Best Practice & Research Clinical Rheumatology Vol. 21, No. 3, pp.

447463, 2007
doi:10.1016/j.berh.2007.02.015 available online at http://www.sciencedirect.com

4 Work related neckshoulder pain: a review on magnitude, risk factors, biochemical characteristics, clinical picture and preventive interventions
Britt Larsson
Senior Physician Division of Rehabilitation Medicine, Department of Neuroscience and Locomotion, Faculty of Health Sciences, and Pain and rehabilitation centre, University Hospital, 581 85 Linko ping, Sweden
MD, PhD

Karen Sgaard
Senior Researcher

MSc, PhD

National Research Centre for the Working Environment, Lers Parkalle 105, DK-2100 Copenhagen, Denmark

Lars Rosendal *

MSc, PhD

Senior Clinical Research Associate Cyncron, Department of Clinical Operations, P.O. Box 130, Datavej 24, DK-3460 Birkerd, Denmark

The purpose of this review is to scrutinize the physiology of neckshoulder pain and trapezius myalgia based on the most recent scientic literature. Therefore, systematic literature searches have been conducted. Occurrence of neckshoulder pain, risk factors for development of neckshoulder pain, and its work-relatedness are addressed. Furthermore, the latest information on the biochemical milieu within healthy and painful neckshoulder muscles is reviewed. Finally diagnosis of and intervention for neck and shoulder pain are discussed. Key words: algesic; biopsy; human; intervention; metabolism; microdialysis; muscle; myalgia; pain; neck; review; risk factor; shoulder; trapezius; work-related.

Musculoskeletal disorders comprise one of the most common and costly public health issues in Europe and North America1,2, and the cost in the Nordic countries and Holland has been estimated to encompass 0.52% of the GNP.3 Among these
* Corresponding author. Tel.: 45 70 20 20 58; Fax: 45 70 20 20 57. E-mail address: LRL@cyncron.com (L. Rosendal). 1521-6942/$ - see front matter 2007 Elsevier Ltd. All rights reserved.

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disorders, persistent neckshoulder pain, including myalgia, is one of the commonest. For several decades well-dened work-related physical and psychosocial factors have been shown to be associated with onset or worsening of pain in this region. In spite of abundant epidemiological knowledge, there is little to indicate that the incidence of neckshoulder pain is diminishing. The pathophysiology of myalgia in this region has been reviewed in a number of papers, with the conclusion that there are multiple possible mechanisms.46 However, whether local muscular processes provide an explanation for this kind of pain is often questioned.7 In the case of chronic neck shoulder pain, in particular, the muscular component is often considered uncertain. However, recently a relatively large number of studies using methods such as muscle biopsy and microdialysis have opened up new possibilities for elucidating the role of peripheral factors and changes in the biochemical milieu in muscle in the development and maintenance of pain and disorders. Research in the eld of work-related myalgia often concerns the plausible connection between muscular activity and muscle damage.6 This relationship, as well as knowledge of pathomechanisms, are partly but not sufciently elucidated.8,9 Accurate and, ideally, standardized diagnosis of neck and shoulder myalgia is a prerequisite for adequate individual ergonomic interventions. Furthermore, prevention must rely on scientically based knowledge regarding risk factors as well as the possible pathomechanisms behind the development of neck pain. This review addresses the occurrence of neckshoulder pain and trapezius myalgia, and risk factors for the development of these complaints. Furthermore, the signicance of histological and biochemical alterations underlying pain, diagnostic possibilities, and interventional aspects of neckshoulder pain will be reviewed. OCCURRENCE OF WORK-RELATED NECKSHOULDER DISORDER There is a vast amount of epidemiological literature dealing with work-related neckshoulder disorders as a major health problem in many occupations. Still, the work-relatedness in the sense of a well-established doseresponse relationship or a calculated etiological fraction is poorly documented. This is due to several factors presenting varying degrees of difculty for a straightforward interpretation. First of all, the term neckshoulder disorders covers a broad spectrum ranging from selfreported pain to a relatively well-dened clinical diagnosis. Therefore, incidence and prevalence of neckshoulder disorders are difcult to compare across studies and countries. In the Finnish population the prevalence of neck pain has in the last two decades shown a steady increase and is the second most frequent musculoskeletal complaint.10 In the working population in general, the estimated prevalence of upper-extremity symptoms is in the range 2030%.1 In a Canadian general population survey the 6-month prevalence of neck pain was more than 50% among all adults.11 Women more often than men experience neck pain and develop persistent pain, and most individuals with neck pain do not experience complete resolution of their symptoms and disability.11 Within certain occupations the prevalence is even higher than in the general population; among Danish computer users the 12-month prevalence of more that 7 days with neck pain was approximately 45%.12 The incidence of neck cases was 25% for women and 15% for men. In addition, those who reported previous symptoms were more likely to also develop symptoms in the follow-up period.12 Prevalence is highest when neck symptoms are quantied by self-reported duration, frequency, and intensity. The prevalence decreases when symptoms are to

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be conrmed by physical examination ndings. Thus, in a study of elderly female computer-users in EU countries, it was found that for as many as 60% of those with selfreported neck symptoms of a certain duration and intensity, a clinical examination could conrm one or more diagnoses, with trapezius myalgia (38%), tension neck syndrome (17%), and cervicalgia (17%) being the most frequent.13 For the individual, the consequences of neckshoulder pain may range from minor episodes of short duration with limited activity, through recurrent episodes with diminished work capacity and performance, to severe and disabling episodes or chronic disability. Therefore, for society the economical consequences similarly range from short-term sick leave, through recurrent long-term sick-leave periods, to early retirement and/or disability pension. Risk factors identied in the scientic literature In 2001 a large review presented a state-of-the-art overview scrutinizing the available documentation on possible risk factors for work-related upper-extremity disorders.14 The conclusion stated that strong evidence was found for a causal relationship between neck disorders and highly repetitive work, forceful exertions, high level of static contractions, prolonged static loads and extreme postures, as well as combinations of these factors. There was insufcient evidence for vibration as a risk factor for neck disorder. Literature search, 20002006 In the present review it was decided to follow up on this earlier review with a systematic search of the newest epidemiological literature to reveal whether new evidence had emerged regarding risk factors for upper-extremity disorders. The search was performed in OSHROM, MEDLINE, EMBASE and Cochrane (CDSR). For details see Appendix 1. The search was conducted as a combination of four sets of keywords, and results were restricted to review papers published from 2000 to 2006 in the English language. This resulted in 156 review papers that were scrutinized to include only systematic reviews with a reproducible search method, a quality estimation and objective criteria for dening sufcient evidence for a risk factor. This procedure resulted in ten reviews primarily based on epidemiological evidence and considering both disorders conrmed by clinical examinations as well as symptoms described as disorders, pain, decreased work ability or performance, etc. Conclusions on the major risk factors are presented as follows. Identied risk factors Gender Individual factors are not considered in this review, with just one exception; gender seems to play a prominent role, since the prevalence of pain in the upper extremity is much higher among women than men.1517 This is the case even when adjusting for confounders such as age and seniority. The difference may be explained by many factors, but one explanation could be that womens jobs, more often than mens,

