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

Arianne P Verhagen; Sita MA Bierma‐Zeinstra; Alex Burdorf; Siobhán M Stynes; Henrica CW de Vet; Bart W Koes

doi:10.1002/14651858.CD008742.pub2

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Figure 1

Study flow diagram.

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Figure 2

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

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Figure 4

Funnel plot of comparison: 1 Exercise versus no treatment controls, outcome: 1.1 Pain intensity, short term.

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Analysis 1.1

Comparison 1 Exercise versus no treatment controls, Outcome 1 Pain intensity, short term.

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Analysis 1.2

Comparison 1 Exercise versus no treatment controls, Outcome 2 Pain intensity, long term.

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Analysis 1.3

Comparison 1 Exercise versus no treatment controls, Outcome 3 Disability, short term.

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Analysis 1.4

Comparison 1 Exercise versus no treatment controls, Outcome 4 Disability, short term.

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Analysis 1.5

Comparison 1 Exercise versus no treatment controls, Outcome 5 Disability, long term.

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Analysis 1.6

Comparison 1 Exercise versus no treatment controls, Outcome 6 Improvement, short term.

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Analysis 1.7

Comparison 1 Exercise versus no treatment controls, Outcome 7 Improvement, short term.

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Analysis 1.8

Comparison 1 Exercise versus no treatment controls, Outcome 8 Sick leave, long term.

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Analysis 2.1

Comparison 2 Exercise versus active treatment controls, Outcome 1 Pain intensity, short term.

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Analysis 2.2

Comparison 2 Exercise versus active treatment controls, Outcome 2 Pain intensity, long term.

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Analysis 2.3

Comparison 2 Exercise versus active treatment controls, Outcome 3 Disability, short term.

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Analysis 2.4

Comparison 2 Exercise versus active treatment controls, Outcome 4 Disability, long term.

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Analysis 2.5

Comparison 2 Exercise versus active treatment controls, Outcome 5 Improvement, short term.

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Analysis 3.1

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 1 Pain intensity, short term.

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Analysis 3.2

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 2 Pain intensity, long term.

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Analysis 3.3

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 3 Disability, short term.

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Analysis 3.4

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 4 Disability, short term.

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Analysis 3.5

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 5 Disability, long term.

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Analysis 3.6

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 6 Disability, long term.

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Analysis 3.7

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 7 Improvement, short term.

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Analysis 3.8

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 8 Improvement, long term.

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Analysis 3.9

Comparison 3 Ergonomic intervention versus no treatment controls, Outcome 9 Sick leave, short term.

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Analysis 4.1

Comparison 4 Ergonomic intervention versus active treatment controls, Outcome 1 Pain intensity, short term.

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Analysis 4.2

Comparison 4 Ergonomic intervention versus active treatment controls, Outcome 2 Pain intensity, long term.

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Analysis 5.1

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 1 Pain intensity, short term.

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Analysis 5.2

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 2 Pain, short term.

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Analysis 5.3

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 3 Disability, short term.

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Analysis 5.4

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 4 Disability, short term.

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Analysis 5.5

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 5 Sick leave, short term.

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Analysis 5.6

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 6 Sick leave, short term.

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Analysis 5.7

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 7 Pain, long term.

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Analysis 5.8

Comparison 5 Behavioural intervention versus no treatment controls, Outcome 8 Disability, long term.

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Analysis 6.1

Comparison 6 Behavioural intervention versus active treatment controls, Outcome 1 Pain intensity, short term.

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Analysis 6.2

Comparison 6 Behavioural intervention versus active treatment controls, Outcome 2 Disability, short term.

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Analysis 6.3

Comparison 6 Behavioural intervention versus active treatment controls, Outcome 3 Work ability, short term.

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Analysis 6.4

Comparison 6 Behavioural intervention versus active treatment controls, Outcome 4 Pain intensity, long term.

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Analysis 6.5

Comparison 6 Behavioural intervention versus active treatment controls, Outcome 5 Disability, long term.

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Analysis 6.6

Comparison 6 Behavioural intervention versus active treatment controls, Outcome 6 Work ability, long term.

