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Are pushing and pulling work-related risk factors for upper extremity symptoms? A systematic review of observational studies
  1. M J M Hoozemans1,2,
  2. E B Knelange1,
  3. M H W Frings-Dresen3,
  4. H E J Veeger1,4,
  5. P P F M Kuijer3
  1. 1MOVE Research Institute, Faculty of Human Movement Sciences, VU University Amsterdam, Amsterdam, The Netherlands
  2. 2CORAL – Centre for Orthopaedic Research Alkmaar, Orthopaedic Outpatient Department, Medical Centre Alkmaar, Alkmaar, The Netherlands
  3. 3Coronel Institute of Occupational Health/Netherlands Center for Occupational Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
  4. 4Faculty of Mechanical, Material and Marine Engineering, Department of Biomechatronics and Biorobotics, Delft University of Technology, Amsterdam, The Netherlands.
  1. 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{at}


Systematically review observational studies concerning the question whether workers that perform pushing/pulling activities have an increased risk for upper extremity symptoms as compared to workers that 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 draw conclusions in terms of strong, moderate or conflicting/insufficient 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 significant 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, significant 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, specifically for shoulder symptoms. There is insufficient or conflicting evidence that pushing/pulling is related to (combinations of) upper arm, elbow, forearm, wrist or hand symptoms.

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