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involve work tasks with static load on the neck muscles, high repetitiveness, low control and high mental demands that are possible risk factors for neckshoulder pain. Repetitive movements Malchaire et al found that 75% of the studies reviewed demonstrated a signicant relationship between repeated movements and upper extremity disorders in general, whereas van der Windt et al found a consistent relationship specically between neckshoulder pain and repeated movements.18,19 However, it was not possible to nd evidence of a detailed doseresponse relation between specic work tasks and the development of specic disorders. All in all the most recent literature reviews conrm the strong evidence found in the National Research Council (NRC) survey for repetitive movements. High force demands Very few work situations demand high force performed directly by neckshoulder muscles. However, forceful manipulation with the hands often requires a high degree of stabilization in the neckshoulder area. Ariens et al found some evidence for a correlation between the work-related force requirements in the arms and neckshoulder pain, as well as between heavy lifting and neckshoulder pain.20 Malchaire et al further found sufcient evidence for a linkage between forceful hand work and both hand/ wrist and neckshoulder disorders.18 Work posture Work posture as a risk factor for neck disorders involves both duration of constrained postures, as well as awkward or extreme postures involving both neck and arm. Malchaire et al found evidence for awkward posture as a risk factor for neckshoulder disorder.18 Likewise, Ariens et al found some evidence for a causal relation between neck disorders and sedentary work for more than 5 hours a day, as well as work demanding bending and twisting of the upper spine.20 Both Ariens et al and WalkerBone et al found that working with the arms lifted above shoulder level was a welldocumented risk factor for neckshoulder disorder.16,20 Vibration Vibration is typically found in work with hand tools or machines. In the NRC report evidence was found for vibration as a risk factor for muscle disorders in general.14 The recent literature survey does not support this clear picture. While Malchaire et al found no relationship between vibration and shoulder or hand disorders18, van der Windt et al reported a consistent association with shoulder disorder19, while Ariens concluded that there was some evidence.20 Computer work The NRC review concluded that there was evidence for an increased risk for development of upper-extremity disorders among computer users.14 It was suggested that this could be due to constrained postures, constant force and highly repetitive movements as well as psychosocial factors such as time constraints and high quantitative demands. This conclusion is supported by the prevailing literature on sustained

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activity of low-threshold motor units during low-force static or repetitive muscle tension in trapezius as well as the forearm muscle.2125 Only a few reviews have been done since 2000 regarding the documentation for computer work and symptoms from the upper extremities. A single review has focused on temperature and disorders, since cold hands and forearms are often reported symptoms among computer users.26 However, no support was found for a connection between temperature changes and disorders among computer users. Gerr et al focused on the association between neck disorders and work postures and duration of computer use measured as hours per day or week.27 The review concluded that there is evidence for work posture as a risk factor for the development of disorders. Specically, the keyboard position below elbow height and support under the forearms were associated with a reduced risk of developing neckshoulder disorders. Even though it was not possible to specify a doseresponse relationship, evidence was found for duration of computer work as a risk factor for neckshoulder disorder, as has also been conrmed in recent studies.27,28 Veiersted et al focused on a possible connection between computer use and clinically diagnosed disorders in neck, shoulder and arms, and is thus narrower in scope than the reviews on symptoms in general.29 They found that there was limited evidence for a causal relationship between computer work, mouse use or keyboard use, and this rather strict denition of neck disorders that does not consider diagnoses such as, for instance, trapezius myalgia.29 Psychosocial factors The NRC report showed documentation for a causal relationship between workrelated stress and high demands, and disorders in the upper extremity.16 Only a few newer overviews add to this. There is some evidence for a relationship between disorders and high quantitative demands, lack of support from colleagues, low job control and low inuence.30 In two other reviews, evidence for a relation between mental stress at work and disorders was also demonstrated.18,31 In addition, a relationship between high quantitative and qualitative demands at work and disorders was evident. However, there was insufcient evidence to evaluate the relationship between disorders and low control, inuence on own job situation, lack of support from colleagues and superiors, general unsatisfactory job content. All in all, the limited amount of literature focusing on causal relationships between psychosocial factors and disorders makes it difcult to estimate the inuence of these factors and how they may interact with the biomechanical and individual factors. MUSCLE NOCICEPTION Neurophysiological studies have indicated that small-diameter, slowly conducting afferent nerve bres from skeletal muscle have to be excited in order to elicit pain. A high proportion of these bres terminate in free nerve endings with nociceptive properties.32 Nociceptors are sensitive to chemical substances released from damaged or overloaded cells and excessive tissue deformation.33 Nociceptors have been shown to respond to several algesic substances such as bradykinin, serotonin, and prostaglandin, to name a few.34 Administration of any of these substances, alone or in combination, results in excitation of nociceptors33 and/or peripheral sensitization. A sensitized nociceptor has a lowered threshold for activation and can thus be activated by stimuli