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Table 1. Criteria for assessing risk of bias in randomised clinical trials

Item	Judgement
1. Was the method of randomisation adequate?	Yes/No/Unsure
2. Was the treatment allocation concealed?	Yes/No/Unsure
Was knowledge of the allocated interventions adequately prevented during the study? 3. Was the participant blinded to the intervention? 4. Was the care provider blinded to the intervention? 5. Was the outcome assessor blinded to the intervention?	Yes/No/Unsure Yes/No/Unsure Yes/No/Unsure
Were incomplete outcome data adequately addressed? 6. Was the dropout rate described and acceptable? 7. Were all randomly assigned participants analysed in the group to which they were allocated?	Yes/No/Unsure Yes/No/Unsure
8. Are reports of the study free of suggestion of selective outcome reporting?	Yes/No/Unsure
Other sources of potential bias: 9. Were the groups similar at baseline regarding the most important prognostic indicators? 10. Were co‐interventions avoided or similar? 11. Was compliance acceptable in all groups? 12. Was the timing of the outcome assessment similar in all groups?	Yes/No/Unsure Yes/No/Unsure Yes/No/Unsure Yes/No/Unsure
Risk of bias was assessed using the 12 criteria above (Furlan 2009). The criteria for a judgement of 'Yes' are outlined in Appendix 2.

Table 1. Criteria for assessing risk of bias in randomised clinical trials

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Comparison 1. Exercise versus no treatment controls

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity, short term Show forest plot	10		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Versus no intervention	5	431	Std. Mean Difference (IV, Random, 95% CI)	‐0.52 [‐1.08, 0.03]
1.2 Versus discussion/counselling	3	235	Std. Mean Difference (IV, Random, 95% CI)	‐0.25 [‐0.87, 0.37]
1.3 Exercises plus additional treatment versus additional only	2	309	Std. Mean Difference (IV, Random, 95% CI)	‐1.02 [‐2.99, 0.95]
2 Pain intensity, long term Show forest plot	4		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Versus no treatment	2	308	Std. Mean Difference (IV, Random, 95% CI)	‐0.31 [‐0.96, 0.33]
2.2 Versus discussion/counselling	2	305	Std. Mean Difference (IV, Random, 95% CI)	‐0.07 [‐0.68, 0.54]
3 Disability, short term Show forest plot	3		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 Versus no treatment	2	295	Std. Mean Difference (IV, Random, 95% CI)	‐0.77 [‐2.50, 0.97]
3.2 Versus discussion/counselling	1	85	Std. Mean Difference (IV, Random, 95% CI)	0.51 [0.08, 0.94]
4 Disability, short term Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

4.1 Exercises plus additional treatment versus additional only	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
5 Disability, long term Show forest plot	3		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

5.1 Versus no treatment	2	308	Std. Mean Difference (IV, Random, 95% CI)	0.14 [‐0.08, 0.37]
5.2 Versus discussion/counselling	1	179	Std. Mean Difference (IV, Random, 95% CI)	‐0.55 [‐0.87, ‐0.23]
6 Improvement, short term Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

6.1 Versus discussion/counselling	1	126	Risk Ratio (M‐H, Random, 95% CI)	0.53 [0.37, 0.78]
7 Improvement, short term Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

7.1 Exercises plus additional treatment versus additional only	2	396	Risk Ratio (M‐H, Random, 95% CI)	1.25 [0.81, 1.93]
8 Sick leave, long term Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

8.1 Versus no treatment	2	308	Std. Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.26, 0.19]

Comparison 1. Exercise versus no treatment controls

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Comparison 2. Exercise versus active treatment controls

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity, short term Show forest plot	5		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Specific exercise versus regular exercises	4	208	Std. Mean Difference (IV, Random, 95% CI)	0.45 [0.14, 0.75]
1.2 Exercise versus manual therapy	1	123	Std. Mean Difference (IV, Random, 95% CI)	0.0 [‐0.35, 0.35]
2 Pain intensity, long term Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Specific versus regular exercise	2	201	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.18, 0.38]
3 Disability, short term Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Totals not selected

3.1 Specific versus regular exercise	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.2 Versus manual therapy	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Disability, long term Show forest plot	2	201	Std. Mean Difference (IV, Random, 95% CI)	0.11 [‐0.17, 0.38]

4.1 Specific versus regular exercise	2	201	Std. Mean Difference (IV, Random, 95% CI)	0.11 [‐0.17, 0.38]
5 Improvement, short term Show forest plot	5		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

5.1 Specific versus regular exercise	3	205	Risk Ratio (M‐H, Random, 95% CI)	0.86 [0.43, 1.71]
5.2 Versus massage	1	47	Risk Ratio (M‐H, Random, 95% CI)	0.78 [0.55, 1.11]
5.3 Versus manual therapy	1	125	Risk Ratio (M‐H, Random, 95% CI)	1.88 [1.29, 2.74]

Comparison 2. Exercise versus active treatment controls

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Comparison 3. Ergonomic intervention versus no treatment controls

