Review
Are pushing and pulling work-related risk factors
Additional matrials is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
oemed-2013-101837)
1 extremity symptoms as compared to workers that
MOVE Research Institute,
Faculty of Human Movement
Sciences, VU University
Amsterdam, Amsterdam,
The Netherlands
2
CORAL Centre for
Orthopaedic Research Alkmaar,
Orthopaedic Outpatient
Department, Medical Centre
Alkmaar, Alkmaar,
The Netherlands
3 draw conclusions in terms of strong, moderate or
Coronel Institute of
Occupational Health/
Netherlands Center for
Occupational Diseases,
Academic Medical Center,
University of Amsterdam,
Amsterdam, The Netherlands
4
Faculty of Mechanical,
Material and Marine
Engineering, Department of
Biomechatronics and
Biorobotics, Delft University of
Technology, Amsterdam,
The Netherlands.
Correspondence to
Dr Marco J M Hoozemans,
MOVE Research Institute,
Faculty of Human Movement
Sciences, VU University
Amsterdam, Van der
Boechorststraat 9, Amsterdam
1081 BT, The Netherlands;
m.j.m.hoozemans@vu.nl
Received 4 September 2013
Revised 24 June 2014
Accepted 3 July 2014
Published Online First
17 July 2014
To cite: Hoozemans MJM,
Knelange EB, Frings-
Dresen MHW, et al. Occup
Environ Med 2014;71:
788795.
788
for upper extremity symptoms? A systematic review
of observational studies
M J M Hoozemans,1,2 E B Knelange,1 M H W Frings-Dresen,3 H E J Veeger,1,4
P P F M Kuijer3
ABSTRACT
Systematically review observational studies concerning
the question whether workers that perform pushing/
pulling activities have an increased risk for upper
perform no pushing/pulling activities. A search in
MEDLINE via PubMed and EMBASE was performed with
work-related search terms combined with push/pushing/
pull/pulling. Studies had to examine exposure to
pushing/pulling in relation to upper extremity symptoms.
Two authors performed the literature selection and
assessment of the risk of bias in the studies
independently. A best evidence synthesis was used to
conicting/insufcient evidence. The search resulted in
4764 studies. Seven studies were included, with three of
them of low risk of bias, in total including 8279
participants. A positive signicant relationship with
upper extremity symptoms was observed in all four
prospective cohort studies with effect sizes varying
between 1.5 and 4.9. Two out of the three remaining
studies also reported a positive association with upper
extremity symptoms. In addition, signicant positive
associations with neck/shoulder symptoms were found in
two prospective cohort studies with effect sizes of 1.5
and 1.6, and with shoulder symptoms in one of two
cross-sectional studies with an effect size of 2.1. There is
strong evidence that pushing/pulling is related to upper
extremity symptoms, specically for shoulder symptoms.
There is insufcient or conicting evidence that pushing/
pulling is related to (combinations of ) upper arm, elbow,
forearm, wrist or hand symptoms.
INTRODUCTION
Workers of various occupations often report upper
extremity symptoms. General estimates indicate
that 2040% of all workers experience symptoms
in the neck/shoulders or arms/wrists/hands in the
previous 12 months1 2 and these symptoms are
associated with considerable work-related nancial
and personal consequences.2 In the Netherlands,
the number of notications of occupational disease
(OD) due to upper extremity disorders was 841 in
2012.3 The three sectors with the highest annual
incidence ( per 100 000 worker years, 95% CI) for
these ODs are construction (228, 95% CI 167 to
289), transport and storage (172, 95% CI 167 to
289) and agriculture, forestry and shing (125,
95% CI 167 to 289).4
Scientic evidence of risk factors for upper
extremity symptoms is essential to develop valid
methods for the assessment of the work-relatedness
Hoozemans MJM, et al. Occup Environ Med 2014;71:788795. doi:10.1136/oemed-2013-101837
of these symptomsthat is, whether (a part of ) the
symptoms can be attributed to work activitiesfor
ergonomic evaluation or effective interventions at
work.5 In the scientic literature, neck, forearm
and wrist/hand symptoms are typically studied in
association with repetitive movements and
awkward (neck/wrist/hand) postures, for instance in
ofce workers.6 Shoulder or neck/shoulder symp-
toms on the other hand are more often investigated
in association with heavy workload.1 7 For instance,
in a recent systematic review, Mayer et al8 reported
strong evidence for an association between shoul-
der symptoms and manual material handling
(MMH), hand-arm vibration, trunk exion or rota-
tion and working with hands above shoulder level,
with ORs ranging between 1.1 and 5.1.
Upper extremity symptoms should be considered
also when evaluating manual handling at work.814
Assuming that work-related musculoskeletal symp-
toms are associated with high musculoskeletal
loading, it can be expected that activities with rela-
tively high external forces at the hands, also in
combination with unfavourable arm postures or
movements, are potential risk activities.
Consequently, for the relationship between MMH
and upper extremity symptoms it would be sensible
to focus on pushing or pulling rather than on
lifting or carrying. In lifting loads from oor level,
gravitational forces at the centre of mass of the arm
and the hand reaction forces are mainly directed at
the glenohumeral joint and thereby resulting in
relatively low mechanical joint loading. However,
during pushing and pulling this may not be the
case, causing relatively large joint moments with
often unfavourable arm postures, for instance when
a worker pulls with one arm a cart that is located
behind the worker while the worker is walking
forward. In laboratory experiments it was shown
that pushing and pulling are accompanied with
relatively high levels of shoulder load and relatively
low levels of low back loading.1518
Pushing and pulling have been dened as the
exertion of a (hand) force, of which the direction
of the major component of the resultant force is
horizontal, by someone on another object or
person.19 In pushing the (hand) force is directed
away from the body and in pulling the force is
directed towards the body. In work, pushing and
pulling are ergonomically evaluated using guide-
lines based on psychophysical criteria,20 of which
the maximal acceptable hand forces also have been
adjusted based on threshold limits for energetic
workload and load at the low back.21 Based on a