452 B. Larsson et al

which are normally innocuous.33 Sensitization is often accompanied by an increase in the sensitive area.33 Different sensitization processes can occur in the central nervous system. Central sensitization and spreading of pain is widely discussed, and is very likely to inuence the clinical symptoms and the course of neck myalgia, but is beyond the aim of this chapter to review. Most research on muscle pain has been conducted on animals; however, this review will primarily focus on human studies of neck and shoulder myalgia, for which the frequently affected trapezius muscle often serves as a model muscle. MORPHOLOGICAL AND BIOCHEMICAL STUDIES OF MYALGIA During recent years, several studies on biochemical and morphological processes in myalgic human muscle have been published and will be the focus in this section. Literature search A systematic literature search was made in MedLine, Science Citation Index and EMBASE. The following combinations of search words were used: (1) trapezius, biopsy, (2) neck, muscle, pain, pathophysiology, (3) muscle, pain, microdialysis, (4) muscle, pain, induced. The searches were limited to papers in English and resulted in 89 articles after duplicates were removed. Firstly, the abstracts of these articles were read, and when abstracts were found to be relevant for this review the full papers were scrutinized. Muscle biopsy studies The muscle biopsy technique provides a snap-shot approach. The biopsy includes muscle bres, connective tissue and extracellular space, and is useful for detection of possible structural alterations in painful conditions. Nine studies addressing trapezius muscle bre abnormalities have been published. Eight of them have previously been reviewed.6,35 Standard histological methods were made with some variations. Major ndings in myalgic and non-myalgic subjects exposed to demanding neck and arm work tasks were increased bre cross-sectional areas and reduced capillarization per bre area, the latter only in women, possibly indicating disturbances of oxidative metabolism.36 Furthermore, various mitochondrial disturbances of type I bres, named moth-eaten bres and ragged red bres, were found to be more frequent in subjects with pain.35 The microdialysis technique Microdialysis is a technique for studying the local biochemistry of individual tissues in the body.37 The technique has been extensively used in neuroscience to monitor neurotransmitter release, but has also found application in monitoring the biochemistry of peripheral tissues in both animals and humans.37 The basic principle is to mimic the function of a capillary blood vessel by perfusing a thin dialysis tube implanted into the tissue with a physiological saline solution. Substances can pass, by simple diffusion, across the dialysis membrane along the concentration gradient. The dialysate is analysed chemically and reects the composition of the extracellular uid. Microdialysis

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thus allows for continuous sampling of compounds in the muscle interstitial space, where nociceptor free nerve endings terminate, and in close proximity to the muscle bres, providing accurate information on regional biochemical changes before such compounds are diluted and cleared by the circulatory system. Biochemical studies of non-myalgic and myalgic muscles in human subjects Metabolites In a study on six healthy men, Rosendal et al found marked changes in muscle interstitial lactate, pyruvate and potassium in response to repetitive low-force contractions of the trapezius muscle, which were not reected in plasma.38 The ndings were interpreted to be due to inhomogeneous activation rather than insufcient blood ow. Likewise, a fast and marked increase in interleukin 6 (IL-6) was found during exercise.39 It was speculated that the high IL-6 level could be partly attributable to local changes in metabolic demands during exercise39, but this could not be conrmed in a study of women with and without long-standing trapezius myalgia.40,41 Although the myalgic women were found to have increased levels of pyruvate and lactate at rest and during exercise, indicating hyper-metabolism, uniform levels of local blood ow were found in the groups during rest and exercise.41 In support of these ndings, in another study on 20 healthy women who performed either 30 or 60 minutes of repetitive low-force arm work, Flodgren et al found that interstitial trapezius muscle glutamate and lactate increased signicantly in response to repetitive low-force work.42 However, no further increase with increasing work duration was found. Neither were alterations in prostaglandin E2 (PGE2) or local muscle oxygenation, assessed by nearinfrared spectroscopy, affected by the duration of work.42 Recently, McIver et al found that eight women with chronic widespread myalgia and hyperalgesia i.e. bromyalgia (FM) patients responded during exercise to nitric oxide with higher muscle interstitial lactate levels compared to controls; nitric oxide is known to have many physiological actions, including vasodilatation.43 Pain-related substances In a myalgic group of women, the algesic substances serotonin and glutamate were increased and correlated to pain intensity and decreased pain pressure thresholds respectively.41 Glutamate is a well-known pain modulator in the human central nervous system, acting via the N-methyl-D-aspartate (NMDA) receptor.44 Direct and indirect evidence in animals has shown that excitatory amino acid receptors i.e. glutamate receptors are present on the peripheral ends of small-diameter primary afferents in several tissues such as muscle.45 The role of glutamate in peripheral nociception in humans is unclear. Tension-type headache is not associated with increased peripheral glutamate46, whereas increased glutamate levels and NMDA receptors have been demonstrated in painful tendon tissue.47 Several studies have demonstrated that injections of glutamate increase pain intensity48,49, but it is difcult to compare these nding with Rosendals studies40,41 because higher doses are used in the injection studies. Although high interstitial glutamate levels were demonstrated in a study of myalgic and non-myalgic women, no differences in interstitial glutamate and PGE2 levels between the groups were found.50 A possible difference between subjects of these studies may contribute to the inconsistent glutamate nding. The pain history, the present pain, and clinical muscular neck status of the subjects are

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sparsely presented in the Flodgren study.50 The myalgic subjects studied by Rosendal et al40,41 comprised subjects reporting considerable long-standing pain, distinct current muscular signs conrmed at clinical examination, and most were on disability leave. Shah et al51 examined the local biochemical milieu in the trapezius muscle of healthy subjects and subjects with neck pain before, during, and after stimulation of the hypersensitive nodule. Bradykinin, calcitonin gene-related peptide, substance P, tumor necrosis factor a, interleukin 1b, serotonin and norepinephrine were found to be signicantly higher in the myalgic group and related to external stimulation rather than the hypersensitive nodule.51 Also Boix et al studied the potent algogen, and key mediator of inammatory hyperalgesia, bradykinin.52 It was found that during bilateral shoulder abduction sustained until exhaustion, healthy women liberated intramuscular bradykinin which correlated positively with pain intensity.52 Ashina and coworkers have investigated local tenderness in trapezius muscle of patients with chronic tension-type headache.53 The subjects performed static exercises (10% of maximal force), and it was found that the exercise-related increase in blood ow was lower in patients than in controls.53 This increase was interpreted as related to increased sympathetic activity in the chronic painful state. No signs of altered metabolism or inammation were found in the tender trapezius muscle of patients with tension-type headache.54 In animal experiments, serotonin (5-HT) has been found to mediate pain and hyperalgesia.55,56 Single injections of a combination of bradykinin and 5-HT in concentrations similar to the ndings of 5HT in resting painful muscle41 results in muscle pain and hyperalgesia.57 The deep craniofacial tissues such as the masseter muscle represent common sites for acute and chronic pain, and masseter myalgia is often associated with pain in neck shoulder muscle.58 Intramuscular administration of 5-HT into the human masseter muscle has been demonstrated to induce pain.58 A positive correlation between pain intensity during the last week, allodynia, and the level of interstitial 5-HT in the masseter muscle in patients with bromyalgia (FM) and patients with localized myalgia compared to controls has been reported.59 Furthermore, FM patients also seem to have a higher fraction of 5-HT in the masseter muscle compared to the level in blood serum.59 The effects of intramuscular glucocorticoid (GC) on the level of 5-HT and associated changes in pain and tenderness of the masseter muscle in subjects with local masseter muscle pain has been examined.60,61 A negative correlation regarding 5-HT and pressure pain threshold and pressure pain tolerance was found after GC injections in this study. PGE2 levels were also found to be related to muscular pain in FM patients62, and intramuscular administration of GC in the masseter muscle of FM patients and subjects with masseter myalgia resulted in a decrease in muscle PGE2 and a decrease in resting pain in FM patients.61 Thus masseter muscle pain was interpreted to be partly due to peripheral inammation in FM. Peripheral inammation as a cause of pain is disputed by other studies. Studies on painful conditions found no indication of PGE2 being associated with trapezius myalgia50 or tendon pain63, as well as nding similar levels of the pro-inammatory cytokine IL-6 in myalgic and non-myalgic subjects.40 Increased potassium levels have also been speculated to be related to muscle pain. Graven-Nielsen et al have presented an in-vivo muscle model of muscle pain, and suggested that pain activation and cessation were related to increased intramuscular sodium and potassium respectively.64 However, Green et al did not nd potassium related to ischaemic myalgia in healthy subjects.65 Despite this, increased potassium

