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Malaysian Journal of Public Health Medicine 2016, Vol. 16 (1): 62-74
REVIEW
MUSCULOSKELETAL DISORDERS AND THEIR RELATIONSHIP WITH PHYSICAL
ACTIVITIES AMONG OFFICE WORKERS: A REVIEW
Ardalan Shariat1,*, Shamsul Bahri Mohd Tamrin1, Manohar Arumugam2, Mahmoud Danaee3, Rajesh Ramasamy4
1Department of Occupational Health, Faculty of Medicine and Health Sciences, University Putra Malaysia, Malaysia.
2Department of Orthopedics, Faculty of Medicine and Health Sciences, University Putra Malaysia, Malaysia.
3Unit for the Enhancement of Academic Performance,University of Malaya, Malaysia.
4Department of Pathology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Malaysia.
ABSTRACT
Lower back, neck and shoulder pain are the most prevalent musculoskeletal problems affecting office workers
worldwide, and they have both personal and socioeconomic consequencesas well. Several hypotheses regarding the
underlying mechanisms and the maintenance behind office work-related musculoskeletal disorders have been
presented. There is some evidence, based on epidemiological studies as well as studies upon smaller groups of
subjects, that individuals who sit and work for a long time not only show cognitive impairment at the workplace, but
also suffer from poorer and fragmented daytime sleep, in addition toincreased risks of developing
variouspsychological, physiological and medical impairments and musculoskeletal disorders. The related physical
mechanisms behind musculoskeletal disorders are discussed in the context of new findings. The main causes, as well
as varying levels in severity of musculoskeletal disorders,not to mentionthe link between such disorders in the neck,
shoulder and lower back regions and physical activity among office workers are also stated. The main objective of
this review paper isto conduct a systematic review to identify musculoskeletal disorders and how these disorders are
correlated with physical activity among office workers. The results of this review indicate that the musculoskeletal
disorder is a critical issue among office workers and the main cause is related to the absence of physical activity as
well as the subjects’ sedentary lifestyle. As a practical message, regular physical activity can be effective in the
prevention and decrease of physical discomfort among office workers who suffer from musculoskeletalpain.
Keywords:Office training; neck pain; shoulder pain; lower back pain
INTRODUCTION
Musculoskeletal issues (mainly lower back, neck
and shoulder pain) are particularly prevalent in
industrialized countries, affecting roughly 70% to
80% of adults at several points in their lives, with
about 1% of the U.S. population chronically
disabled as a result of lower back, neck or
shoulder pain1. Such a disability causes poor
quality of life while increasing the amount of
daily work absenteeism and the number of long-
term disability claims. Those who are affected
often experience sleep disturbances, chronic
fatigue and nervousness, and many fall victim to
prescription medication abuse2. The scale of this
problem is anticipated to grow with both an
aging population and increasing pace of
industrialization in the developing world. A
variety of risk factors contribute to lower back,
neck and shoulder pain, including age, race, sex,
and marital status, but the most prevalent
factor—especially among adolescents—is the
amount of time spent on sitting 3.The term
musculoskeletal disorders (MSD) refers to a broad
range of conditions that can affect any part of
the musculoskeletal system, including the
muscles, bones, nerves, joints and spinal discs,
along with supporting blood vessels and
connective tissues such as tendons, ligaments
and cartilage4. Injuries can occur, such as
sprains, tears and strains, in addition to any form
of acute or chronic soreness or pain within the
support frame of the body. These disorders are
normally degenerative, worsening over time if
the conditions that lead to them are not
addressed properly5.
There is a growing interest in research on the
occupational hazards related to lower back, neck
and shoulder pain and its risk factors among
large populations of office workers. It is
necessary to conduct studies on the prevalence
of musculoskeletal disorders (MSD), as well as
evaluate the effectiveness of practical treatment
methods for lower back, neck and shoulder pain.
Identifying the specific risk factors for individuals
and minimizing those factors are crucial steps in
dealing with this issue in its varied forms 6.
A number of studies have supported the claim
that people who work in offices are particularly
prone to experiencing musculoskeletal
discomfort, creating an increased awareness of,
and concern for, the welfare of office workers7.
The most commonly cited reasons for the high
percentage of lower back, neck and shoulder
pain are related to factors including the
ergonomic conditions of one’s workplace and a
sedentary lifestyle8, as well as the absence of
routine physical activity9. Unfortunately, even
though the prevalence of the problem is
increasing, little attention is paid by neither
government nor company,despite the fact that
prolonged sitting and working have already
beenaddressed.
According to the European Guidelines for the
prevention of lower back, neck and shoulder
Malaysian Journal of Public Health Medicine 2016, Vol. 16 (1): 62-74
pain, such pain is generally divided into three
categories: acute, sub-acute, and chronic pain.