few studies22 23 we proposed to include also shoulder loading in
the evaluation of pushing and pulling.24 However, as far as we
know, the literature has not been systematically reviewed for evi-
dence of a relationship between pushing and pulling and upper
extremity symptoms, which justies an evaluation of the associ-
ation between work-related pushing and pulling and the pres-
ence of upper extremity symptoms. Therefore, the objective of
the present study was to systematically review observational
studies concerning the question whether workers that have to
perform pushing and pulling activities at work have an increased
risk for upper extremity symptoms as compared to workers that
have to perform less or no pushing or pulling activities at work.
METHODS
Search strategy
A manual and computerised literature search was performed
using the databases of MEDLINE via PubMed and EMBASE on
28 January 2014. No publication date restrictions were
imposed. The keywords used in the PubMed database were
push or pull or pushing or pulling, combined with the
more sensitive search strategy for the study of putative occupa-
tional determinants of diseases as suggested by Mattioli et al.25:
(occupational diseases [MH] OR occupational exposure [MH]
OR occupational exposure* [TW] OR occupational health OR
occupational medicine OR work-related OR working environ-
ment [TW] OR at work [TW] OR work environment [TW] OR
occupations [MH] OR work [MH] OR workplace* [TW] OR
workload OR occupation* OR worke* OR work place* [TW]
OR work site* [TW] OR job* [TW] OR occupational groups
[MH] OR employment OR worksite* OR industry) AND ( push
OR pull OR pushing OR pulling).
This search strategy was adapted for EMBASE, but was per-
formed without MEDLINE:
occupational diseases/exp or occupational exposure/exp or
occupational health/exp or occupational medicine/exp or
work-related or working environment/exp or at work
or work environment/exp or occupations/exp or work/exp
or workplace* or workload/exp or occupation* or worke* or
work place or work site or job* or occupational groups/exp
or employment/exp or worksite* or industry/exp and (push
or pull or pushing or pulling) and [embase]/lim
References of key publications and included studies were
checked for other relevant studies or reviews and personal data-
bases of the authors were consulted.
Inclusion criteria
The papers identied using the search strategies in PubMed and
EMBASE were screened by two authors (MH and PK) using the
following inclusion criteria: (1) the study examined exposure to
pushing and/or pulling in relation to upper extremity symptoms
at the neck, shoulder, arm, wrist and/or hand, (2) the study
design was cross-sectional, casecontrol or prospective cohort,
(3) the study was published in English, German or Dutch. If the
title and abstract did not provide enough information to decide
whether the inclusion criteria were met, the full paper was
checked. Next, the inclusion criteria were applied to the full
paper. When doubts existed about whether a paper fullled the
inclusion criteria, a decision was made based on consensus
between both authors.
Assessment of risk of bias
After study selection and inclusion, the same two authors (MH
and PK) independently assessed the risk of bias in each of the
studies using a standardised set of 10 predened criteria (table 1)
Hoozemans MJM, et al. Occup Environ Med 2014;71:788795. doi:10.1136/oemed-2013-101837
Review
according to the method presented by Ijaz et al.26 Each item had
to be rated as a low (LR), a high (HR) or an unclear (UR) risk of
bias. In accordance with Ijaz et al,26 the 10 items were divided
into two hierarchical groups. The group with the major ve
domains of bias included exposure denition, exposure assess-
ment, reliability of exposure assessment, analysis/research specic
bias and confounding. The remaining ve domains of bias were
considered as the group with the minor ve domains: attrition,
blinding of assessors, selective reporting, funding and conict of
interest. Thereafter, each study was rated as a low risk or high
risk of bias study. Studies were considered as low risk of bias if
the study showed LR in four or ve of the major domains of bias
and in two or more of the minor domains of bias. The results of
the assessments of risk of bias of the two authors were compared
and differences were discussed during a consensus meeting.
Data extraction
The following information was extracted from the included arti-
cles: primary author (including country), year of publication,
study design (prospective cohort, casecontrol or cross-
sectional), characteristics of the study population (numbers of
participants and respondents, age, sex and occupation), duration
of follow-up, instruments used for exposure assessment and
exposure denition, instruments used for outcome assessment
and outcome denition, the main results of the study concern-
ing the association between pushing or pulling and upper
extremity symptoms, potential confounders assessed in the
study and confounders included in the analyses (see online sup-
plementary table S2). The data were extracted by one of the
review authors (MH) and another review author (PK) checked
the extraction.
Levels of evidence
A forest plot was made of the effect sizes found in the observa-