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levels have been shown in response to repetitive work38 and in subjects with trapezius myalgia.40 CLINICAL DIAGNOSIS OF NECK AND SHOULDER MYALGIA The basis for the diagnostic criteria of neck and shoulder myalgia is relatively vague, and the diagnostic terminology and methods for assessment of neck and upper-limb musculoskeletal disorders are variable. This implies that several more or less specic and partly overlapping diagnoses exist in clinical practice and epidemiological research. A typical anamnesis with progressing neck and shoulder pain and no other symptoms or signs does not require investigations such as radiography, magnetic resonance imaging, electromyography or nerve conductance velocity testing. The patients complaints and the manual clinical examination are the most important instruments in the process of diagnosis. A standardized clinical examination protocol leading up to diagnoses of the neck and upper extremity based on carefully dened criteria (Table 1) was developed and has recently been modied.13,66 In short, the standardized clinical examination included questions on pain, tiredness and stiffness on the day of examination, as well as physical tests including range of motion and tightness of muscles, pain threshold and sensitivity, muscle strength, and palpation of tender points. The protocol has been widely used in epidemiological research and may also be appropriate in clinical practise. Sluiter et al reviewed the literature on upper-extremity musculoskeletal disorders and proposed criteria for signs and symptoms for the most common work-related disorders.67 When criteria for assessing pain and non-articular soft-tissue disorders of neck and upper limb were reviewed, it was concluded that the diagnosis relies heavily on the clinical opinions of the investigators.68 Furthermore, data were found to be insufcient to indicate that the criteria are repeatable, sensitive or specic; 27 classications systems for upper-limb musculoskeletal disorders were reviewed, and only slight agreement was found between the systems.69 PREVENTIVE INTERVENTIONS The rst recommendations given by the NRC report is that a broad comprehensive effort to promote ergonomic as well as other preventive strategies is highly justied.14 This is based on the consequences of musculoskeletal disorders for both the individual and society, in combination with the evidence that these problems are at least to some degree preventable. The broad consensus of the multifactorial element in the development of musculoskeletal neckshoulder disorders indicates the need for a combined physical, psychosocial and organizational approach to prevention.70 This view is supported by a number of newer reviews that also stress the participatory element as important for successful intervention.71 However, only a few reviews of effect-evaluated interventions are available. In 2006 a Cochrane review was performed evaluating randomized controlled studies until year 2000 on the effect of physical activity compared to organizational changes on disorders in the low back and neck regions.72 However, there were not found any randomised controlled trials focusing on the neck. Apart from this Cochrane review, there are several more general but systematic reviews on preventive interventions. Silverstein and Clark reviewed 73 studies and concluded that the largest body of evidence for the prevention of neckshoulder disorders stems from multicomponent interventions, and that subject-oriented interventions are the

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Table 1. Criteria for diagnosis of disorders of the neck and upper limbs. All ndings were required. Diagnosis Tension neck syndrome Criteria Neck pain; sense of fatigue or stiffness in the neck; pain radiating from the neck to the back of the head; tightness of muscles; tender spots in the muscles Pain radiating from the neck to the upper extremity; limited neck movement; radiating pain provoked by test movements; decreased sensibility in hands/ngers; muscle weakness of the upper limb Neck pain, limited neck movement in at least four of six directions. Diagnosis only if tension neck syndrome or cervical syndrome is not present Neck pain, tightness of muscles, tender points in the muscles. Diagnosis only if tension neck syndrome or cervical syndrome is not present Pain radiating to upper extremity, in the distribution of the ulnar nerve; paresthesia in the distribution of the ulnar nerve; positive Roos test (increase of the subjective symptom, not only fatigue); intense tenderness over the brachial plexus. Diagnosis only if tension neck syndrome or cervical syndrome is not present Shoulder pain; progressive stiffness of the shoulder during the last 3e4 months; limited outward rotation, and abduction Shoulder pain: local tenderness over the tendon insertion; pain at resisted isometric abduction Shoulder pain; local tenderness over the tendon insertion; pain at resisted isometric outward rotation Shoulder pain; local tenderness over the tendon(s); pain at resisted isometric elevation of the arm (straight and elevated 90 ) and/or resisted isometric exion of the elbow (exed 90 hand supinated) Shoulder (epaulet pain); palpable tenderness of the joint; pain provoked by horizontal adduction and/or by outward rotation of the arm (90 abducted, with exed elbow) Elbow pain; palpable tenderness of the lateral and/or medial epicondyle; pain at resisted isometric extension or exion of the wrist; for the diagnosis lateral epicondylitis, pain and/or weakness in gripping Pain at the wrist; tenderness at palpation of tendons the thumb side of the wrist. Localized swelling, redness and heat Wrist pain; palpable tenderness of the wrist capsule of the thenar- and hypothenar muscles and of the intrinsic muscles of the hand Wrist pain; palpable tenderness of the tendon(s); local swelling; redness, or heat Nocturnal numbness of the hand; paraesthesia in the distribution of the median nerve; positive Tinels sign over the carpal tunnel; positive Phalens test; decreased sensibility in the distribution of the median nerve: decreased strength in opposition of the thumb Pain of the medial/proximal part of the forearm; local tenderness over the edge of m. pronator teres; pain and decreased strength in pronation; decreased exion strength in pronation; decreased exion strength of the wrist and/or of the distal phalanxes of the ngers IeII