The principle upon which this classification is
based relies on the duration of the pain. Acute
pain is an episode which lasts for less than 6
weeks; sub-acute pain lasts between 6 to 12
weeks, and chronic pain lasts for about 12 weeks
or longer10. Several studies point to physical
inactivity associated with a sedentary lifestyle
resulting from prolonged periods of time spent in
sitting positions that suggest an incorrect posture
(which leads to damage and weakening of
postural muscles). Another potential issue is
muscle spasms resulting from various forms of
psychological stress11. It seems that taking a
short break or brief walk during working hours
can be useful.
Physical activity is a necessary precursor to
healthy living, and it is vital in keeping the
musculoskeletal system in proper functioning
order. Lack of exercise is able to cause or worsen
lower back, neck and shoulder pain as a result of
increased stiffness and damaged muscles.
Individuals who live sedentary lifestyles lose not
only the strength but flexibility of their muscles,
both of which are important components of
health-related physical fitness and natural
posture. However, these people fail to benefit
from the benefits of usual exercises in ways that
go beyond the more common and obvious
associations of cardiorespiratory fitness,
muscular strength and flexibility - regular
exercise provides nourishment of the ligaments,
spinal discs and soft tissues. When a person’s
lifestyle lacks exercise, these tissues become
malnourished and begin to degenerate9. In
addition, sitting in a workplace chair for hours at
a time provides a cause for or worsens existing
lower back, neck and shoulder pain. Sitting
forward or slouching in a chair for extended
periods stretches the spinal ligaments frequently
and puts undue strain on the intervertebral discs
and nearby structures in the vertebral columns12.
After a while, improper sitting positions and poor
office ergonomics can contribute8 to or cause
repeated encounters with back pain7.
Strengthening and stretching movements for the
muscles of the back, neck and shoulders can
assist in the recovery as well as preserve the
health of the spine. Physical therapists and other
professionals use stretching and resistance
training to assist individuals in regaining lost
motion and strength resulting from pain or
immobilization. Being active in a standard
exercise plan that contains stretching as well as
strength conditioning promotes the recovery of
existing problems 13 and prevents future
ailments14. Getting regular exercise increases
people's overall abilities to perform daily tasks.
Improving the flexibility and strength of their
muscles can also boost their vertebral column
and decrease the frequency of injuries in this
area of the body. As a result, the amount of pain
they experience will be reduced, thereby
allowing much easier and more restful sleep,
which in turn lowers levels of fatigue9.
A good deal of research has been done on this
topic, but most of it has simply highlighted the
prevalence of these issues among office workers;
some studies have suggested a general and
simple training protocol for the whole body,
whereas others have recommended ways to
modify the ergonomic conditions of their working
environments. However, there has been a lack of
research related to introducing a specific routine
for training office workers to deal with lower
back, neck and shoulder pain. In order to clarify
the effectiveness of any methods used by office
workers, a specific comparison of the effects of
any program upon lower back, neck and shoulder
pain has to be made first. Research done up to
this point has demonstrated a significant
connection between the physical and ergonomic
demands of an individual’s life and
musculoskeletal disorders of the lower back,
neck and shoulder regions, especially among
office workers. However, some issues regarding
methodology will have to be addressed carefully
in this research in order to develop specific risk-
assessment tools for identifying the complex
array of interactive factors involved in office
work. The accurate identification of these risk
factors will, in turn, facilitate establishment of
targeted forms of intervention to reduce the
incidence of musculoskeletal disorders at work.
MATERIALS AND METHODS
In this study, systematic review methods are
used based on the purpose of research. A
systematic investigation of recurrent literature
databases was navigated between 2003 and
2014. Science Direct, PubMed and Scopus were
searched for the subsequent key words: office
worker, musculoskeletal disorders, neck pain,
shoulder pain, lower back pain, physical activity
as well as health and field studies. Papers were
also recognized and used by the chief author’s
collected works. Initially 800 researches were
recognized. As there are a huge number of
researches about office working disorders, we
could not analyse all the original articles, so we
analysed and reviewed previous researches. It is
notable that there is a lack of review research
from 2005 till 2010. From the year 2010 onwards,
the number of review articles in this field is
increased. In some cases, based on the
importance of the study, we have incorporated
the original articles that were cited in the
previous review articles. Moreover, it must be
noted that, the results of this review are
dictated by our search terms.
RESULTS
Musculoskeletal disorders can affect any person,
regardless of age or gender, and are often
Malaysian Journal of Public Health Medicine 2016, Vol. 16 (1): 62-74
directly related to a person's job15. In instances
where this connection exists, either as a result of
the working environment or a work-related
incident of some kind, these conditions are
referred to as work-related MSD. A study
performed in Nigeria reveals that
musculoskeletal disorders were prevalent
throughout the workforce; Fabunmi et al. 16
reported that, within a 12-month period of time,
the rate of self-reported musculoskeletal
disorders at any given work site was 91%. MSD’s
canthus account for anywhere between 42% and
58% of work-related health concerns17. However,
MSD’s vary across different industries as well as
between different countries, and particular
occupations - whether within or across different
industries - can have rates of musculoskeletal
disorders three to four times higher than the
overall average of the general workforce18.