tional studies without a summary estimate, due to the hetero-
geneity in exposure and outcomes in the observational studies.
To determine whether pushing or pulling at work is related to
upper extremity symptoms a best evidence synthesis, presented
by Kuijer et al27 and adapted from Van Tulder et al28 and De
Croon et al,29 was applied consisting of three levels of evidence,
taking into account the risk of bias, the design of the study (pro-
spective cohort, casecontrol or cross-sectional) and the out-
comes of the included studies. (1) Strong evidence was dened
as consistent ndings in at least two prospective cohort studies
with low risk of bias and effect sizes in the same direction. (2)
Moderate evidence was dened as consistent ndings in at least
one prospective cohort study with low risk of bias and one
cross-sectional/casecontrol study with low risk of bias or one
prospective cohort study with high risk of bias. In all other cases
the evidence was dened as (3) Insufcient or conicting evi-
dence. We used the following rules for consistent ndings2729:
(1) if there are four or more studies, the statistically signicant
ndings of 75% or more of the studies have to be in the same
direction; (2) if there are three studies, the statistically signicant
ndings of at least two studies have to be in the same direction;
(3) if there are two studies, the statistically signicant ndings of
both studies have to be in the same direction.
RESULTS
Search and selection
The search strategy resulted in 1926 hits in PubMed and 2838
hits in EMBASE (gure 1). A total of eight studies met the
inclusion criteria, including three cross-sectional studies, one
casecontrol study and four prospective cohort studies. Seven
789
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Table 1 List of criteria used to assess the risk of bias in and across the included studies26
1 Exposure definition HR Definition of exposure covers only one aspect of exposure (duration, frequency, intensity) or is based on job description
LR Definition of exposure covers more than one aspect of exposure (duration, frequency, intensity)
UR Exposure definition is not clear or not reported
2 Exposure assessment HR Exposure is assessed subjectively (self-report/questionnaire/interview) or using a proxy used to allocate exposure status ( job matrix,
job title)
LR Exposure is assessed objectively (direct measurements or systematic observations) or using a questionnaire that is validated using
direct measurements or systematic observations
UR Exposure assessment methods are unclear or not reported
3 Reliability of exposure HR Inter/intraobserver reliability is reported by means of a subjective judgment of reliability
assessment LR Good inter/intraobserver reliability achieved with reliability values reported or when objective measures were used
UR Inter/intraobserver reliability is unclear or not reported
4 Analysis/research HR Authors did not obtain methods to reduce bias or did not justify their choice of statistical models to reduce research specific bias
specific bias LR Authors reported use of one or more methods to reduce bias (standardisation, matching, adjustment in multivariate model,
stratification, propensity scoring), assessed doseresponse in some way (subgroup, regression) or justified sample size
UR Methods to reduce research specific bias are unclear or not reported
5 Confounding HR Major confounding factors/effect modifiers (age, working/lifting above shoulder height, repetitive work) were not assessed or
assessed partially
LR Major confounding factors/effect modifiers (age, working/lifting above shoulder height, repetitive work) were assessed in full
UR Confounding factors are unclear or not reported
6 Attrition HR Total loss to follow-up (non-response in casecontrol studies) is larger than acceptable (20% or more) or drop out differs between
the groups more than 10% or the reasons for drop out are different for exposed and non-exposed groups
LR Loss to follow-up (non-response in casecontrol studies) below 20% in total and not different between the two groups (up to 10%
difference)
UR Attrition bias is unclear or not reported
7 Blinding of assessors HR Assessors are reported or indicated not to be blind to exposure status (or case status in casecontrol studies), exposure and
outcome are assessed by self-report
LR Assessors are reported or indicated to be blind to exposure status (or case status in casecontrol studies)
UR Blinding of assessors is unclear or not reported
8 Selective reporting HR Incomplete/selective reporting of the tested hypotheses (compared to aim and objectives) and/or crude estimates are presented
only
LR Adjusted estimates presented for all hypothesis tested as per aims
UR Unclear or not reporting of tested hypothesis
9 Funding HR Study funded by industry (one or more corporate sponsors) or industry is involved in data analyses
LR Study funded by non-profit organisation(s) that is not involved in the conduct or interpretation of the research
UR Funding is unclear or not reported
10 Conflict of interest HR One or more of the authors indicates a conflict of interest
LR No conflicts of interests are declared or declared interests are not deemed conflicting
UR Conflicts of interests are unclear or not reported
HR, high risk of bias, LR, low risk of bias, UR, unclear risk of bias.