Cervical syndrome

Cervialgiaa

Trapezius myalgiaa

Thoracic outlet syndrome

Frozen shoulder Supraspinatus tendinitis (n18) Infraspinatus tendinitis Bicipital tendinitis

Acromioclavicular syndrome

Lateral and medial epicondylitis

De Quervains tendinitisa Overused hand syndromea

Peritendinitis/tenosynovitis Carpal tunnel syndrome

Pronator syndrome

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Table 1 (continued ) Diagnosis Radial tunnel syndrome Criteria Pain in the elbow during rest; tenderness about 2e3 inches distally of the lateral epicondyle; pain of the proximal, lateral part of the forearm and pain and decreased strength in supination; decreased strength in ulnar deviation Pain and paresthesia of numbness in the distribution of the ulnar nerve; decreased sensibility of the ngers IVeV and of the ulnar part of the back of the hand; positive Tinels sign over the cubital tunnel; decreased strength in spreading the ngers and in exion of the distal phalanx of nger V Pain and paresthesia or numbness in the distribution of the ulnar nerve: decreased sensibility of the ngers IVeV; positive Tinels sign over Guyons tunnel (volar/ulnar at the wrist); decreased strength in spreading the ngers

Ulnar nerve entrapment at the elbow

Ulnar nerve entrapment the wrist

Modied from Ohlsson et al (Ergonomics 1994; 37: 891897) with permission from Kerstina Ohlsson. a Diagnosis added by personal communication with Kerstina Ohlsson since the table was originally published by Ohlsson et al (1994),66 and these have been added in 2006.13

tters and Burdof reviewed 40 studies and concluded that although least efcient.73 Lo many different interventions all showed some effect, the greatest effect resulted from primary prevention in the physically heavy jobs.74 Buckle and Devereux evaluated the reduction in biomechanical risk factors by organizational changes and work-place adjustments, and found that exposure could be reduced which could potentially reduce neckshoulder disorder.75 Likewise Leonard focused on education, and concluded that this could also potentially reduce risk factors by changing the behaviour of employees.76 Brewer et al included 31 studies in a review on interventions in ofce work. Overall it was concluded that, due to the limited number of studies, there was only moderate evidence for an effect by any form of intervention in ofce work.77 However, there probably could be a positive effect of interchanging the input device in computer work77, and here it should be remembered that absence of evidence is not the same as evidence of absence. Two reviews have looked at physical activity. Hildebrandt et al focused on 39 studies on leisure-time activity, and Proper et al included 26 studies on work-place activities.78,79 Physical activity in leisure time was not associated with neckshoulder disorders, but sedentary workers with low levels of leisure-time activity had a higher prevalence of neck disorders. Proper et al found strong evidence for a positive effect of physical activity at work on neckshoulder disorders.79 However, the evidence for a similar positive effect on sickness absence was rather limited due to a lack of highquality studies. Since these reviews were published, a number of intervention studies have focused on systematic strength training as an intervention among women with chronic disorders. While less intensive training, stretching, and aerobic training generally showed no effect, a follow-up design could even document a long-term effect of strength training.8082 In one study light resistance training has also been found to decrease the intensity of neck pain among ofce workers83, while Brox and Frystein found no evidence for decrease in sickness absence with low-intensity physical activity interventions.84

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Practice points  musculoskeletal disorder in the neckshoulder is one of the most frequent disorders in the working population, and is more frequent among women than men  recent reviews conrm the strong evidence for an association between neck shoulder disorders and gender, repetitive movements, high force, work postures, and combinations of these factors  there is some evidence for psychosocial factors being involved, particularly for high quantitative and mental demands  duration of computer use is evident as a risk factor for self-reported disorders  there are several studies that report altered metabolism and increased intramuscular levels of algesic substances in subjects with long-standing neck and shoulder myalgia  a single, universal, simple classication system would probably advance the management of these disorders, but at present no such classication system exists  the patients complaints and manual clinical examination are at present the most important instruments in the process of diagnosis  strength training at the workplace seems to be a promising intervention to decrease neck pain, while more controversy exists regarding less intensive physical activity

Research agenda  to augment the knowledge of pathomechanisms in chronic myalgia, future research should preferably address intramuscular algesics with receptors already identied in skeletal muscle, and include experimental models to study algesic substances as well as relevant nociceptors  a single, universal, simple classication system is needed to advance the management of these disorders

SUMMARY This review has focused on the physiology of neckshoulder pain and trapezius myalgia, its possible relationship to work, risk factors for its development, the latest knowledge on changes in structure and biochemical milieu in painful muscles, and the most-used standards for diagnosing neckshoulder disorders as well as the state of the art in rehabilitation. The review conrms earlier ndings of evidence for a causal relationship between neck and shoulder disorders and highly repetitive work, forceful exertions, high level of static contractions, prolonged static loads, and extreme postures, as well as combinations of these factors. Whether local muscular processes can explain chronic neckshoulder pain is often questioned, and this has turned the focus towards central processing as the primary

