Work-related musculoskeletal disorders (WMSDs) are among the most prevalent occupational health conditions worldwide and remain a major cause of disability, reduced productivity, and economic burden [1]-[3]. From a human factors and ergonomics perspective, WMSDs arise from the interaction between physical, organizational, and psychosocial work demands rather than from a single exposure [1][4]-[6]. Physical risk factors include repetitive movements, awkward or sustained postures, excessive mechanical loading, prolonged static work, and suboptimal workplace design [1][7][8], while psychosocial stressors such as high job demands, low job control, emotional strain, and limited workplace support may contribute to symptom development, persistence, and disability [5][6]. Globally, musculoskeletal disorders account for a substantial proportion of disability and occupational productivity loss, with low-back pain representing a leading contributor to years lived with disability worldwide [9]-[12].

Educators represent a particularly vulnerable occupational group. Preschool educators are frequently exposed to child lifting and carrying, repetitive bending, prolonged kneeling or squatting, and work at child-height furniture [13]-[16]. School teachers may experience prolonged standing, repetitive writing and typing, sustained computer use, and other occupational ergonomic demands [17]-[20]. Consequently, reported 12-month prevalence rates of WMSDs among educators are high, with the lower back, neck, and shoulders among the most commonly affected regions [13][17]-[20]. These disorders are associated with reduced work ability, absenteeism, and impaired job performance [21].

The development of WMSDs among educators is influenced by both biomechanical and psychosocial factors. Physical exposures include repetitive tasks, awkward or sustained postures, physically demanding caregiving activities, and suboptimal workplace ergonomics [7][8][13]-[16], whereas psychosocial stressors such as workload, emotional demands, burnout, and limited workplace support may amplify fatigue, perceived strain, and delayed recovery [5][6][22]-[24]. Longitudinal evidence further suggests that physical and psychosocial work factors may operate concurrently in shaping subsequent musculoskeletal risk [5][6].

To address these risks, workplace interventions have generally focused on three domains. Ergonomic interventions target workplace design, task modification, equipment adaptation, and participatory problem-solving [7][16][25][26]. Physical or exercise-based interventions aim to improve strength, mobility, physical capacity, and symptom management [27]-[30]. Psychosocial interventions include mindfulness, stress-management, organizational support, and cognitive-behavioral approaches [22][24][31][32].

Despite growing research activity, the evidence remains fragmented. Most studies evaluate single-domain interventions and rarely examine whether broader, multidomain approaches produce wider benefits across musculoskeletal, psychosocial, and organizational outcomes. Furthermore, no education-specific framework currently integrates ergonomic, physical, and psychosocial intervention domains within a unified model.

Therefore, this systematic review aimed to: 1) synthesize evidence on the prevalence and risk factors of WMSDs among preschool and school educators; 2) map workplace-based ergonomic, physical, psychosocial, and integrated interventions; and 3) examine patterns of outcome breadth across intervention domains. Due to substantial heterogeneity in interventions and outcome measures, a narrative synthesis was conducted. Findings were subsequently used to develop the Education-Oriented Tri-Domain Intervention Model (ETDIM), a synthesis-based framework intended to guide future intervention design and occupational health strategies in educational settings.

This systematic review synthesized workplace-based interventions addressing work-related musculoskeletal disorders (WMSDs) among preschool and school educators across ergonomic, physical/exercise-based, psychosocial, and multicomponent domains. The findings indicate that the current intervention literature remains dominated by single-domain and dual-domain approaches. Although multicomponent interventions generally demonstrated broader outcome profiles than single-domain programs, none of the included studies integrated ergonomic, physical, and psychosocial components within a single workplace-based intervention. This represents an important gap in the occupational health literature and highlights the limited translation of the multidimensional etiology of WMSDs into comprehensive intervention design.

Whydosingle-anddual-domaininterventionsdominate?

The predominance of single-domain interventions likely reflects practical and organizational constraints rather than a lack of recognition of WMSD complexity. Educational workplaces are characterized by limited resources, demanding schedules, and limited opportunities for the delivery of multidisciplinary interventions. Consequently, psychosocial interventions are typically delivered as standalone mindfulness- or stress-management programs [57][58]; ergonomic interventions often focus on task redesign or posture education; physical interventions emphasize exercise and movement programs, and ergonomic interventions often focus on task redesign or posture education [54][55][59][60].