studies were performed in Europe and one in the USA. One
cross-sectional study30 and one prospective cohort study23 were
from the same study population. We decided to exclude the
cross-sectional study30 from the evidence syntheses. The most
important reason for excluding seemingly relevant studies was
that pushing or pulling was not included in the analyses as a
separate exposure, but as part of an exposure measure that
included MMH in general, including lifting, carrying, pushing
and pulling. The characteristics and results of the seven included
studies are presented in online supplementary table S2.
Study characteristics
In the seven studies a total of 8279 participants were observed
(Median=683, IQR=705). Four studies1 9 22 23 had a prospect-
ive cohort design with a follow-up period ranging from 1223 to
24 1 9 22 months. Response rate ranged from 32%9 to 91%.22
Shoulder symptoms were specically explored in ve
papers22 23 3032 and neck/shoulder symptoms in two papers.1 9
Other upper extremity regions and combinations of regions
were each studied in only one of the papers. Upper extremity
symptoms were generally assessed using self-administered
questionnaires and in one study31 by physical examination and
in one other study11 using MRI. Also pushing and/or pulling
were mainly assessed by self-administered questionnaires.
Other methodologies used were systematic observation,23
job-surveillance checklist,31 interview11 and job description.32
Exposure to pushing and/or pulling was often dened in terms
of frequency, sometimes in combination with load mass or dur-
ation. Only one study31 did not report an effect size in terms of
OR or HR.
Assessment of risk of bias
Of the total of 70 items for the seven studies, the two raters
agreed on 48 items (69%, table 2). After reaching consensus,
and following the method presented by Ijaz et al,26 three pro-
spective cohort studies were determined to be of low risk of
bias and the other (four) studies of high risk of bias. Of the
major domain of bias, reliability of exposure assessment was the
item that was scored negative (HR or UR) most often (six out of
seven studies).
Pushing and pulling in relation to upper extremity
symptoms
For upper extremity symptoms in general (thus discarding body
region), a positive signicant association with pushing and/or
pulling was observed in all four prospective cohort
studies,1 9 22 23 of which three were scored as low risk of bias.
For the high exposed categories the signicant and adjusted
effect sizes ranged from 1.5 (n=1513)1 to 4.86 (n=459).23 In
three of four studies, only the high exposure category showed a