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explanation for pain. However, new methodology and many recent publications have indicated a role for local muscular processes as being causally related to pain. Several studies have reported altered metabolism and increased intramuscular levels of algesic substances in subjects with chronic neck and shoulder myalgia. Furthermore, there are some indications of structural abnormalities in biopsies from painful muscles. Despite this, criteria for neckshoulder disorders are not sufciently repeatable, sensitive or specic, and there is little agreement between the different classication systems. A single, universal, simple classication system would probably advance the management of these disorders, but at present no such classication system exists. A step towards reducing these disorders may be a consensus on the key elements of a classication system. Evidence for physical activity for rehabilitation of neckshoulder pain is slowly emerging, and promising results are appearing on the effect of strength training. Still, because the pathophysiology of neckshoulder pain seems to be multifactorial, interventional models including physical, psychosocial and organizational elements will probably have the greatest effect on pain in the long run. ACKNOWLEDGEMENTS rn Gerdle, Division of Rehabilitation The authors would like to thank Professor Bjo ping, Sweden, and Professor Gisela Sjgaard, National Institute of Medicine, Linko Occupational Health, Denmark, for their scientic input into this review based on their great insight into risk factors, pain physiology and rehabilitation medicine, and their contribution to many studies advancing the knowledge in this eld. Researcher Anne Katrine Blangsted is also thanked for her skilled assistance in searching for and condensing the literature on risk factors. This review was supported by the Swedish Research Council (K2005-27X-15316-01A) and the Swedish Council for Working life and Social research (2004-0289). CONFLICT OF INTEREST STATEMENT There are no conicts of interest. No nancial or personal relationship has inappropriately inuenced this work. Appendix 1. Literature search on risk factors for work-related neckshoulder pain As described under Literature search, 20002006, a systematic search for the newest epidemiological literature on risk factors for neckshoulder was performed. The search was performed in OSHROM, MEDLINE, EMBASE and Cochrane (CDSR) as combinations of the four sets of keywords listed below. The results were restricted to review papers published from 2000 to 2006 in the English language. The search terminology was arranged as sets of search keywords: 1. shoulder, neck, arm, upper extremity, forearm, head, musculoskeletal, upper limb, cervical, muscle 2. pain, discomfort, illness, nociception, fatigue, tired, stress, injury, strain, unpleasantness, disorder, myalgia

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3. work, workplace, job, occupational, work-related 4. risk factors, static load, repetitiveness, force, monotonous, ofce work, computer, industry, psycho social, psychosocial, psychosocial factors at work, emotional demands, bottling up emotions, job insecurity, job strain, job control, social support, management quality, reward, meaning, predictability, conicts at work, perceived stress, stress at work, high job demands, effort reward imbalance, social support, social network, job demands, role conicts, role clarity, burnout, job satisfaction, family-work. REFERENCES
1. Punnett L & Wegman DH. Work-related musculoskeletal disorders: the epidemiologic evidence and the debate. Journal of Electromyography and Kinesiology 2004; 14(1): 1323. 2. Baldwin ML. Reducing the costs of work-related musculoskeletal disorders: targeting strategies to chronic disability cases. Journal of Electromyography and Kinesiology 2004; 14(1): 3341. 3. Armstrong T, Buckle P, Fine L et al. Can some upper extremity disorders be dened as work-related? The Journal of Hand Surgery 1996; 21(4): 727729. 4. Forde MS, Punnett L & Wegman DH. Pathomechanisms of work-related musculoskeletal disorders: conceptual issues. Ergonomics 2002; 45(9): 619630. *5. Sjgaard G & Sgaard K. Muscle injury in repetitive motion disorders. Clinical Orthopaedics 1998; 351: 2131. *6. Visser B & van Dieen JH. Pathophysiology of upper extremity muscle disorders. Journal of Electromyography and Kinesiology 2006; 16(1): 116. 7. Mitchell RI & Carmen GM. The functional restoration approach to the treatment of chronic pain in patients with soft tissue and back injuries. Spine 1994; 19(6): 633642. 8. Sjgaard G, Sgaard K, Hermens HJ et al. Neuromuscular assessment in elderly workers with and without work related shoulder/neck trouble: the NEW-study design and physiological ndings. European Journal of Applied Physiology 2006; 96: 110121. 9. Schulte E, Kallenberg LAC, Christensen H et al. Comparison of the electromyographic activity in the upper trapezius and biceps brachii muscle in subjects with muscular disorders: a pilot study. European Journal of Applied Physiology 2006; 96: 185193. 10. Hakala P, Rimpela A, Salminen JJ et al. Back, neck and shoulder pain in Finnish adolescents: National cross sectional surveys. British Medical Journal 2006; 325: 743746. 11. Cote P, Cassidy JP, Carroll LJ & Kristman V. The annual incidence and course of neck, and shoulder pain in the general population: a population based cohort study. Pain 2004; 112: 267273. 12. Jensen C. Development of neck and hand-wrist symptoms in relation to duration of computer use at work. Scandinavian Journal of Work, Environment and Health 2003; 29(3): 197205. *13. Juul-Kristensen B, Kadefors R, Hansen K et al. Clinical signs and physical function in neck and upper extremities among elderly female computer users: the NEW-study. European Journal of Applied Physiology 2006; 96: 136145. *14. National Research Council and the Institute of medicine. Musculoskeletal Disorders and the Workplace. Washington, D.C.: National Academy Press, 2001. 15. Punnett L & Herbert R. Work-related musculoskeletal disorders: is there a gender differential, and if so, what does it mean? Women and Health 2000; 38(6): 474492. 16. Walker-Bone K, Palmer KT, Reading I & Cooper C. Soft-tissue rheumatic disorders of the neck and upper limb: prevalence and risk factors. Seminars in Arthritis and Rheumatism 2003; 33(3): 185203. 17. Treaster DE & Burr D. Gender differences in prevalence of upper extremity musculoskeletal disorders. Ergonomics 2004; 47(5): 495526. 18. Malchaire J, Cock N & Vergracht S. Review of the factors associated with musculoskeletal problems in epidemiological studies. International Archives of Occupational and Environmental Health 2001; 74(2): 7990. 19. van der Windt DA, Thomas E, Pope DP et al. Occupational risk factors for shoulder pain: a systematic review. Occupational and Environmental Medicine 2000; 57(7): 433442. 20. Ariens GA, van Mechelen W, Bongers PM et al. Physical risk factors for neck pain. Scandinavian Journal of Work, Environment and Health 2000; 26(1): 719.

