Akkarakittichoke et al. 2021

The effects of active break and postural shift interventions on recovery from and recurrence of neck and low back pain

Active breaks and postural shifts reduced recovery time from neck and low back pain.

Conclusions are not generalizable due to some methodological issues.

Yet, the study’s findings are interesting for further research on this topic.


The question of whether an ideal posture exists has long been debated. From back school interventions in manual workers to posture interventions in office workers, it seems that having and maintaining an ideal posture is very important. Others don’t believe in the existence of ideal postures and recommend frequently changing sitting positions and spreading heavy work duties. Past studies showed that active breaks and postural changes promoted recovery from muscle discomfort. However, their effects have not been studied with respect to recovery and recurrence of neck and low back pain.



The authors set up a 3-arm parallel-group cluster randomized trial to evaluate the efficacy of active breaks and postural shifts in office workers at high risk for neck or lower back pain. Being at risk for neck pain was evaluated by the Neck Pain Risk Score for Office Workers (NROW) and the risk for future low back pain was examined by the Back Pain Risk Score for Office Workers (BROW).

Individuals without neck and low back pain at baseline were followed for 12 months and those with incident neck or low back pain during follow-up were included in this study. They were randomized into six clusters: two groups receiving intervention A (active breaks), two groups receiving intervention B (postural shift) and two groups receiving the placebo intervention.

The active break group received a custom-designed apparatus consisting of a seat pad, processor, and smartphone application. Data regarding sitting and break duration as well as number of postural shifts was collected and processed to recommend active breaks and postural shifts for each individual. Instructions about active breaks were sent to the participants’ smartphone during the workday. Instructions regarding postural shifts were sent from the processor to the seat pad and were induced by the apparatus gradually pumping air into various parts of the seat pad placed underneath a participant’s buttocks. In the control group, a placebo seat pad was used.



193 office workers were included in the trial and 174 were followed for 12 months.

Neck and low back pain recovery

Recovery from neck and low back pain took a median time of 2 months (range 1-8 months). At 1 month, 2 months and 8 months respectively, 43%, 68%, and 93% had recovered from their complaints. A significant difference in recovery duration between the active break and control group was observed and the same was true when comparing the postural shift with the control group. Participants in the active break and postural shift groups recovered from their neck and low back pain after approximately one month, where participants in the control group needed 2 months to recover. The authors also found that individuals with higher baseline pain levels had longer recovery time.


recovery from neck pain
From: Akkarakittichoke et al. 2021


Neck and low back pain recurrence

Over the 12-month follow-up respectively 21%, 18%, and 44% of participants in the active break group, postural shift group and control group reported neck and low back pain recurrence. The control group had greater risk of recurrence than the active break and postural shift groups. Interestingly, in the control groups recurrence occurred faster than in the active break and postural shift groups, as can be seen in the figure below.

neck pain recurrence
From: Akkarakittichoke et al. 2021


Questions and thoughts

So let’s start with some questions. Do these results show that frequently changing positions can help in recovery of neck and low back pain or influence the recurrence of these complaints? It appears so at least. According to the results, active breaks and frequently shifting positions help to recover faster and lead to less recurrence.

However, a group of office workers was selected from six organisations including governmental and private companies. Despite the fact that the workers were randomly allocated to the study groups, the fact that the authors used convenience sampling to recruit office workers makes it difficult to draw statistical conclusions from the obtained findings. Convenience sampling is a technique that can be used to pilot studies, from where the conclusions can be tested in more rigorous designs. Selection bias can be introduced by this form of sampling as more interested individuals are more likely to participate in the study than those who are not interested or those who are not willing to invest time. Therefore, the sampling technique used in this study prevents drawing firm conclusions.


Talk nerdy to me

Let’s start with some good aspects of this study. The trial was prospectively registered and a deviation to the submitted protocol was mentioned. Participants were randomized and results were analysed with an intention-to-treat analysis. It was asked to keep leisure time physical activity unchanged, but this variable was not controlled for. The authors took into account 45 possible covariates (although they were not specified) in the multivariate analysis. Participants allocated to the same intervention were clustered into the same offices. This can be seen as a good aspect – as no contamination of the interventions can occur. On the other hand, as people are clustered together, they can be more easily influenced by other’s experiences.

Some limitations include that due to COVID-19 a large proportion of participants had to work from home and not all of them took the seat pad to their home offices. There was an attempt to overcome this by introducing home work as a confounder. But no information on what percentage continued their intervention from home was available so here we are groping in the dark. The same is true for the daily occupational sitting time that was not monitored and the lack of information regarding compliance of the participants to their allocated intervention.

On the following variables, participants among the three groups differed at baseline: age, BMI, education level, duration of employment, physical job demand, social support, number of working hours, and job security. This may have played an important role in the analysis and it was not further specified whether this was controlled for.

Another important limitation is the fact that this study recruited office workers at risk for neck and low back pain, so the results may not be generalizable to all office workers. Important to note is how they defined office workers’ risk for neck or low back pain. The use of the NROW and BROW questionnaires imply that the risk was assessed based on a subjective measure. Furthermore, with a specificity of 48% and positive predictive value of 29% (NROW) and specificity of 68% and positive predictive value of 16% (BROW), it seems that these questionnaires were unable to define which office workers were at risk for these symptoms. Last but not least, in the assessment of the recovery rate, unequal follow-up durations may have affected the conclusions of the authors.


Take home messages

Active breaks from work and regularly shifting in sitting positions seem promosing in the recovery and recurrence of neck and low back pain in office workers. Although the authors claim the benefits of the interventions, results should be interpreted cautiously as several methodological issues could have influenced the findings. However, since active breaks and postural shifts require little extra effort, they can be a promising strategy for interrupting a long workday. Therefore, despite the cautious interpretation of this study’s results, we would still recommend taking regular active breaks, given that this extra physical activity can be beneficial on more than just neck and back pain.



Akkarakittichoke, N., Waongenngarm, P., & Janwantanakul, P. (2021). The effects of active break and postural shift interventions on recovery from and recurrence of neck and low back pain in office workers: A 3-arm cluster-randomized controlled trial. Musculoskeletal Science and Practice56, 102451.


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