790 Hoozemans MJM, et al. Occup Environ Med 2014;71:788795. doi:10.1136/oemed-2013-101837


Figure 1 Study ow diagram.
signicant association. Only the study of Hoozemans et al23
showed a stronger association for the medium exposed group
compared to the high exposed group. Of the other three
studies, two cross-sectional and one casecontrol study, one
showed no association between pushing and/or pulling (effect
size 0.9, 95% CI 0.5 to 1.8),11 33 34 and the other two showed
signicant associations (effect sizes between 2.0 and 5.0)31 32 of
which one study31 mentioned that pushing and pulling were not
in the nal stepwise logistic regression model (variables stayed
in the model at p values of <0.20). Considering these results
there is strong evidence for pushing and/or pulling being signi-
cantly related to upper extremity symptoms.
Shoulder symptoms specically were studied by two prospect-
ive cohort studies with low risk of bias22 23 and two cross-
sectional studies with high risk of bias.31 32 As prospective
cohort studies and one of the cross-sectional studies found sig-
nicant adjusted effect sizes it is concluded that there is strong
evidence that pushing and/or pulling are related to shoulder
symptoms.
Neck/shoulder symptoms were examined in two prospective
cohort studies.1 9 Both studies, of which one was scored as low
risk of bias and the other as high risk of bias, reported signi-
cant effect sizes for the high-exposure groups of 1.51 and 1.6.9
According to the denitions of the presented levels of evidence,
there is moderate evidence that pushing and/or pulling is related
to neck/shoulder symptoms.
With respect to upper arm, elbow, forearm, wrist and hand
symptoms, each of these outcome measures was included in
only one of the studies. Andersen et al1 found pushing and
pulling to be signicantly associated (effect size 1.8, 95% CI 1.1
to 3.1) with elbow/forearm/hand pain. Hughes et al31 reported
signicant univariate associations for the combinations elbow/
forearm and hand/wrist, however, pushing and pulling were not
in the nal multiple logistic regression model. Seidler
et al11 33 34 found no signicant association between pushing
and pulling and the presence of supraspinatus tendons tears and
Van der Beek et al32 reported signicant adjusted ORs of 4.1
Hoozemans MJM, et al. Occup Environ Med 2014;71:788795. doi:10.1136/oemed-2013-101837
Review
and 5.0 for upper arm and forearm symptoms, respectively, in
lorry drivers who handled wheeled cages in comparison with
lorry driver who only had a driving task. Therefore, there is
insufcient or conicting evidence that pushing and pulling are
related to (combinations of ) upper arm, elbow, forearm, wrist
or hand symptoms.
DISCUSSION
This systematic review is the rst to reveal that there is strong
evidence for pushing and/or pulling at work being signicantly
related to upper extremity symptoms with effect sizes in terms
of risk ratios ranging between 1.3 and 5.0. More specically, the
evidence synthesis of this literature review shows that there is
strong evidence that pushing and/or pulling at work are related
to shoulder symptoms, moderate evidence that pushing and/or
pulling at work are related to neck/shoulder symptoms and that
there is insufcient or conicting evidence that pushing and/or
pulling at work are related to (combinations of ) upper arm,
elbow, forearm, wrist or hand symptoms.
The literature search resulted in only seven eligible studies, of
which four were prospective cohort studies with a follow-up
period of maximally 2 years. This means that, although the
levels of evidence were strictly dened, the conclusions are
based on a relatively low number of studies. Two of the seven
studies had a cross-sectional design. This design is not suitable
to detect whether pushing or pulling cause upper extremity
symptoms. If workers with upper extremity symptoms changed
to jobs that require pushing or pulling activities, this could
result in the observed positive association between pushing or
pulling and upper extremity symptoms in the two cross-
sectional studies. However, this explanation seems not likely. In
addition, the episodic nature of upper extremity symptoms
hampers establishing a causeeffect relationship altogether and
we, therefore, decided to include also cross-sectional studies.
Moreover, in the best evidence syntheses, cross-sectional studies
only minimally affect the levels of evidence, that is, when only
cross-sectional studies are available the evidence is conicting
791
 Review