Work related neckshoulder pain 461 21. Mork PJ & Westgaard R. Low-amplitude trapezius activity in work and leisure and the relation to shoulder and neck pain. Journal of Applied Physiology 2006; 100: 11421149. 22. Olsen HB, Christensen H & Sgaard K. An analysis of motor unit ring pattern during sustained low force contraction in fatigued muscle. Acta Physiologica et Pharmacologica Bulgarica 2001; 26(1/2): 7378. 23. Sgaard K, Sjgaard G, Finsen L et al. Motor unit activity during stereotyped nger tasks and computer mouse work. Journal of Electromyography and Kinesiology 2001; 11(3): 197206. 24. Birch L, Christensen H, Arendt-Nielsen L et al. The inuence of experimental muscle pain on motor unit activity during low level contraction. European Journal of Applied Physiology 2000; 83(23): 200206. 25. Forsman M, Birch L, Zhang Q & Kadefors R. Motor unit recruitment in the trapezius muscle with special reference to coarse arm movements. Journal of Electromyography and Kinesiology 2001; 11: 207216. 26. Meijer EM, Sluiter JK & Frings D. What is known about temperature and complaints in the upper extremity? A systematic review in the VDU work environment. International Archives of Occupational and Environmental Health 2006; 79(6): 445452. 27. Gerr F, Marcus M & Monteilh C. Epidemiology of musculoskeletal disorders among computer users: lesson learned from the role of posture and keyboard use. Journal of Electromyography and Kinesiology 2004; 14(1): 2531. 28. Juul-Kristensen B, Sgaard K, Stryer J & Jensen C. Computer users risk factors for developing shoulder, elbow and back symptoms. Scandinavian Journal of Work, Environment and Health 2004; 30(5): 390398. 29. Veiersted KB, Nordberg T, Waersted M. A critical review of evidence for a causal relationship between computer work and musculoskeletal disorders with physical ndings of the neck and upper extremity. Den Videnskabelige Komite Dansk Selskab for Arbejdsog Miljmedicin, editor. 153. 2006. 30. Ariens GA. Psychosocial risk factors for neck pain: a systematic review. American Journal of Industrial Medicine 2001; 39(2): 180193. 31. Bongers PM, Kremer AM & Laak JT. Are psychosocial factors, risk factors for symptoms and signs of the shoulder, elbow, or hand/wrist? a review of the epidemiological literature. American Journal of Industrial Medicine 2002; 41(5): 315342. 32. Mense S. The pathogenesis of muscle pain. Current Pain and Headache Reports 2003; 7(6): 419429. 33. Mense S. Nociception from skeletal muscle in relation to clinical muscle pain. Review article. Pain 1993; 54: 241289. 34. Textbook of pain. 4th edn. London: Livingstone, 1999. gg GM. Human muscle bre abnormalities related to occupational load. European Journal of Applied 35. Ha Physiology 2000; 83(23): 159165. *36. Larsson B, Bjork J, Kadi F et al. Blood supply and oxidative metabolism in muscle biopsies of female cleaners with and without myalgia. The Clinical Journal of Pain 2002; 20(6): 440446. 37. Ungerstedt U. Microdialysisprinciples and applications for studies in animals and man - review. Journal of Internal Medicine 1991; 230(4): 365373. *38. Rosendal L, Blangsted AK, Kristiansen J et al. Interstitial muscle lactate, pyruvate, and potassium dynamics in the trapezius muscle during repetitive low-force contractions, measured with microdialysis. Acta Physiologica Scandinavica 2004; 2004(182): 379388. 39. Rosendal L, Sgaard K, Kjr M et al. Increase in interstitial interleukin-6 of human skeletal muscle with repetitive low-force exercise. Journal of Applied Physiology 2005; 98: 477481. 40. Rosendal L, Kristiansen J, Gerdle B et al. Increased levels of interstitial potassium but normal levels of muscle IL-6 and LDH in patients with trapezius myalgia. Pain 2005; 119: 201209. *41. Rosendal L, Larsson B, Kristiansen J et al. Increase in muscle nociceptive substances and anaerobic metabolism in patients with trapezius myalgia: microdialysis in rest and during exercise. Pain 2004; 2004(112): 324334. 42. Flodgren GM, Hellstrom FB, Fahlstrom M & Crenshaw AG. Effects of 30 versus 60 min of low-load work on intramuscular lactate, pyruvate, glutamate, prostaglandin E(2) and oxygenation in the trapezius muscle of healthy females. European Journal of Applied Physiology 2006; 97(5): 557565. 43. McIver KL, Evans C, Kraus RM et al. NO-mediated alterations in skeletal muscle nutritive blood ow and lactate metabolism in bromyalgia. Pain 2006; 120(12): 161169. 44. Coggeshall RE & Carlton SM. Receptor localization in the mammalian dorsal horn and primary afferent neurons. Brain Research. Brain Research Reviews 1997; 24(1): 2866.

