None of the ergonomic interventions was more beneficial for any outcome measures when compared with another treatment or with no treatment or with placebo .
Behavioural interventions had inconsistent effects on pain and disability , with some subgroups showing benefit and others showing no significant improvement when compared with no treatment , minor intervention controls or other behavioural interventions .In the eight studies that evaluated various other interventions , there was no evidence of a clear beneficial effect of any of the interventions provided .
We found very low- quality evidence indicating that pain , recovery , disability and sick leave are similar after exercises when compared with no treatment , with minor intervention controls or with exercises provided as additional treatment to people with work-related complaints of the arm , neck or shoulder .
Low- quality evidence also showed that ergonomic interventions did not decrease pain at short-term follow-up but did decrease pain at long-term follow-up .
There was no evidence of an effect on other outcomes .
For behavioural and other interventions , there was no evidence of a consistent effect on any of the outcomes .
BACKGROUND Work-related upper limb disorder ( WRULD ) , repetitive strain injury ( RSI ) , occupational overuse syndrome ( OOS ) and work-related complaints of the arm , neck or shoulder ( CANS ) are the most frequently used umbrella terms for disorders that develop as a result of repetitive movements , awkward postures and impact of external forces such as those associated with operating vibrating tools .
Work-related CANS , which is the term we use in this review , severely hampers the working population .
OBJECTIVES To assess the effects of conservative interventions for work-related complaints of the arm , neck or shoulder ( CANS ) in adults on pain , function and work-related outcomes .
A Health System Program To Reduce Work Disability Related to Musculoskeletal Disorders
Context Nonoccupational musculoskeletal disorders account for a large proportion of work disability and represent a major financial burden on society . Contribution A voluntary , r and omized , controlled intervention study consisted of avoidance of bed rest , early mobilization , avoidance of splints , stretching exercises , ergonomic training , provision of educational booklets , and suggestions for optimal levels of physical activity . Although return to work was never forced , temporary work disability , long-term disability , and costs were significantly decreased in the intervention group . Implication s The personal and financial impact of work disability due to musculoskeletal disorders ( not related to work injury ) may be mitigated by a voluntary program of education and rehabilitation . The Editors Musculoskeletal disorders ( MSDs ) are prevalent and potentially disabling conditions ( 1 ) that consume a large proportion of health care re sources ( 2 - 4 ) and together are the leading cause of functional loss in adults ( 3 - 8 ) . The social costs of MSDs are enormous , often overshadowing those of other chronic conditions ( 9 , 10 ) . In industrialized societies , MSDs are one of the most common causes of temporary work disability and the chief cause of permanent work disability ( 11 ) , accounting for productivity losses equivalent to 1.3 % of the U.S. gross national product ( 12 ) . Work disability related to MSDs is a challenge to employability , business productivity , and the capacity of health and social security systems . Various strategies for addressing MSD-related work disability have been promoted in the field of occupational health , including strategies involving legislation , risk management , ergonomics , prevention , education , and social work ( 13 ) . However , the role of health systems remains ill-defined in this field . The purpose of this study was to evaluate whether an intervention program , integrated into the health system and offered to the working population , could reduce the impact of recent-onset MSD-related temporary work disability . Methods Setting Of the 5.5 million persons in Madrid , Spain , 98 % receive health coverage from the Instituto Madrileo de Salud . Care is organized into 11 health districts . Patients have direct access to primary care physicians , who refer patients to specialized care if needed . Disability compensation payments are made by the Instituto Nacional de la Seguridad Social ( INSS ) , a division of the Ministry of Work . Any worker who requires sick leave is given a temporary work disability initiation form that states the diagnosis made by the primary care physician and entitles the worker to receive INSS compensation payments . The form is renewed weekly by the primary care physician until the worker 1 ) recovers and receives an ending form , 2 ) reaches a maximum of 18 months of temporary work disability , or 3 ) receives a proposal for evaluation for permanent work disability . Proposals for permanent work disability are evaluated by the INSS , which determines the need for and type of long-term compensation . Inspection services in each health district oversee all administrative aspects of these processes . Design We did a r and omized , controlled study , unblinded for both patients and physicians , to test whether a clinical intervention could improve the outcome of patients with recent-onset MSD-related temporary work disability . The study began in March 1998 in health district 7 and in March 1999 in health districts 4 and 9 . Selection and r and omization of patients was done during the first year of the study in each district . Follow-up lasted for another year . Patients and Selection Criteria Health districts 4 , 7 , and 9 were chosen . Health district 4 had a total population of 508249 persons and an active working population of 192939 persons ; health district 7 had a total population of 522742 persons and an active working population of 179155 persons ; and health district 9 had a total population of 371294 persons and an active working population of 135475 persons ( 14 ) . The inclusion criterion was the issue of a common diseases temporary work disability initiation form , with an MSD-related cause reported by the primary care physician , within the inclusion period . The MSD-related causes included all arthropathies , connective tissue disorders , back disorders , soft-tissue rheumatisms , bone and cartilage disorders , musculoskeletal pain not caused by cancer , and nerve entrapment syndromes . Patients were excluded if they had a common diseases temporary work disability form with an MSD-related cause result ing from trauma or surgery . They were also excluded if they had work accidents or professional diseases noted on the temporary work disability initiation form . Work accidents are primarily sudden , external , violent causes of disease occurring at work or during travel to work , and they represent less than 27 % of cases of temporary work disability . Professional diseases include silicosis , asbestos-related mesothelioma , and noise-induced hearing loss , and they represent less than 1 % of cases of temporary work disability . R and omization All temporary work disability initiation forms meeting the selection criteria were collected daily by a study rheumatologist and coded . The patients associated with the forms were r and omly assigned to either the intervention group , which received a specific care program , or the  control group  , which received st and ard care ( Figure 1 ) . Computer-generated lists of pseudor and om numbers were produced for each district . Group assignments were r and omly done in blocks of 50 patients with intervention : control ratios of 1:1 in district 7 and 2:3 in districts 4 and 9 . This was done so that similar numbers of patients would be seen by the rheumatologists in all areas . The ratios were based on the number of episodes of MSD-related temporary work disability registered in previous years . Patients maintained their group assignments in successive episodes of MSD-related temporary work disability during follow-up . Figure 1 . Flow diagram of the study . Care in the Intervention Group A secretary contacted all patients assigned to the intervention group by telephone or mail as soon as possible after the initiation form was issued , offering them an appointment in the program . Patients who voluntarily decided to enter the program were attended by 2 rheumatologists in each district who worked full-time for the study . Patients were seen as often as necessary until the episode of temporary work disability was resolved or recovery was deemed unrealistic . Patients who were assigned to the intervention group but were unable or unwilling to participate , were already working , or could not be located were considered to be assigned to the intervention group throughout the study for statistical purpose s. Within the intervention program , care was delivered in regular visits and included education , clinical management , and administrative duties . Education At the first 45-minute visit , patients received a specific diagnosis , reassurance that no serious disease was present , instructions on self-management , instructions on taking medications on a fixed schedule , and information on indications for return to work before complete symptom remission . Return to work was negotiated with patients and was never forced on them . Instructions on self-management included instructions to avoid bed rest , instructions to promote early mobilization of the painful regions , restrictions on the use of splint and neck collars , training in stretching and strengthening exercises ( 15 - 18 ) , teaching of ergonomic care ( 19 ) , delivery of booklets in instances of back or neck pain ( 19 ) , and information on optimal levels of physical activity ( 20 ) . Patients with higher degrees of disability or abnormal pain behavior received immediate extra reassurance , information on pain-relieving positions , and a telephone call or second visit within 72 hours . Specific protocol s were created for low-back ( 21 ) , neck , shoulder , arm and h and , knee , and foot pain ( 19 , 22 - 25 ) and included the 3-level clinical -management system described later . Moving a patient from the lower to the upper levels of the system implied the need for further diagnostic or therapeutic procedures and was indicated 1 ) after a patient spent a predefined period at the lower level without return to work or substantial clinical improvement or 2 ) by the clinical judgment of the rheumatologist . At the first level of the system , patients received the clinical management started at the first visit , including a diagnosis based on clinical criteria , pharmacologic treatment of pain and inflammation , pharmacologic treatment of anxiety and depression , peripheral intra- and periarticular injections ( 26 ) , and education . Time spent at the first level averaged 2 to 6 weeks . At the second level , patients received maintenance of therapy plus referral for formal rehabilitation and laboratory tests , radiography , computerized tomography , magnetic resonance imaging , and electromyography . After 4 to 8 weeks with no improvement at the second level , patients were moved to the third level and received further diagnostic procedures or referral for surgical or other specialized care . Red flags were defined , including age older than 50 years for patients with axial pain , previous trauma , cancer , serious medical illness , inflammatory pain , night pain , drug abuse , corticosteroid use , fever , weight loss , progressively deteriorating function , and progressive neurologic deficit . The presence of a red flag precluded the use of the level system , and the patient in question was managed according to clinical criteria , with a focus on excluding serious illness . Treatment Failures Patients who did not respond to interventions at the second level of the system were examined for the presence of yellow flags , which included psychiatric illness , family problems , sociolabor conflicts , unemployment , and occupational causes of disability . The presence of a
None of the ergonomic interventions was more beneficial for any outcome measures when compared with another treatment or with no treatment or with placebo .
Behavioural interventions had inconsistent effects on pain and disability , with some subgroups showing benefit and others showing no significant improvement when compared with no treatment , minor intervention controls or other behavioural interventions .In the eight studies that evaluated various other interventions , there was no evidence of a clear beneficial effect of any of the interventions provided .
We found very low- quality evidence indicating that pain , recovery , disability and sick leave are similar after exercises when compared with no treatment , with minor intervention controls or with exercises provided as additional treatment to people with work-related complaints of the arm , neck or shoulder .
Low- quality evidence also showed that ergonomic interventions did not decrease pain at short-term follow-up but did decrease pain at long-term follow-up .
There was no evidence of an effect on other outcomes .
For behavioural and other interventions , there was no evidence of a consistent effect on any of the outcomes .
BACKGROUND Work-related upper limb disorder ( WRULD ) , repetitive strain injury ( RSI ) , occupational overuse syndrome ( OOS ) and work-related complaints of the arm , neck or shoulder ( CANS ) are the most frequently used umbrella terms for disorders that develop as a result of repetitive movements , awkward postures and impact of external forces such as those associated with operating vibrating tools .
Work-related CANS , which is the term we use in this review , severely hampers the working population .
OBJECTIVES To assess the effects of conservative interventions for work-related complaints of the arm , neck or shoulder ( CANS ) in adults on pain , function and work-related outcomes .