In addition, intervention research in this field remains largely discipline-specific. Occupational health and human factors researchers, physical interventions by physiotherapists or exercise scientists [27][51][61], and psychosocial interventions by psychologists commonly lead ergonomic interventions. This disciplinary separation may contribute to intervention designs that address isolated risk pathways rather than the interacting physical, ergonomic, and psychosocial factors known to contribute to WMSDs. The greater methodological complexity associated with evaluating integrated interventions may further explain the scarcity of comprehensive workplace programs [40].

TowardanIntegratedInterventionFramework

The findings reveal a clear mismatch between the multidimensional causes of WMSDs and the predominantly single-domain strategies used to address them. While biomechanical exposures, physical capacity, and psychosocial demands are known to interact within educational work environments, current interventions generally target only a subset of these factors. As a result, opportunities to address multiple risk pathways simultaneously may be missed.

Importantly, no identified study deliberately combined ergonomic, physical, and psychosocial components within a unified intervention framework specifically designed for educators. Existing interventions either focused on a single domain or combined only two domains. This gap provided the rationale for developing the Education-Oriented Tri-Domain Intervention Model (ETDIM) [1][5][6].

TheEducation-OrientedTri-DomainInterventionModel(ETDIM)

ETDIM is proposed as a synthesis-based conceptual framework designed to align intervention strategies with the multidimensional nature of WMSDs among educators. Rather than serving as a prescriptive treatment protocol, the model provides an organizing structure that integrates three complementary domains: ergonomic modification, workplace-based physical activity, and psychosocial support.

The model was derived inductively from the patterns identified in this review. Single-domain interventions were generally associated with narrower outcome profiles, whereas dual-domain approaches demonstrated broader effects but still failed to address the full range of factors associated with educator health and work participation. ETDIM therefore offers a framework for designing future interventions that address multiple interacting exposure pathways within the same workplace environment.

Beyond its conceptual contribution, ETDIM has practical implications for intervention planning and evaluation. The framework encourages researchers and practitioners to assess musculoskeletal, psychosocial, and work-related outcomes concurrently and to consider intervention implementation as a coordinated system-level process rather than a collection of isolated activities. In doing so, ETDIM may support the development of more sustainable and context-sensitive occupational health strategies for educational settings.

ClinicalandOrganizationalImplications

From a clinical perspective, the findings support a multidimensional approach to WMSD prevention and management that extends beyond pain reduction alone. Assessment of functional capacity, work participation, psychosocial well-being, and recovery trajectories may provide a more comprehensive understanding of intervention effectiveness.

From an organizational perspective, sustainable improvements are unlikely to be achieved through individual-level interventions alone. Leadership support, workload management, participatory implementation processes, and organizational commitment are likely to play important roles in determining intervention success. ETDIM therefore highlights the need to align clinical and workplace-level strategies when addressing educator musculoskeletal health [60][61].

Several limitations should be considered when interpreting the findings of this review. Substantial heterogeneity in study designs, intervention components, outcome measures, and follow-up periods precluded quantitative meta-analysis and limited di-rect comparisons across intervention domains. Classification of interventions was based on the programme content reported in the included studies and may therefore have been affected by incomplete or insufficiently detailed reporting. In addition, most studies assessed short- to medium-term outcomes, limiting conclusions regarding the long-term sustainability of intervention effects. Restricting inclusion to Eng-lish-language, peer-reviewed publications may also have resulted in the omission of relevant evidence.

Although the intervention-classification framework was predefined and applied con-sistently, several interventions contained overlapping components, requiring a degree of judgement when assigning them to specific domains. Despite these limitations, consistent patterns were observed across the included studies, particularly the pre-dominance of single-domain and dual-domain interventions. Moreover, based on the predefined classification framework and the intervention components reported by the included studies, no workplace intervention was identified that deliberately integrated ergonomic, physical, and psychosocial components within a single programme.