One major risk factor that has a strong
connection to the development of MSD’s is
computer usage. People who work in an office
environment have an increased likelihood of
developing MSD’s, as their jobs typically require
them to spend long hours in front of a
computer19. Therefore, industries in which a
large percentage of employees work in office
environments are likely to have a higher
vulnerability to MSD’s. The banking industry is
one such example, and studies indicate that the
prevalence of MSD’s among bank workers ranges
from 60% to 80%, indicating that they have a high
susceptibility to these kinds of injuries20.The
connection between occupation and the
incidence of MSD’s is not entirely based on the
physical strain of the working environment. Risk
factors for musculoskeletal complaints among
office workers who spend large amounts of time
using computers are associated not only with
physical but also with psychosocial
characteristics21.
A study performed in Europe provides evidence
that socioeconomic status can contribute to the
burden of musculoskeletal disorders, specifically
for arthritis, spinal conditions and osteoporosis22.
Another study performed in the UK shows that
musculoskeletal disorders, particularly those of
the back, knee, neck and shoulders, were more
widespread in economically disadvantaged
areas23. Even so, the prevalence of MSD’s has
been prominently associated with its connection
to occupation, which seems to be the largest
overall factor– hence the use of the term ―work-
related MSD’s‖. In an extensive systematic
review using 1761 articles and 63 separate
studies, Costa and Vieira (2010) highlight that
the labor-intensive nature of an individual’s
occupation, body mass index (BMI), smoking, and
psychosocial work demand, as well as past
injuries or history of any MSD, are the most
important individual risk factors. Repetitive
motions, prolonged awkward postures and heavy
lifting are the most commonly cited ergonomic
risk factors mentioned in the literature (Table
1).
Other reviews and epidemiological studies, along
with a major report from the National Research
Council (NRC) and Institute of Medicine (IOM)
commissioned by the US Congress in 2001, have
clearly demonstrated substantial relationships
between MSD and the work environment 5.
Lower Back, Neck and Shoulder Pain
Lower back, neck and shoulder pain, which
affect the lumbar spine, are the most commonly
reported musculoskeletal disorders.
Approximately 80% of the general population is
affected by these disorders at a certain point
during their lifetime, with some estimates being
as high as 84%. The specific etiology of lower
back, neck and shoulder pain is often unknown,
leading to frequent usage of the diagnostic label
―non-specific pain‖ when no precise pathologic
process or structure is identifiable24. While these
are usually benign disorders that can often be
resolved within a few weeks, approximately 10%
of the patients develop chronic pain, which not
only has a significant effect on an individual's
quality of life, but also creates a burden to a
society's healthcare system while simultaneously
lowering productivity levels and increasing work
absenteeism25. The proportion of people disabled
by lower back, neck and shoulder pain is
between 11% and 12% of the population24. From
an economic standpoint, such types of pain have
become one of the most financially burdensome
disorders as a result of their growing prevalence
in industrialized countries26. Recent figures have
put the estimated direct expenditures at around
US $91 billion per year and, on average, people
who experience lower back, neck and shoulder
pain incur overall healthcare costs that are
approximately 60% higher than individuals who
are pain-free27.
The most commonly used approach for the
treatment of MSD’s is exercise therapy28. For
most cases of lower back, neck and shoulder
pain, moderate exercise therapy is generally an
effective treatment. However, treating those
with non-specific pain has often proved more
challenging, largely due to the wide range of
potential causes involved29. Unfortunately for
healthcare professionals, a large percentage of
those who suffer from lower back, neck and
shoulder pain fall into this category. More than
80% of all patients who complain of lower back,
neck and shoulder pain suffer from nonspecific
pain, in which no direct organic signs or
immediate structural correlations to the
sensations they experience can be observed30.
Insufficient diagnostic procedures may, among
other potential factors, contribute to the lack of
certainty in this area.
Malaysian Journal of Public Health Medicine 2016, Vol. 16 (1): 62-74
In most cases of non-specific lower back, neck
and shoulder pain, the effectiveness of physical
therapy is limited. The kinds of treatment used
for such non-specific issues tend to be
inconsistent, ranging from psychosocial care and
pharmacotherapy to radiotherapy and surgery,
and the results are often mixed31. Some evidence
suggests the influence of psychosocial factors in
the development of lower back, neck and
shoulder pain, in addition to such organic causes
as spinal instability resulting from poor ligament
function and deficits in neuromuscular
coordination. Whatever the cause, in order for a
treatment to be truly effective, it should not
only relieve pain, but also bring about a tangible
change in the body's level of functionality and
the individual's overall quality of life32.