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity, short term Show forest plot	5		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Versus placebo	1	80	Std. Mean Difference (IV, Random, 95% CI)	0.53 [0.01, 1.04]
1.2 Versus no treatment	3	506	Std. Mean Difference (IV, Random, 95% CI)	‐0.07 [‐0.36, 0.22]
1.3 Ergonomic intervention plus additional treatment versus additional only	1	94	Std. Mean Difference (IV, Random, 95% CI)	‐0.60 [‐1.01, ‐0.18]
2 Pain intensity, long term Show forest plot	4		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Versus no treatment	4	402	Std. Mean Difference (IV, Random, 95% CI)	‐0.76 [‐1.35, ‐0.16]
3 Disability, short term Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 Versus placebo	1	80	Mean Difference (IV, Random, 95% CI)	0.93 [0.28, 1.57]
3.2 Ergonomic intervention plus additional treatment versus additional only	1	94	Mean Difference (IV, Random, 95% CI)	‐9.0 [‐15.02, ‐2.98]
4 Disability, short term Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

4.1 Versus no treatment	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
5 Disability, long term Show forest plot	2	107	Std. Mean Difference (IV, Random, 95% CI)	‐0.33 [‐0.71, 0.06]

5.1 Versus no treatment	2	107	Std. Mean Difference (IV, Random, 95% CI)	‐0.33 [‐0.71, 0.06]
6 Disability, long term Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

6.1 Versus no treatment	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
7 Improvement, short term Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

7.1 Versus placebo	1	80	Risk Ratio (M‐H, Random, 95% CI)	1.89 [0.85, 4.21]
7.2 Versus no treatment	1	310	Risk Ratio (M‐H, Random, 95% CI)	0.88 [0.78, 0.99]
8 Improvement, long term Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

8.1 Versus no treatment	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
9 Sick leave, short term Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

9.1 Versus no treatment	2	330	Risk Ratio (M‐H, Random, 95% CI)	0.49 [0.32, 0.76]

Comparison 3. Ergonomic intervention versus no treatment controls

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Comparison 4. Ergonomic intervention versus active treatment controls

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity, short term Show forest plot	3		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Versus ergonomic intervention	3	134	Std. Mean Difference (IV, Random, 95% CI)	0.11 [‐0.24, 0.46]
2 Pain intensity, long term Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Versus ergonomic interventions	2	89	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐1.22, 1.18]

Comparison 4. Ergonomic intervention versus active treatment controls

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Comparison 5. Behavioural intervention versus no treatment controls

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity, short term Show forest plot	7		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

1.1 Versus no treatment	4	374	Std. Mean Difference (IV, Random, 95% CI)	‐0.67 [‐1.49, 0.16]
1.2 Versus waiting list controls	3	121	Std. Mean Difference (IV, Random, 95% CI)	‐0.74 [‐1.32, ‐0.15]
2 Pain, short term Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

2.1 Versus no treatment	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
2.2 Behavioural intervention plus additional treatment versus additional only	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
3 Disability, short term Show forest plot	4		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

3.1 Versus no treatment	2		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
3.2 Versus waiting list controls	2		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
4 Disability, short term Show forest plot	2		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

4.1 Versus no treatment	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
4.2 Behavioural intervention plus additional treatment versus additional only	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
5 Sick leave, short term Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

5.1 Versus no treatment	2	298	Std. Mean Difference (IV, Random, 95% CI)	0.02 [‐0.21, 0.24]
6 Sick leave, short term Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

6.1 Versus no treatment	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
7 Pain, long term Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

7.1 Versus no treatment	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
8 Disability, long term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

8.1 Versus no treatment	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 5. Behavioural intervention versus no treatment controls

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Comparison 6. Behavioural intervention versus active treatment controls

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain intensity, short term Show forest plot	5	396	Std. Mean Difference (IV, Random, 95% CI)	‐0.06 [‐0.25, 0.14]

1.1 Versus behavioural interventions	2	63	Std. Mean Difference (IV, Random, 95% CI)	‐0.23 [‐0.73, 0.27]
1.2 Versus exercises	3	333	Std. Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.24, 0.19]
2 Disability, short term Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

2.1 Versus exercises	2	293	Std. Mean Difference (IV, Random, 95% CI)	‐0.57 [‐1.66, 0.52]
3 Work ability, short term Show forest plot	2		Std. Mean Difference (IV, Random, 95% CI)	Subtotals only

3.1 Versus exercises	2	303	Std. Mean Difference (IV, Random, 95% CI)	‐0.15 [‐0.84, 0.54]
4 Pain intensity, long term Show forest plot	1		Std. Mean Difference (IV, Random, 95% CI)	Totals not selected

4.1 Versus exercises	1		Std. Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
5 Disability, long term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

5.1 Versus exercises	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]
6 Work ability, long term Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Totals not selected

6.1 Versus exercises	1		Mean Difference (IV, Random, 95% CI)	0.0 [0.0, 0.0]

Comparison 6. Behavioural intervention versus active treatment controls

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