Future research should prioritize the development and evaluation of workplace interventions that deliberately integrate ergonomic, physical, and psychosocial components within a single intervention framework. Future studies should concurrently evaluate musculoskeletal, psychosocial, functional, and work-related outcomes while incorporating longer follow-up periods to determine sustainability. Cluster-randomized and implementation-focused study designs may be particularly valuable for evaluating both effectiveness and real-world feasibility in educational settings. Such research will be essential for evaluating the proposed ETDIM framework and determining whether integrated tri-domain interventions provide broader and more sustainable benefits than the single-domain and dual-domain approaches that currently dominate the literature.

Workplace interventions targeting WMSDs among educators remain predominantly single-domain or dual-domain despite the multidimensional nature of occupational musculoskeletal risk. The proposed Education-Oriented Tri-Domain Intervention Model (ETDIM) provides a conceptual framework for developing and evaluating integrated workplace interventions that simultaneously address ergonomic, physical, and psychosocial determinants of educator health.

The authors thank all investigators whose published studies contributed to this systematic review.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

No new datasets were generated or analysed during this study. All data supporting the findings of this systematic review are available within the article and its Supplementary Materials.

Ethical approval was not required because this study is a systematic review of previously published studies.

This supplementary file presents the full search strategy used to identify studies examining work-related musculoskeletal disorders (WMSDs), ergonomic risk factors, and workplace-based interventions among preschool and school educators.

Databases searched: PubMed/MEDLINE, Scopus, Web of Science, and ProQuest.

Search date: 5 December 2025.

Search period: From database inception to 5 December 2025.

Language restriction: English.

Publication type restriction: Peer-reviewed journal articles.

Core search concepts:

1) Educators and educational workers

2) Work-related musculoskeletal disorders and musculoskeletal pain

3) Ergonomics, occupational health, workplace risk factors, and interventions

PubMed/MEDLINE

((“teacher*”[Title/Abstract] OR “school teacher*”[Title/Abstract] OR “preschool teacher*”[Title/Abstract] OR “kindergarten teacher*”[Title/Abstract] OR “educator*”[Title/Abstract] OR “teaching assistant*”[Title/Abstract] OR “childcare worker*”[Title/Abstract] OR “child care worker*”[Title/Abstract] OR “nursery teacher*”[Title/Abstract] OR “early childhood educator*”[Title/Abstract] OR “early childhood teacher*”[Title/Abstract] OR “school staff”[Title/Abstract]))

AND

((“musculoskeletal disorder*”[Title/Abstract] OR “work-related musculoskeletal disorder*”[Title/Abstract] OR “work related musculoskeletal disorder*”[Title/Abstract] OR WMSD[Title/Abstract] OR WMSDs[Title/Abstract] OR MSD[Title/Abstract] OR MSDs[Title/Abstract] OR “musculoskeletal symptom*”[Title/Abstract] OR “musculoskeletal pain”[Title/Abstract] OR “musculoskeletal complaint*”[Title/Abstract] OR “low back pain”[Title/Abstract] OR “back pain”[Title/Abstract] OR “neck pain”[Title/Abstract] OR “shoulder pain”[Title/Abstract] OR “upper limb pain”[Title/Abstract] OR “lower limb pain”[Title/Abstract]))

AND

((“ergonomic*”[Title/Abstract] OR “occupational health”[Title/Abstract] OR “occupational safety”[Title/Abstract] OR “workplace”[Title/Abstract] OR “work environment”[Title/Abstract] OR “risk factor*”[Title/Abstract] OR “physical demand*”[Title/Abstract] OR “psychosocial factor*”[Title/Abstract] OR “workload”[Title/Abstract] OR “job demand*”[Title/Abstract] OR “intervention*”[Title/Abstract] OR “prevention”[Title/Abstract] OR “workplace intervention*”[Title/Abstract] OR “participatory ergonomics”[Title/Abstract] OR “exercise”[Title/Abstract] OR “physical activity”[Title/Abstract] OR “physiotherapy”[Title/Abstract] OR “stretching”[Title/Abstract] OR “strengthening”[Title/Abstract] OR “mindfulness”[Title/Abstract] OR “stress management”[Title/Abstract] OR “cognitive behavioral”[Title/Abstract]))

Filters applied: English.