Table 1 Past studies on different methods of treatment for musculoskeletal disorders, especially lower
back, neck and shoulder pain.
Classification
Lower back, neck and shoulder pain are
generally classified according to the signs and
symptoms exhibited. Pain that is spread
throughout the back region, which does not
respond to any specific motion and which
remains localized within the back without
radiating to bodily regions, is classified as
nonspecific - which is by far the most
prevalent33. Pain that radiates down the leg
beyond the knee, which can be either localized
to a particular side or on both sides and which
changes in sternness in reply to positive positions
or maneuvers, is measured in radicular terms -
accounting for roughly 7% of lower back, neck
and shoulder pain cases. If pain is accompanied
by such symptoms as trauma and fever, an extra
grave primary issue may be present and such a
case would be classified as in need of urgent or
specialized attention34. Duration is another
method of classification, and pain can be
categorized using such criteria as acute, sub-
chronic (sub-acute) or chronic35. There is no
universally agreed duration required to classify
an individual into these categories, but
prolonged bouts of pain lasting fewer than six
weeks would usually be classified as acute, while
pain lasting six to twelve weeks would be
considered sub-chronic, and anything beyond
twelve weeks would fall into the realm of
chronic pain. Depending upon the duration of
Author
Subjects
Issue
Treatment
Robertson
MM, 2003
Officers workers
Musculoskeletaldiscomfort
Office ergonomics workplace and
training
Sherman KJ,
2005
101 adults
Chronic low back pain
Yoga or
conservativehealingtrainingcourses
or a self-care
Robertson M,
2009
96 office workers
Musculoskeletal
disorders
Office ergonomics training
Sherman KJ,
2011
228 adults
Chronic lower back, neck
and shoulder pain
Yoga and stretching
Irmak A,
2012
39
healthy office workers
Musculoskeletal pain
Exercise reminder software
programs
van
NiekerkSM,
2012
Review
Musculoskeletal
dysfunction
Workstation modifications
Del Pozo-
Cruz B, 2012
100 office workers
Sub-acute low back pain
Web-based multidisciplinary
involvement and standard care
Sihawong R,
2014
563 office workers
Lower back, neck and
shoulder pain
Exercise program consisting of
muscle stretching and endurance
training
Lomond KV,
2014
58 subjects with
chronic, recurrent
lower back, neck and
shoulder pain
lower back, neck and
shoulder pain
Trunk stabilization vs. general
strength and conditioning
exercises
Durmus D,
2014
121 patients with
definite CLBP
Chronic low back pain
Modified exercise programs
Partner SL,
2014
20 LBP individuals
Lower back, neck and
shoulder pain
Exercise with biofeedback
Malaysian Journal of Public Health Medicine 2016, Vol. 16 (1): 62-74
symptoms, the initial prognosis and subsequent
management of the pain may change36.
Signs and Symptoms of Lower Back, Neck and
Shoulder Pain
Acute lower back, neck and shoulder pain
normally presents itself following activities that
involve lifting, twisting or bending forward. The
onset of symptoms may occur soon afterwards,
or soreness may appear the next morning upon
awaking from sleep. The varietyof symptoms
normally ranges from mild discomfort at a
particular region of the body to extensive pain
spread across the entire lower back, neck and
shoulders. It will often get worse with more
strenuous actions, such as raising a leg or hand,
or when the body is in particular positions, such
as sitting or standing, although this may not
always be the case. Sciatica - a pain radiating
down the legs - may also occur. Most people
typically have their first experience of lower
back, neck and shoulder pain between the ages
of 20 and 40 and, as mentioned above, this type
of pain recurs in a significant proportion of
individuals, by means of repeated encounters
that are typically more severe than the initial
bout37.
Other problems may also occur in conjunction
with this type of pain. Sleep problems are
particularly prevalent, and may include requiring
much longer periods of time to induce sleep
itself, in addition to turbulence throughout
sleep, shorter periods of sleep, and less restful
sleep. The majority of those who suffer from
chronic lower back, neck and shoulder pain also
begin to exhibit symptoms of mental disorders
such as depression or anxiety24.
Causes of Lower Back, Neck and Shoulder Pain
Pain in the lower back, neck and shoulders are
not specific ailments in their own right, but are,
instead, symptoms caused by a variety of
probable and fundamental issues, some more
serious than others. They do not have a single or
obvious root cause. Rather, it is supposed to be
the effect of muscular or skeletal issues such as
sprains or strains, often complicated by other
factors. Some of these may include obesity,
smoking, rapid weight gain (particularly as a
result of pregnancy), stress, low overall physical
fitness, poor posture and awkward positioning
during sleep38.