or insufcient at best. For the prospective cohort studies, popu-

HR/
lations were free from symptoms at baseline and the incidences

HR
HR

HR
HR
LR

LR
LR
LR
of symptoms in the follow-up period point to a potential causal
relationship with pushing or pulling. However, the methodology

minor
nrLR
of the assessment of exposure and outcome used, generally self-

3
2
2

1
2

2
1
administered questionnaires and the episodic characteristic of
upper extremity symptoms increase the risk of biased relation-
major

ships. If exposure misclassications are independent of the pres-

nrLR

4
4
5

0
2

2
0
ence of symptoms, or precursors of symptoms, the reported
effect sizes may even be underestimated.35 It is, however, dif-
Conflict of

cult to rule out differential misclassication. The presence of

interest

minor symptoms at baseline, which is sometimes dened as pain

free,1 9 may result in the self-report of relatively high exposure,
UR
UR
UR

UR

UR
UR
LR
which undermines the causal relationship. However, in one of
Funding

our own studies,23 systematic observation was used to assess

exposure to work-related activities and this more reliable classi-
UR

UR
UR

UR
LR
LR

LR

cation appeared to be signicantly associated with shoulder

symptoms. Furthermore, ignoring signicance, three of the four
prospective cohort studies found doseresponse relationships
reporting
Selective

when looking at the effect sizes. Thus, it can be considered

likely that work-related pushing and/or pulling can actually
LR
LR
LR

LR
LR

LR
LR

cause (self-reported) upper extremity symptoms.

LR, low risk of bias; nrLR major, number of domains with LR in the major 5 domains; nrLR minor, number of domains with LR in the minor 5 domains; UR, unclear risk.