462 B. Larsson et al 45. Coggeshall RE & Carlton SM. Ultrastructural analysis of NMDA, AMPA, and kainate receptors on unmyelinated and myelinated axons in the periphery. The Journal of Comparative Neurology 1998; 391(1): 7886. 46. Ashina M, Jorgensen M, Stallknecht B et al. No release of interstitial glutamate in experimental human model of muscle pain. European Journal of Pain 2005; 9(3): 337343. 47. Alfredson H, Thorsen K & Lorentzon R. In situ microdialysis in tendon tissue: high levels of glutamate, but not prostaglandin E2 in chronic Achilles tendon pain. Knee Surgery, Sports Traumatology, Arthroscopy 1999; 7(6): 378381. 48. Cairns BE, Wang K, Hu JW et al. The effect of glutamate-evoked masseter muscle pain on the human jaw-stretch reex differs in men and women. Journal of Orofacial Pain 2003; 17(4): 317325. 49. Gazerani P, Wang K, Cairns BE et al. Effects of subcutaneous administration of glutamate on pain, sensitization and vasomotor responses in healthy men and women. Pain 2006; 124(3): 338348. 50. Flodgren GM, Crenshaw AG, Alfredson H et al. Glutamate and prostaglandin E2 in the trapezius muscle of female subjects with chronic muscle pain and controls determined by microdialysis. European Journal of Pain 2005; 9(5): 511515. 51. Shah JP, Phillips TM, Danoff JV & Gerber LH. An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. Journal of Applied Physiology 2005; 99(5): 1977 1984. *52. Boix F, Roe C, Rosenborg L & Knardahl S. Kinin peptides in human trapezius muscle during sustained isometric contraction and their relation to pain. Journal of Applied Physiology 2005; 98(2): 534540. 53. Ashina M, Stallknecht B, Bendtsen L et al. In vivo evidence of altered skeletal muscle blood ow in chronic tension-type headache. Brain 2002; 125(Pt 2): 320326. 54. Ashina M, Stallknecht B, Bendtsen L et al. Tender points are not sites of ongoing inammation -in vivo evidence in patients with chronic tension-type headache. Cephalalgia 2003; 23(2): 109116. 55. Giordano J & Rogers LV. Peripherally administered serotonin 5-HT3 receptor antagonists reduce inammatory pain in rats. European Journal of Pharmacology 1989; 170(12): 8386. 56. Taiwo YO & Levine JD. Serotonin is a directly-acting hyperalgesic agent in the rat. Neuroscience 1992; 48(2): 485490. 57. Babenko VV, Graven-Nielsen T, Svensson P et al. Experimental human muscle pain induced by intramuscular injections of bradykinin, serotonin, and substance P. European Journal of Pain 1999; 3(2): 93102. 58. Ernberg M, Hedenberg-Magnusson B, Kurita H & Kopp S. Effects of local serotonin administration on pain and microcirculation in the human masseter muscle. Journal of Orofacial Pain 2006; 20(3): 241248. 59. Ernberg M, Hedenberg-Magnusson B, Alstergren P & Kopp S. The level of serotonin in the supercial masseter muscle in relation to local pain and allodynia. Life Sciences 1999; 65(3): 313325. 60. Ernberg M, Hedenberg-Magnusson B, Alstergren P & Kopp S. Effect of local glucocorticoid injection on masseter muscle level of serotonin in patients with chronic myalgia. Acta Odontologica Scandinavica 1998; 56(3): 129134. 61. Hedenberg-Magnusson B, Ernberg M, Alstergren P & Kopp S. Effect on prostaglandin E2 and leukotriene B4 levels by local administration of glucocorticoid in human masseter muscle myalgia. Acta Odontologica Scandinavica 2002; 60(1): 2936. 62. Hedenberg-Magnusson B, Ernberg M, Alstergren P & Kopp S. Pain mediation by prostaglandin E2 and leukotriene B4 in the human masseter muscle. Acta Odontologica Scandinavica 2001; 59(6): 348355. 63. Alfredson H. The chronic painful Achilles and patellar tendon: research on basic biology and treatment. Scandinavian Journal of Medicine and Science in Sports 2005; 15(4): 252259. 64. Graven-Nielsen T, McArdle A, Arendt-Nielsen L et al. In vivo model of muscle pain: Quantication of intramuscular chemical, electrical and pressure changes associated with saline induced muscle pain in humans. Pain 1997; 69: 137143. 65. Green S, Langberg H, Skovgaard D et al. Interstitial and arterial-venous [K] in human calf muscle during exercise: effect of ischaemia and relation to muscle pain. Journal of Physiology 2000; 15(529): 849861. Pt 3. *66. Ohlsson K, Attewell RG, Johnsson B et al. An assessment of neck and upper extremity disorders by questionnaire and clinical examination. Ergonomics 1994; 37(5): 891897. 67. Sluiter JK, Rest KM & Frings-Dresen MHW. Criteria document for evaluating the work-relatedness of upper extremity musculoskeletal disorders. Scandinavian Journal of Work, Environment and Health 2001; 27(suppl 1): 1102. Finland, Vammalan Kirjapaino Oy.

Work related neckshoulder pain 463 68. Walker-Bone KE, Palmer KT, Reading I & Cooper C. Criteria for assessing pain and nonarticular softtissue rheumatic disorders of the neck and upper limb. Seminars in Arthritis and Rheumatism 2003; 33(3): 168184. 69. Van Eerd D, Beaton D, Cole D et al. Classication systems for upper-limb musculoskeletal disorders in workers: a review of the literature. Journal of Clinical Epidemiology 2003; 56: 925936. 70. Bernard B. Musculoskeletal disorders and workplace factors: a critical review of epidemiologic evidence for work-related musculoskeletal disorders of the neck, upper extremity, and low back. 2 edn. Cincinnati, USA: U.S. Department of Health and Human Services, NIOSH, 1997. 71. Huang GD, Feuerstein M & Sauter SL. Occupational stress and work-related upper extremity disorders: concepts and models. American Journal of Industrial Medicine 2002; 41(5): 298314. 72. Verhagen AP, Karels C, Bierma-Zeinstra SMA et al. Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults. Cochrane Database of Systematic Reviews 2006; (3): CD003471. doi:10.1002/14651858.CD003471.pub3. *73. Silverstein B & Clark R. Interventions to reduce work-related musculoskeletal disorders. Journal of Electromyography and Kinesiology 2004; 14(1): 135152. 74. Lotters F & Burdof A. Are changes in mechanical exposure and musculoskeletal health good performance indicators for primary interventions? International Archives of Occupational and Environmental Health 2002; 75(8): 549561. 75. Buckle PW & Devereux JJ. The nature of work-related neck and upper limb musculoskeletal disorders. Applied Ergonomics 2002; 33(3): 207217. 76. Leonard D. The effectiveness of intervention strategies used to educate clients about prevention of upper extremity cumulative trauma disorders. Work 2000; 14(2): 151157. 77. Brewer S, Eerd DV, Amick III IB et al. Workplace interventions to prevent musculoskeletal and visual symptoms and disorders among computer users: a systematic review. Journal of Occupational Rehabilitation 2006; 16(3): 317350. 78. Hildebrandt VH, Bongers PM, Dul J et al. The relationship between leisure time, physical activities and musculoskeletal symptoms and disability in worker populations. International Archives of Occupational and Environmental Health 2000; 73(8): 507518. 79. Proper KI, Koning M, Van der Beek AJ et al. The effectiveness of worksite physical activity programs on physical activity, physical tness, and health. Clinical Journal of Sport Medicine 2003; 13(2): 106117. 80. Ylinen J, Takala EP, Nykanen M et al. Active neck muscle training in the treatment of chronic neck pain in women: a randomized controlled trial. The Journal of American Medical Association 2003; 289(19): 25092516. 81. Ylinen J, Takala EP, Kautiainen H et al. Effect of long-term neck muscle training on pressure pain threshold: a randomized controlled trial. European Journal of Pain 2005; 9(6): 673681. 82. Ylinen JJ, Takala EP, Nykanen MJ et al. Effects of twelve-month strength training subsequent to twelve month stretching exercise in treatment of chronic neck pain. Journal of Strength and Conditioning Research 2006; 20(2): 304308. 83. Sjogren T, Nissinen KJ, Jarvenpaa SK et al. Effects of a workplace physical exercise intervention on the intensity of headache and neck and shoulder symptoms and upper extremity muscular strength of ofce workers: a cluster randomized controlled cross-over trial. Pain 2005; 116(12): 119128. 84. Brox JI & Frystein O. Health-related quality of life and sickness absence in community nursing home employees: randomized controlled trial of physical exercise. Occupational Medicine 2005; 55: 558563.