Such pain may also be caused or complicated by
less common conditions, like osteoarthritis or
degeneration of vertebral discs, or injuries such
as spinal disc herniation, a broken vertebra or, in
extremely rare instances, an infection of or a
tumor in the spine. Women are at additional risk
from a handful of medical conditions that
specifically affect the female reproductive
system, as well as ovarian cysts and ovarian
cancer39.
Pathophysiology
Back structures
The backbone is made up of 33 vertebrae,
between which are fibro cartilaginous discs,
which function as cushions and serve the dual
purpose of preventing inter-vertebral friction
while simultaneously protecting the spinal cord.
Nerves connect to the spinal cord from side to
side a series of gaps between the vertebrae,
providing messages and sensations to the muscles
and skin40. An individual intervertebral disc has a
gelatinous core which is surrounded by a ring of
fibrous material. In its usual condition, the
majority of the disc is not directly connected to
the circulatory or nervous system, as it is
composed of particular cells that can stay alive
without a straight blood provide41. Over time,
the flexibility of the discs starts to dissipate,
which subsequently reduces their ability to take
up physical stress. This reduced aptitude creates
increased stress to other parts of the spine,
which results in a thickening of the ligaments of
the spine and causes bony growths to expand on
the vertebrae, resulting in fewer spaces from
first to last, which the spinal cord and nerve
roots can bypass.
When a disc degenerates as a consequence of
damage or illness, changes in its structure are
bound to follow suit: blood vessels and nerves
may be formed its center, and it is possible for
herniated disc substances to be forced directly
onto the root of a nerve, all of which are
changes that may lead to back pain. Ligaments
and muscles of the back and abdomen provide
the vertebral column with stability, while a
group of small joints referred to as facet joints
direct the motion of the spine while limiting its
range42.
A group of muscles known as the multifidus
muscles run along the back of the spine,
providing additional stability and ensuring that
the spine remains straight while the body is
engaged in a myriad of rudimentary activities
such as sitting, walking and lifting. These are
commonly injured in the bodies of those who
suffer from chronic back pain, as the initial pain
often causes them to use their back muscles
sporadically in an attempt to avoid the pain.
Problems with the back muscles often persist
even after the initial bout of pain has been
treated, and are also probably responsible for
recurring pain43.
Pain Sensation
Pain is usually an uncomfortable sensation
resulting from an activity that injures or can
potentially harm the body's tissues. There are
four major ladders in the procedure of feeling
pain: transduction, transmission, perception and
modulation44. The nerve cells that become aware
of pain contain cells situated in the dorsal roots
of ganglia and sensory fibers with the aim of
sending out signals to the spinal cord. The
Malaysian Journal of Public Health Medicine 2016, Vol. 16 (1): 62-74
procedure of feeling pain starts when the pain-
inducing activity or incident triggers the endings
of sensory nerve cells that respond specifically to
certain sensations, such as pain. These cells then
convert the response when intensified by an
electrical signal through transduction. More than
a few different kinds of nerve fibers transmit the
electrical signal from the transducing cell to the
tip of the spinal cord, from near to the brain
stem, and after that from the brain stem to
several parts of the brain, such as the thalamus
and the limbic organization45. Inside the brain,
the pain signals are processed and the individual
is soon aware of the pain inflicted on his/her
body. Throughout this process, the brain is able
to carry out additional nerve impulses by
lessening or adding the release of the
neurotransmitters involved in the sensory and
ascending pathways45.
However, there are times when parts of the
pain-feeling process and dispensation
organization might not be conducted correctly,
especially while the sensation of pain is
arbitrarily induced, or while a particular activity
or incident has caused tremendous pain to the
body, or even while pain is triggered by an
activity or incident that does not usually inflict
pain. Apart from that, the pain modulation
mechanisms might not function correctly either.
These phenomena are linked to chronic pain46.
Lower Back, Neck and Shoulder Pain and Office
Work
After stress, lower back, neck and shoulder pain
are the most common causes of long-term
sickness in the UK. From 2010 to 2011, roughly
7.6 million working days have gone to waste due
to work-related lower back, neck and shoulder
pain and other musculoskeletal disorders among
office workers4. The primary causes are strained
muscles or ligaments, routine wear and tear,
prolonged periods of retaining a particular
position involving bad posture, as well as stress.
Extended periods of time spent on sitting on an
office chair have been shown to cause or worsen
lower back, neck and shoulder pain47. The
primary reason for this is that sitting, whether on
an office chair or in general, is a static posture
that places continual stress on the back,
shoulders, arms and legs, and is particularly hard
on the back muscles and spinal discs.
The natural tendency for most people is to
slouch on a chair after an extended period of
sitting, and this posture is able to overstretch
the spinal ligaments and place undue strain on
the spinal discs and related structures. Over
time, repeated instances of prolonged sitting
using an incorrect posture can damage spinal
structures and result in or worsen lower back,
neck and shoulder pain. Most people will
experience pain in the lower back, neck or
shoulders at some point in their lives, and
despite the discomfort it poses, most cases of
such pain are not fatal. For most people, the
pain lasts anywhere between a few days to a few
weeks and will usually dissipate in about six
weeks48. Currently, the most common way to
measure the severity of musculoskeletal
disorders is using standard questionnaires.