Effect sizes (see gure 2 and online supplementary table S2)

Minor domains of bias

Blinding of

are difcult to compare because of differences in confounding

assessors

variables that have been taken into account. We therefore

assessed potential confounders assessed and confounders
HR
HR

HR
HR

HR
HR
LR

adjusted for during data extraction (see online supplementary

Attrition

table S2). In addition, we have considered working/lifting

above shoulder height to be an important potential confounder
HR
HR

HR
HR

HR
HR
LR

in the assessment of risk of bias (see table 1 and online

supplementary table S2). As such, working/lifting above shoul-
Confounding
26

der height should have been assessed and its confounding effect
Table 2 Results of the assessment of risk of bias observed in the included studies (see also table 1)

should have been explored in the individual studies, for instance

UR
HR

HR

using multiple regression analysis. However, this does not mean

LR
LR
LR

LR

that working or lifting above shoulder height has to be taken

into account in the nal regression model. It depends on the
Analysis /research

presence of this potential confounder in the work of the study

specific bias

population and on the distribution over exposure categories

whether it biases the effect size, that is, the regression coef-
cients of pushing and pulling, in that particular study. If the
HR

HR
LR
LR
LR

LR

LR

effect sizes are not largely affected by including the potential

HR, high risk of bias; HR/LR, final score of study for high risk (HR) or low risk (LR) of bias;

confounders they should not appear in the nal model. Also, it

Reliability of exposure

is often not clear whether studies had taken multicollinearity of

potential confounding factors into account. Multicollinearity
was only specically reported in the studies of Andersen et al,1
assessment

Harkness et al22 and Hoozemans et al.23 Although Anderson

et al1 reported no additional information and stated that the
UR
UR

UR

UR
HR

HR
LR

one with the highest point estimate in the partially adjusted

model was used, Harkness et al22 mentioned that Lifting
weights at or above shoulder level was strongly correlated with
assessment

working with hands above shoulder level and with lifting

Exposure

weights with one or two hands and only used the last one in
Major domains of bias

the nal analyses. Hoozemans et al23 indicated that working

HR
HR

HR
HR
LR
LR
LR

behind a video display and driving vehicles were highly corre-

lated with pushing and pulling and, therefore, were not included
in the analyses.
definition
Exposure

