[tiab] OR solution[tiab] OR reorganis[tiab] OR reorganiz[tiab] OR re-organis[tiab] OR re-organiz*[tiab] OR redesign[tiab] OR re-design[tiab] OR restructuring[tiab] OR re-structuring[tiab])
	#4	#1 AND #2 AND #3
		“randomized” OR “cross sectional” OR “cohort” OR “prophylactic study” OR “observational study” OR “case control”
Web of Science	#1	TS=(“cumulative trauma disorder” OR “musculoskeletal disorder” OR “musculoskeletal disease” OR “hand-arm vibration syndrome” OR tendinopath OR tendinos* OR tendinit* OR tendonit* OR tendonopath* OR epicondylit* OR “repetition strain injur” OR “repetitive motion disorder” OR “overuse syndrome” OR “carpal tunnel” OR “iliotibial band syndrome” OR “ulnar nerve compression” OR “cubital tunnel syndrome”) OR TS= (musculoskeletal OR “low back” OR “back” OR “neck” OR “shoulder” OR “upper extremit” OR “chronic” OR “lower extremit” OR “foot” OR “feet” OR “wrist” OR “leg” OR “knee” OR “hand” OR “trigger finger” OR “arm”) AND TS=(“pain” OR “ache” OR “injur*”)
	#2	TS=(work* OR employ* OR job* OR labor OR labour OR occupation* OR workplace* OR “work location” OR work-site OR “work site” OR worksite OR “work place” OR workplace OR “job site” OR “working environment” OR “working condition” OR workload OR employment)
	#3	TS=(“primary prevention” OR ergonomic* OR “change management” OR exercise OR “risk reduction behavior” OR “occupational health” OR strategy OR solution OR “risk prevention” OR intervention OR prevention OR organizational OR organisational OR redesign OR change*)
	#4	#1 AND #2 AND #3
		TS=(“randomized” OR “cross sectional” OR “cohort” OR “prophylactic study” OR “observational study” OR “case control”)
Lilacs	#1	(tw:((“cumulative trauma disorder” OR “Trastornos de Traumas Acumulados” OR “Transtornos Traumáticos Cumulativos”) OR (“Musculoskeletal Diseases” OR “Enfermedades Musculoesqueléticas” OR “Doenças Musculoesqueléticas”) OR (Tendinopathy OR Tendinopatía OR Tendinopatia) OR ((musculoskeletal OR musculoesquelético OR musculoesquelético) OR (“low back” OR “espalda baja” OR lombar) OR (neck OR cuello OR pescoço) OR (shoulder OR hombro OR ombro) OR (“upper extremit” OR “extremidad superior” OR “extremidade superior”) OR (chronic OR crónico OR crônica) OR (“lower extremit*” OR “extremidad inferior” OR “extremidade inferior”) OR (foot OR pie OR pé) OR (wrist OR muñeca OR punho) OR (leg OR pierna OR perna) OR (knee OR rodilla OR joelho) OR (hand OR mano OR mão) OR (arm OR brazo OR braço) AND (pain OR dolor OR dor))))
	#2	(tw:((work OR trabajo OR Trabalho) OR (employment OR empleo OR emprego) OR (occupations OR ocupaciones OR ocupações) OR (workplace OR “lugar de trabajo” OR “local de trabalho”) OR (“working environment” OR “ambiente de trabajo” OR “ambiente de trabalho”) OR (“working conditions” OR “condiciones de trabajo” OR “condições de trabalho”) OR (workload OR “carga de trabajo” OR “carga de trabalho”)))
	#3	(tw:((“primary prevention” OR “prevención primaria” OR “prevenção primária”) OR (ergonomics OR ergonomía OR ergonomia) OR (exercise OR “ejercicio físico” OR “exercício físico”) OR (“change management” OR “gestión del cambio” OR “gestão de mudança”) OR (strategies OR estrategias OR estratégias) OR (“occupational health” OR “salud laboral” OR “saúde do trabalhador”)))
	#4	(tw:((“cumulative trauma disorder” OR “Trastornos de Traumas Acumulados” OR “Transtornos Traumáticos Cumulativos”) OR (“Musculoskeletal Diseases” OR “Enfermedades Musculoesqueléticas” OR “Doenças Musculoesqueléticas”) OR (Tendinopathy OR Tendinopatía OR Tendinopatia) OR ((musculoskeletal OR musculoesquelético OR musculoesquelético) OR (“low back” OR “espalda baja” OR lombar) OR (neck OR cuello OR pescoço) OR (shoulder OR hombro OR ombro) OR (“upper extremit” OR “extremidad superior” OR “extremidade superior”) OR (chronic OR crónico OR crônica) OR (“lower extremit*” OR “extremidad inferior” OR “extremidade inferior”) OR (foot OR pie OR pé) OR (wrist OR muñeca OR punho) OR (leg OR pierna OR perna) OR (knee OR rodilla OR joelho) OR (hand OR mano OR mão) OR (arm OR brazo OR braço) AND (pain OR dolor OR dor)) )) AND (tw:((work OR trabajo OR Trabalho) OR (employment OR empleo OR emprego) OR (occupations OR ocupaciones OR ocupações) OR (workplace OR “lugar de trabajo” OR “local de trabalho”) OR (“working environment” OR “ambiente de trabajo” OR “ambiente de trabalho”) OR (“working conditions” OR “condiciones de trabajo” OR “condições de trabalho”) OR (workload OR “carga de trabajo” OR “carga de trabalho”))) AND (tw:((“primary prevention” OR “prevención primaria” OR “prevenção primária”) OR (ergonomics OR ergonomía OR ergonomia) OR (exercise OR “ejercicio físico” OR “exercício físico”) OR (“change management” OR “gestión del cambio” OR “gestão de mudança”) OR (strategies OR estrategias OR estratégias) OR (“occupational health” OR “salud laboral” OR “saúde do trabalhador”)))
PEDro	Therapy: health promotion Subdiscipline: ergonomics and occupational health Method: clinical trial	Published Since: 2001 When Searching: Match all search terms (AND)