Table 2 Questionnaires in musculoskeletal disorders assessment
No
Questionnaires
Description
1
Nordic Questionnaire
The questionnairecontains of prepared, compulsory, dual or
multiple option variants and be able to be used as self-
administered questionnaires or in interviews. There are two
kinds of questionnaires: a general questionnaire, and specific
ones concentrating on the low back and neck/shoulders.
2
Oswestryquestionnaire
The Oswestry index is an index resulting from the Oswestry
Low Back Pain Questionnaire presented by clinicians and
scientists to measure disability for low back pain. The self-
completed questionnaire includes ten topics about strength of
pain, lifting, capability to mind for individual, capability to
walk, sit, sexual performance, stand, life, sleep value, and
travel.
3
Cornell questionnaire
Cornell Musculoskeletal Discomfort Questionnaires (CMDQ)
have been developed by Dr. Alan. The questionnaires are
based on earlier published researches of musculoskeletal
disorder among office workers.
Lower Back, Neck and Shoulder Pain and
Physical Activity
The importance of exercise and physical activity
(PA) is a main component in the care and cure of
acute and chronic pain. Those who suffer from
chronic pain are advised to remain physically
active, and early and gradual physical activity is
encouraged while bed rest is discouraged in
primary care guidelines49. However, managing
such pain effectively, and preventing it from
recurring and becoming chronic, remains a major
Malaysian Journal of Public Health Medicine 2016, Vol. 16 (1): 62-74
challenge. There is an increasing focus on
preventing long-term negative consequences of
chronic pain, and a potential role for PA has thus
been planned. A new assessment has established
proof to support the use of physical activity as a
key part in active self-management amongst
people with chronic pain50. At the same time, as
graded activity programs have been
experimented on as a collectiveorganizational
plan for populations in which both acute and
chronic forms of lower back, neck or shoulder
pain are hypothesized to be present, these
researches did not evaluate activity levels in
daily life outside a controlled environment.
Therefore, it is not possible to infer the
existence of aconnection linking any change in
physical activity to instances of recovery from
pain based on this research51.
The planned result of pain on activity levels of
patients with lower back, neck or shoulder pain
has largely been based upon the deconditioning
model of these types of pain, which is supported
by the confirmation of changes in physical
performance, neuromuscular changes,
psychological property, decreased levels of
physical fitness, and alterations in the patterns
and levels of activity of patients 52. This
evidence has been challenged, and there are
several studies which report no difference in
either fitness or activity levels of patients with
lower back, neck or shoulder pain in comparison
with healthy control groups53. In this context,
there is little conclusive data about whether the
activity levels of patients with lower back, neck
or shoulder pain are associated with LBP (low
back pain) outcomes, and the role of physical
activity in such populations has yet to be
determined. The activity level of patients with
lower back, neck or shoulder pain does not
appear to be a significant predictor of prognosis,
although it has not often been specifically
examined in most studies54. Overall, remaining
active as a supplement to physiotherapy healing
seems to have positive consequences for both
acute and chronic lower back, neck or shoulder
pain populations; however, the literature which
supports this hypothesis does not contain
researches that deliberately take PA of such
individuals into account.
The possible function that PA might play
regarding the frequency of lower back, neck or
shoulder pain has also been investigated, but
with no definitive conclusions55. A recent review
that examines the connection between physical
movement and the prevalence of lower back,
neck and shoulder pain reported that both high
and low levels of activity heightened the
probability of chronic post-activity pain,
particularly in female subjects56. Only one
longitudinal study has specifically divided the
levels of movement into low, moderate and high
levels at baseline before using self-reporting as a
measure to explore the link between activity
level and pain outcome57. This study has found
no meaningful connection between the levels of
activity recorded at baseline and changes in pain
and disability 5 years later. No other researchers
have specifically gone on to discover if the
implementation of maintained moderate physical
activity while dealing with lower back, neck or
shoulder pain, in comparison with low or high
levels of movement, can actually affect longer-
term outcomes. Therefore, additional
longitudinal research into the potentially
undesirable effects of inadequate or extreme
activity levels is necessary.
Impact of Physical Activity on Lower Back,
Neck or Shoulder Pain
Lower back, neck or shoulder pain, which often
precipitates diminished physical activity and
negative mood changes, may actually lead to a
decline in fitness or be perceived as such, and
the significance of this problem should be
addressed. The influence of LBP on physical
activity is not absolutely clear, even though
health and fitness are generally thought to
influence the prevalence of lower back, neck and
shoulder pain58. A previous study has shown that
exercise provides many benefits for individuals
suffering from lower back, neck or shoulder pain.
