Workplace interventions for increasing standing or walking for decreasing musculoskeletal symptoms in sedentary workers Edited (no change to conclusions)

Abstract

Abstract Background

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

Objectives

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

Search methods

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

Selection criteria

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

Data collection and analysis

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

Main results

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

Physical work environment

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

Individual approach

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

Organisational level

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

Multi‐component approach

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

Authors' conclusions

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

Author(s)

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

Abstract

Plain language summary

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

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

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

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

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

Effects of changes to the physical work environment

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

Effects of interventions targeted at the individual

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

Effects of interventions targeted at the organisation

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

Effects of combining multiple interventions

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

Conclusions

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

Author(s)

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

Reviewer's Conclusions

Authors' conclusions

Implications for practice

The overall quality of the evidence is low. This review did not find a statistically significant reduction in musculoskeletal symptoms (intensity or presence of symptoms) from interventions that increased standing or walking for sedentary workers with baseline musculoskeletal symptoms. For participants with baseline musculoskeletal symptoms, the intensity of these symptoms was low. Most of the studies in this review included a mixed population of sedentary workers ‐ those with and without musculoskeletal symptoms ‐ and these studies were designed to measure other health outcomes (sedentary behaviour or cardiometabolic outcomes) rather than musculoskeletal outcomes. Therefore, the population of participants with baseline pain is a mixture of people specifically recruited because they have musculoskeletal symptoms and those who incidentally have musculoskeletal symptoms. Expectations and responses to the interventions are likely to be different if the primary goal of a study is to modify musculoskeletal symptoms rather than to change other health behaviours. Arguably, the intention of the study could account for different responses to an intervention, which could explain the overall finding of this review.

The effect of standing on musculoskeletal symptoms could also be mediated through a variety of mechanisms, depending on the nature of the symptoms and the body regions affected. For example, individuals with low and upper back symptoms may respond favourably or adversely to standing or walking, depending on the factors that underlie their musculoskeletal symptoms. For some people, loading the spinal region by standing or walking could exacerbate symptoms, whereas for others, this may bring symptom relief. Targeting interventions that promote standing or walking may be most suitable for people who indicate that standing or walking relieves symptoms, or for those who find that prolonged sitting increases musculoskeletal symptoms.

One of the findings from this review is that there was not a statistically significant increase in lower limb musculoskeletal symptoms when standing or walking interventions were provided to participants with baseline lower limb symptoms, and no other significant adverse events were reported. One of the potential barriers to implementing standing or walking interventions is the perceived potential to cause or exacerbate lower limb musculoskeletal symptoms. However, the number of participants with baseline lower limb musculoskeletal symptoms in this review was very low, and it is unclear whether participants with baseline pain in different body regions developed lower limb symptoms. Therefore, it is not clear whether standing or walking interventions contribute to lower limb musculoskeletal symptoms.

Implications for research

Although some large RCTs have examined interventions targeted at the physical work environment and at the organisation by providing sit‐stand workstations and multi‐component interventions, these studies have included a general population of sedentary workers. No large‐scale, multi‐site trials have specifically recruited participants with baseline musculoskeletal symptoms nor have they assessed a range of clinical outcomes. It may be useful to also explore interventions to increase standing and walking for specific people who find that sitting provokes musculoskeletal symptoms.

One of the largest barriers to implementing interventions to increase standing or walking is the cost of providing interventions such as sit‐stand workstations. Some studies have bypassed this barrier by allowing manufacturers to provide workstations. Some new workplaces or re‐designed workplaces are opting to provide sit‐stand workstations for all workers. Monitoring of workers before and after an office move may be a useful way to examine the effects of sit‐stand workstations. Although it is not possible to randomise workers into a control workplace in this situation, a matched controlled work site could be recruited. Stratification of participants based on baseline musculoskeletal symptoms at the start of a controlled before‐and‐after trial would provide valuable information regarding the differential effects of standing interventions for people with and without baseline musculoskeletal symptoms. Opportunistic research of this nature, although not yielding evidence of highest quality, could provide important findings when research is cost‐prohibitive.

Alternatively, other lower‐cost interventions should be examined, such as interventions targeted at increasing incidental office walking and standing by encouraging standing or walking meetings. These interventions would have to be targeted at the organisational level, as organisational support is essential when work practices that may be perceived to reduce worker productivity are changed.

Most of the studies in this review were short term (less than six months), with only a few reporting medium‐ and long‐term outcomes. Musculoskeletal adaptations to variation in sitting and standing may not provide evidence in the short and medium term, so it is important to provide long‐term interventions while monitoring to assess whether changes in occupational standing or walking behaviour can be sustained over time, and if associated changes in musculoskeletal symptoms are evident.

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