Scopus

TITLE-ABS-KEY (teacher* OR “school teacher*” OR “preschool teacher*” OR “kindergarten teacher*” OR educator* OR “teaching assistant*” OR “childcare worker*” OR “child care worker*” OR “nursery teacher*” OR “early childhood educator*” OR “early childhood teacher*” OR “school staff”)

AND

TITLE-ABS-KEY

(“musculoskeletal disorder*” OR “work-related musculoskeletal disorder*” OR “work related musculoskeletal disorder*” OR WMSD OR WMSDs OR MSD OR MSDs OR “musculoskeletal symptom*” OR “musculoskeletal pain” OR “musculoskeletal complaint*” OR “low back pain” OR “back pain” OR “neck pain” OR “shoulder pain” OR “upper limb pain” OR “lower limb pain”)

AND

TITLE-ABS-KEY

(ergonomic* OR “occupational health” OR “occupational safety” OR workplace OR “work environment” OR “risk factor*” OR “physical demand*” OR “psychosocial factor*” OR workload OR “job demand*” OR intervention* OR prevention OR “workplace intervention*” OR “participatory ergonomics” OR exercise OR “physical activity” OR physiotherapy OR stretching OR strengthening OR mindfulness OR “stress management” OR “cognitive behavioral”)

AND (LIMIT-TO (LANGUAGE, “English”))

Web of Science

TS = (teacher* OR “school teacher*” OR “preschool teacher*” OR “kindergarten teacher*” OR educator* OR “teaching assistant*” OR “childcare worker*” OR “child care worker*” OR “nursery teacher*” OR “early childhood educator*” OR “early childhood teacher*” OR “school staff”)

AND

TS = (“musculoskeletal disorder*” OR “work-related musculoskeletal disorder*” OR “work related musculoskeletal disorder*” OR WMSD OR WMSDs OR MSD OR MSDs OR “musculoskeletal symptom*” OR “musculoskeletal pain” OR “musculoskeletal complaint*” OR “low back pain” OR “back pain” OR “neck pain” OR “shoulder pain” OR “upper limb pain” OR “lower limb pain”)

AND

TS = (ergonomic* OR “occupational health” OR “occupational safety” OR workplace OR “work environment” OR “risk factor*” OR “physical demand*” OR “psychosocial factor*” OR workload OR “job demand*” OR intervention* OR prevention OR “workplace intervention*” OR “participatory ergonomics” OR exercise OR “physical activity” OR physiotherapy OR stretching OR strengthening OR mindfulness OR “stress management” OR “cognitive behavioral”)

Refined by: Language = English.

ProQuest

AB, TI(teacher* OR “school teacher*” OR “preschool teacher*” OR “kindergarten teacher*” OR educator* OR “teaching assistant*” OR “childcare worker*” OR “child care worker*” OR “nursery teacher*” OR “early childhood educator*” OR “early childhood teacher*” OR “school staff”)

AND

AB,TI(“musculoskeletal disorder*” OR “work-related musculoskeletal disorder*” OR “work related musculoskeletal disorder*” OR WMSD OR WMSDs OR MSD OR MSDs OR “musculoskeletal symptom*” OR “musculoskeletal pain” OR “musculoskeletal complaint*” OR “low back pain” OR “back pain” OR “neck pain” OR “shoulder pain” OR “upper limb pain” OR “lower limb pain”)

AND

AB,TI(ergonomic* OR “occupational health” OR “occupational safety” OR workplace OR “work environment” OR “risk factor*” OR “physical demand*” OR “psychosocial factor*” OR workload OR “job demand*” OR intervention* OR prevention OR “workplace intervention*” OR “participatory ergonomics” OR exercise OR “physical activity” OR physiotherapy OR stretching OR strengthening OR mindfulness OR “stress management” OR “cognitive behavioral”)

Limits applied: English; peer-reviewed journals.

Additional Search Procedures

Reference lists of all included articles and relevant review papers were manually screened to identify additional eligible studies. Journal websites and citation tracking were also checked when potentially relevant studies were identified but not retrieved through database searching. Duplicate records were removed before title and abstract screening. Titles and abstracts were screened first, followed by full-text assessment according to the predefined eligibility criteria.

Table S1. Methodological quality assessment of included studies using joanna briggs institute (jbi) critical appraisal tools.

PRISMA2020Checklist

Title:DoIntegratedInterventionsAchieveBroaderOutcomes? ASystematicReviewofWork-RelatedMusculoskeletalDisorderInterventionsinEducatorsandtheETDIMFramework.