This study has also revealed that exercise has
imparted positive effects in the same individuals
with regards to their feelings as well as stress
and anxiety levels, in addition to their
encounters with depression59, even though they
seldom attended any exercise program prior to
the study. However, a multi-purpose
conditioning exercise with aerobic conditioning
has proven to be effective in minimizing the
number of sick-leave days among workers with
chronic lower back, neck or shoulder pain60. It is
discovered that the overall benefits of flexibility
are to be seen in biomechanical, neurological as
well as molecular systems, which include
myofibrillogenesis as a long-term consequence.
Increases in size of overall flexibility can also be
considered to enhance resistance to soreness and
viscous elastic properties in the muscles and
tendons. After subjecting participants to muscle
conditioning, a period of rest that lasts anywhere
between thirty six to forty eight hours is
recommended as an intermission between
workout sessions. Also, since flexibility exercises
alter muscle proteins, a relaxation period of 36-
48 hours between exercise sessions is imperative
to avoid excessive catabolism29.
Physical Capacity and Intensity of Exercise
The scientific literature indicates that workouts
produce positive effects on patients suffering
from lower back, neck and shoulder pain, and
such patients who have completed workout
programs show statistically substantial
improvements in cardiovascular capacity as
well61. It has also been found that an exercise
Malaysian Journal of Public Health Medicine 2016, Vol. 16 (1): 62-74
routine involving 20 cluster sessions has
dramatically reduced the frequency of low back
pain recurrence in patients who have
experienced it in the past62. That being said, not
only does pain decrease, but many patients have
found that their physiological health has
improved, too. One study has found that a power
>50% VO2 maximum and >10 minutes of workout
were necessary to eradicate workout analgesia.
A number of scientific studies have indicated
that individuals working out at 80% VO2
maximum show substantial reductions in anxiety
levels63. Kemppainen et al. have also found that
exercise intensities at>70% maximum in
cardiovascular capacity can heighten both
exercise capacity and pain limits64. Another
study has found that those with normal
cardiovascular health who have participated in
workouts acquired above-average cardiovascular
fitness65.
Exercise and Pain/Disability
A workout may also be helpful in reducing aches
after exercise, with one study finding that
exercise-induced analgesia existed for 50
minutes after exercise. Additionally, people who
performed workouts on a regular basis displayed
better resistance towards aches, as opposed to
non-active controls66. Koltyn et al. have found
that, immediately after exercise, the pain limit
was at a considerably higher level and the
amount of pain experienced was considerably
lower67.
Long-term decreases in lower back, neck or
shoulder pain as a result of participation in
exercise programs have been detected, and high-
intensity workouts have been observed to lower
levels of pain, physical impairment and mental
strain in those with long-term lower back, neck
or shoulder pain. People with long-term lower
back, neck or shoulder pain have thus revealed
significant improvements in pain scores and
heart rates after exercise, and pain was
significantly lowered 30 minutes after workout
sessions that involved lower-limb cycling.
Furthermore, pain relief for at least half an hour
after workouts was found in healthy subjects as
well as in those with long-term lower back, neck
or shoulder pain68. In addition, Van der Velde and
Mierauhave observed a statistically significant
loss of pain and decreased difficulty in standing
among individuals participating in exercise
regimes69, while others have reported decreases
in lower back, neck and shoulder pain as well as
general physical disabilities among patients a
year after an exercise regimen59.
Several reports have dealt with participants
suffering from extreme or sub-acute lower back,
neck or shoulder pain60. Also, Mortimer et al.
have recruited similar individuals who did not
seek proper medical care in the last 6 months,
and were thus classified as acute or sub-acute70.
Other reports have recorded the effects of
training by using self-reports and accelerometry,
but found little change with regards to physical
incapacitation60. In populations such as these,
the link between lack of physical exercise and
problems due to chronic lower back, neck or
shoulder pain emphasizes the possibility that
increasing physical activity might be
advantageous in decreasing the amount of
disabilities. When resources are scarce, it is
always possible that physicians will assume that
patients with greater physical difficulties tend to
exercise less, and can devise a suitable exercise
treatment with this in mind.
Furthermore, directly overseeing the exercise
regimen is likely to be beneficial; for instance,
overseeing a new patient’s use of a pedometer
and accelerometer will enable specific advice to
be given60. Heneweer et al. have identified that
the relationship between training and risks
connected with persistent lower back, neck or
shoulder pain was U-shaped, indicating that
excessive exercise might introduce further
problems71. That being said,Depalma et al. have
compared patients suffering from persistent
lower back, neck or shoulder pain with
controlled, healthy subjects undergoing identical
amounts of training. They found that habits
connected with training may vary between
patients and healthy controls, with this
imbalance usually contributing to the patient’s
difficulties72. In conjunction with this point, it
has often been assumed that a person with pain-
related impairments (due to lower back, neck or
shoulder pain) trains less, and treatment should
aim at the maintenance and gradual increase in
the amount of activity. Such a reduction in
activity need not apply to all those with such
pain, even though the disadvantages of reduced
levels of activity during training are clear60.