A general limitation of this review is the limited number of

studies, the relatively large differences in workload, and the
HR
HR

HR
LR
LR
LR

LR

diverse methodologies used for the assessment of exposure and

Harkness et al22

outcome. This also refrained us from performing a meta-analysis

Andersen et al1

Hughes et al31

Smedley et al9
Van der Beek

and calculating a summary estimate for the forest plot (gure

et al11 33 34
Hoozemans

2). Generally, exposure should be dened in terms of duration,

Seidler
et al23

et al32

frequency and intensity.36 However, in the included studies, the

denition of exposure to pushing and pulling varied

792 Hoozemans MJM, et al. Occup Environ Med 2014;71:788795. doi:10.1136/oemed-2013-101837


Figure 2 Forest plotwith the axis presented in logarithmic scaleof studies included. P&P, pushing and pulling, ns/na, effect size is not
signicant and not available.
considerably using for instance job title, number of workdays
and weights pushed or pulled besides duration and frequency.
Signicant risk ratios were observed for pushing or pulling
>355 kg/h,1 >32 kg,22 >300 working days,33 >5 times/shift,9
88234 times/day23 and >783 s/day.23 Unfortunately, this vari-
ation in exposure denition also makes it hard to establish
threshold limits or cut-off points in exposure to prevent upper
extremity symptoms.
Determining threshold limits for the assessment of work
relatedness of upper extremity symptoms and/or ergonomic
evaluation is also hampered by the variation in denition of
upper extremity symptoms. Upper extremity symptoms were
assessed mainly using questionnaires and in two studies using
physical examination or MRI. As self-report using question-
naires and physical examination are associated with reliability
and validity issues,37 the use of MRI may be the most reliable
and valid method. However, MRI is a very expensive diagnostic
method and its validity for the assessment of upper extremity
symptoms can be questioned. Using MRI and ultrasonographic
examination, rotator cuff tears have been found in people
without shoulder symptoms, with prevalences varying between
8 and 34%.3840 Therefore, the assessment of upper extremity
symptoms using MRI should be applied with caution.
It is not clear yet which structures of the upper extremities
should be examined in relation to the mechanical load asso-
ciated with pushing and pulling. For instance, during pushing a
cart with two hands at shoulder height it is expected that gleno-
humeral joint stability is essential. This means that during
pushing the humeral head has to be kept inside the glenoid
cavity for which rotator cuff activity is important. Another fre-
quently observed activity is walking forward while pulling a cart
behind the body with one hand. In this situation it is expected
that passive structures, such as capsules and ligaments and
Hoozemans MJM, et al. Occup Environ Med 2014;71:788795. doi:10.1136/oemed-2013-101837
Review
muscles (considering their passive characteristics) be at high-
strain levels.
Clearly, epidemiological data do indicate that pushing and
pulling are related to upper extremity symptoms but do not
suggest what exposure level is harmful and which specic upper
extremity disorders are to be expected. To arrive at evidence-
based guidelines for the prevention of work-related upper
extremity symptoms due to pushing or pulling, or forceful exer-
tions using the upper extremity in general, we recommend per-
forming prospective cohort studies with appropriate assessments
of exposure and outcome. However, in practice these studies are
time-consuming and labour intensive. Another approach would
be to specically focus on the biomechanics of the upper
extremity. We have recommended24 applying the shoulder-
moment strength mean prediction equations for exertions in the
sagittal plane published in the book of Chafn et al41 for the
evaluation of shoulder load. This is, however, a limited data set
and based on the rationale that workload should be (some-
where) below the maximal forces or moments that a certain
population can generate. Future studies should be aimed at
mapping out the mechanical load on the upper extremities
during forceful exertions in different postures, for instance
using mechanical models.4244 Net shoulder moments or gleno-
humeral joint compression forces are outcome parameters of
these models that can be used to reect overall shoulder
loading.16 45 Efforts should be undertaken to determine the
actual structures at risk, such as the rotator cuff or passive struc-
tures. However, mechanical models are not yet capable of asses-
sing the load on passive structures. Moreover, this should be
accompanied by studies aimed at determining the capacity of
those structures in mainly submaximal situations to account for
the frequency and duration effects of exposure, for instance
using in vitro experiments or energy models.46 47
793
 Review
In the present systematic review only studies aimed at pushing
and/or pulling and upper extremity symptoms were included.
Pushing and pulling have been the subject of other epidemio-
logical studies in which the upper extremity was indirectly
included, for instance in terms of musculoskeletal injuries48 or
widespread body pain.49 50 Most studies on pushing and
pulling, however, have focused on the low back. Although older
cross-sectional studies found signicant associations between
pushing and/or pulling and low back symptoms,19 more recent
studies indicated that this relationship is at least questionable24 51
and biomechanical studies showed that low back loading during
pushing or pulling is not as high as for instance in lifting
loads.1518 Still, the low back may be at risk because it is rela-
tively unstable during pushing and/or pulling and therefore vul-
nerable to unexpected perturbations.5255 Altogether,
considering that pushing and pulling are associated with muscu-
loskeletal symptoms, as well as sickness absence56 and
unemployment,57 work-related pushing and pulling should be
the subject of future epidemiological and biomechanical investi-
gations to develop evidence-based ergonomic guidelines and
preventive measures.
In conclusion, this systematic literature review provides strong
evidence that work-related pushing and/or pulling is related to
upper extremity symptoms and more specically shoulder symp-
toms. However, only a few studies have been published to date,
and further prospective cohort studies are recommended,
including valid and reliable assessment of exposure and
outcome. Only in this way can valid and reliable threshold
limits be established for the assessment of the work-relatedness
of upper extremity symptoms due to pushing and pulling.
Contributors MJMH, EBK, PPFMK were involved in conception, design, analysis
and interpretation. MHWF-D, HEJV were involved in revising the paper critically for
important intellectual content and nal approval of the version to be published.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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