Open Access Research article

Musculoskeletal pain and effort-reward imbalance- a systematic review

Peter Koch1*, Anja Schablon1, Ute Latza2 and Albert Nienhaus13

Author Affiliations

1 Centre of Excellence for Epidemiology and Health Services Research for Healthcare Professionals (CVcare), University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg 20246, Germany

2 Unit Prevention of Work-Related Disorders, Division Work and Health, Federal Institute for Occupational Safety and Health, Nöldnerstraße 40, Berlin 10317, Germany

3 Health Protection Division (FBG), Institution for Statutory Accident Insurance and Prevention in the Health and Welfare Services (BGW), Pappelallee 33, Hamburg 22089, Germany

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BMC Public Health 2014, 14:37  doi:10.1186/1471-2458-14-37

Published: 15 January 2014



Musculoskeletal pain may be triggered by physical strains and psychosocial risk factors. The effort-reward imbalance model (ERI model) is a stress model which measures psychosocial factors in the working world. The question is whether workers with an effort-reward imbalance report musculoskeletal pain more frequently than those with no effort-reward imbalance. A systematic review using a best evidence synthesis approach was conducted to answer this question.


A literature search was conducted for the period from 1996 to 2012, using three databases (Pubmed, Embase and PsycINFO). The research criteria related to psychosocial, work-related stress as per the ERI model and to musculoskeletal pain. A quality score was developed using various quality criteria to assess the standard of the studies. The level of evidence was graded as in (Am J Ind Med 39:180–193, 2001).


After applying the inclusion criteria, a total of 19 studies were included in the review: 15 cross-sectional studies, three prospective studies and one case–control study. 74% of all studies exhibited good methodological quality, 53% collected data using the original ERI questionnaire, and in 42% of the studies, there was adequate control for physical working conditions. Furthermore, different cut-off points were used to classify exposed and non-exposed individuals. On the basis of 13 studies with a positive, statistically significant association, a moderate level of evidence was inferred for the association between effort-reward imbalance and musculoskeletal pain. The evidence for a role of over-commitment and for its interaction with effort-reward imbalance was rated as inconclusive - on the basis of eight and five studies, respectively.


On the basis of the available evidence, no reliable conclusion may be drawn about any association between the psychosocial factors ascertained using the ERI model and musculoskeletal pain. Before a reliable statement can be made on the association between ERI and musculoskeletal pain, additional longitudinal studies must be performed - with a standardised method for recording and classifying exposure, as well as control of physical confounders. Appropriate preventive measures can then be specified.

Effort-reward imbalance; Musculoskeletal pain; Psychosocial work stress; Review