Physical Activity and Movement among Office
Workers
Office workers do not have enough time to
engage themselves in physical activity, and thus
suffer often from musculoskeletal disorders,
especially lower back, neck and shoulder pain.
Previous studies have shown that walking during
a short break reduces their discomfort, and other
academic scholarship has discovered that
stretching exercises for a period of 6-8 weeks
pose benefits in curbing pain. These results
indicate the positive effects of physical activity
on reducing pain73. The theory behind the value
of stretching exercises, especially for back
muscles, is related to muscle tightness. Sitting
for a long time and the absence of physical
activity can lead to muscle tightness. The
flexibility exercises used in previous researches
were general and not specifically for back
muscles74. Also, there was no research to show
the effect of strength training on lower back,
neck or shoulder pain among office workers.
However, some past researches have revealed
Malaysian Journal of Public Health Medicine 2016, Vol. 16 (1): 62-74
that positive effects can be obtained from
thermotherapy and manual therapy in reducing
muscle pain among office workers36.
Unfortunately, a package of exercises specific to
flexibility and strength training for office
workers does not exist.
An absence of physical activity leads to a
decreased range of movement (ROM). Measuring
ROM is part of the clinical measurements used by
physiotherapists and orthopedics when
investigating lower back, neck and shoulder pain.
ROM is measured with the use of a goniometer.
Previous studies have shown that decreased ROM
is related to lower back, neck or shoulder pain.
Therefore, flexibility exercises can be used to
increase ROM in the neck, shoulder and lower
back joints. Decreased physical activity and
sitting for a long time can thus affect ROM
adversely24. However, there is, to this day, little
research with adequate methodology involving
office workers concerning the effect of flexibility
exercises on ROM, especially in the neck,
shoulder and lower back joints, and its
association with lower back, neck and shoulder
pain.
Modified Risk Factors and Ergonomics
Intervention in Office Workers
Two physical aspects among office workers can
easily lead to injuries amongst themselves. The
body posture usually leads to extension or
compression of muscles, and anxiety is present
as well. The more time invested in a limited or
perhaps difficult physical activity, the more
likely it is for the body to build up
musculoskeletal disorders (MSD’s). For instance,
working with the body bent forwards, backwards
or perhaps alternatively can easily induce
excessive stress in the lower back region75. In
addition, flexing the shoulders and neck will
contribute to MSD’sas well. In order to perform
any controlled movement using the arm, the
shoulder and neck muscles need to remain
contracted throughout the movement.
Contracted muscles exert pressure on blood
vessels, which in return reduces the flow of
blood towards the muscles that are used for hand
movements76.On the other hand, increased blood
flow is required during intense muscle effort.
Two consequences arise: 1. the neck, shoulder or
lower back muscles become fatigued, even
though there may be little or no motion involved;
2. at the same time, the decreased blood flow,
coupled with increased use of energy by the
active muscles, renders them far more
vulnerable to damage. Finally, a suitable position
when working or relaxing can help prevent
repetitive pressure injury (RSI), one among
several known sources of backache. Sitting
upright can reduce this problem, too.
Doing this often, even for short periods of time,
is much better than doing it for longer periods of
time but less frequently. This procedure enables
muscle tissues to loosen up. The majority of
office tasks provide some opportunities to
perform such actions, notably through looking at
a TV screen, eating a snack, going for a brief
walk and even filing or photocopying documents.
Past scientific studies have confirmed that the
use of an ergonomically-designed desk, a
correctly adjusted seat (including the top of the
seat and its height), and comfortable work space
can slow the development of MSD’s and reduce
musculoskeletal aches. Also, short bursts of
activity duringworking hours can lessen
symptoms of backache, etc.76.
CONCLUSION
To sum it up, musculoskeletal disorders,
especially in the neck, shoulders and lower back
constitute an ailment that plagues office workers
worldwide, the main reasons being their
sedentary lifestyle and absence of physical
activity. Future studies, preferably large
prospective cohort studies, should include data
on practical treatment among office workers
with regards to the severity of pain as current
academic scholarship on the topic is mostly
theoretical rather than practical and therefore
not easy to apply in an office environment.
ACKNOWLEDGEMENTS
We would like to express our special thanks to
Professor Ina Shaw and Professor Brandon S.
Shaw, University of Johannesburg, South of
Africa for reviewing the manuscript in spite of
their busy schedule. The last but not the least
thanks to Professor David Pyne, Australian
Institute of Sport, Canberra, Australia for his
assistance with the manuscript.
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