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# Changing the way we work: elevating energy expenditure with workstation alternatives

## Introduction

In 2007, Hamilton et al.1 presented compelling evidence that sedentary behaviors, such as those ubiquitous to contemporary workplaces,2 may be contributing to the current obesity epidemic and corollary chronic diseases, including cardiovascular disease and Type 2 diabetes. For example, Hu et al.3 estimated that each 2-hour increase in occupational sitting time was associated with a 5–7% increase in risk for obesity and Type 2 diabetes. Over the past 50 years in the US, there has been a shift toward occupations that are largely composed of desk-based sedentary behavior and this trend has been associated with population-level weight gain.4 The direct5 and indirect (non-medical)6 costs of obesity are high; for employers these indirect costs include absenteeism and disability6 and reduced productivity associated with presenteeism.7

The prevailing ergonomic paradigm has advocated office furniture and environmental design in favor of continually reducing physical workloads, and thus energy expenditure (EE).8 Recent research, however, has reported the feasibility of replacing work-related sedentary behavior with low-intensity non-exercise physical activity (PA) via workstation alternatives to the traditional seated office chair and desktop computer-based combinations.9, 10, 11 These office environmental countermeasures to stoic occupational sedentarism are intended to generate an innocuous additional EE that is: elevated above that associated with sitting, tolerable for extended durations and minimally distracting from the primary work task. As such, workstation alternatives can be contrasted with conventional worksite wellness initiatives, including worksite fitness facilities and/or structured exercise programs12, 13 that focus on participation in structured and typically higher intensity activities scheduled during non-working time. The novelty of workstation alternatives is characterized by large gaps in scientific understanding that present great research opportunities. The purpose of this review article is to introduce a simple taxonomy to facilitate classification and study of workstation alternatives, catalog the diversity of research undertaken to date as it relates to energy balance-related questions and summarize the research gaps and opportunities. As our primary focus will be related to energy balance, we organize the presentation by answering the following questions about workstation alternatives: (1) Will they increase EE? And if so, by how much? (2) Will they interfere with work? (3) Will workers use them? And how long will they use them? (4) Are interventions designed around workstation alternatives successful?

## Materials and Methods

A PubMed search was updated on November 04/2013 using the following Boolean phrase: (workstation OR desk) AND (sitting OR standing OR sit–stand OR walking OR stepping OR pedaling OR cycling OR treadmill OR bicycle OR ball). Additional filters pinpointed articles published in English since 2000 (the year that Levine et al.14 published a seminal article titled ‘Energy expenditure of non-exercise activity’) and involving human adults of typical full-time working age 19–64 years. Fifty-seven articles were identified. Titles and abstracts were reviewed and selection criteria required that the research focus on simulated or actual work-related tasks (for example, computer-based tasks, reading, and so on) while using the workstation alternative, or otherwise be intended for use in the workplace. Additional research was located by examining reference sections of previously identified articles, corresponding with authors and extending the publication date to earlier years (for example, 198915) as needed. Ultimately, we identified nine controlled studies of EE (5 with comparable data presented in Figure 1), 14 studies focused on task performance (Table 2) and 8 intervention studies focused on sit–stand desks (Table 3; 4 studies), treadmill desks (Table 4; 4 studies) and 2 multi-component studies (that also utilized one or two types of active workstations) directly relevant to our energy balance-related questions listed above. Twenty-five studies that provide insight into acceptability of workstation alternatives are presented in the text below. There is overlap between topics; some studies provide evidence related to more than one of the energy balance-related questions guiding this review.

### Will workstation alternatives increase energy expenditure? And by how much?

A number of controlled studies have quantified objectively determined EE values associated with traditional seated working and various workstation alternatives.10, 16, 17, 18, 19, 20, 21, 22 Studies of working seated in an office chair, seated on a stability ball, standing, seated pedaling and walking on a treadmill that could also be compared by mean kcal min−1 are depicted in Figure 1. Two studies are conspicuously absent.16, 22 Beers et al.16 presented results (for resting, sitting in an office chair, sitting on a stability ball and standing) graphically only, making it difficult to extract exact EE data. Cox et al.22 studied different speaking conditions while seated, standing and walking on a treadmill at 1.6 km h−1 and reported mean oxygen consumption values (ml kg−1 min−1), but not expressly EE (dependent upon an individual’s body mass).

Overall, there appears to be little variation in EE associated with working while sitting in an office chair, sitting on a stability ball, or even standing (together averaging 1.2 kcal min−1, but ranging from 0.99 to 1.46 kcal min−1, both extremes measured in a traditional seated working condition), which suggests these particular workstation alternatives would have little impact on reducing body weight relative to the traditional seated condition. To be clear, differences in EE between seated work and either sitting on a stability ball or standing work are less than what can be described as even modest. Although reported as statistically significant, Beers et al.16 calculated the difference to be no more than 4.1 kcal h−1. Considering an 8-hour work day and relative to seated work, the increment in EE from these two types of workstation alternatives only net an extra 32 kcal day−1. Based on the simplistic guidelines that a pound of fat is approximately equivalent to 3500 kcals,23 this difference indicates that over 100 full-time working days sitting on a stability ball or standing at a desk must be endured to reduce body fat by one pound! Although it is possible that a standing individual may be more inclined to accumulate random movement patterns (fidgeting,14 weight shifting associated with postural sway,24 incidental steps25) than one confined to a chair, the direct evidence suggests that it is unlikely that sit–stand/standing workstation alternatives could effectively counteract positive energy balances associated with traditional sedentary workstations in an any meaningful way. The data summarized in Figure 1 indicate that efforts to decrease sitting behavior only by replacing it with standing behavior appear to promise only a negligible difference in EE. That is not to say that their use may be associated with other potential health benefits of decreased sitting behaviors.1 For example, heart rate is significantly elevated in the standing working position vs the seated working position, suggesting enhanced blood flow.16, 26 Regardless, herein we shall remain focused on questions related to energy balance.

In contrast to sit–stand/standing desks, treadmill desks appear to present a greater potential impact for altering EE above that associated with conventional seated workstations. Heart rate responses to using a treadmill desk at 1.6 and 3.2 km h−1 are elevated in a graded manner relative to the seated working condition.27 Levine and Miller18 reported that the EE of working while walking on a treadmill at a self-selected pace of 1.77 km h−1 was 3.2 kcal min−1 (Figure 1). Although there is no directly measured corroborating evidence at this time, this increment represents a 2.7-fold increase over the EE expected of seated work (assuming this average is 1.2 kcal min−1 based on Figure 1). Treadmill workstations could theoretically increase an individual’s EE over the seated condition by >100 kcal h−1 (depending upon body mass),18 which could have more dramatic impacts on energy balance, for example, by potentially >800 kcal day−1 if workers could realistically tolerate it for a full 8-hour workday. Still, even a single hour of daily use represents a quotidian EE increment that has been posited to prevent weight gain.28 Thompson et al.29 used an accelerometer to indirectly estimate that physicians burned an additional 197 kcal day−1 walking and working an average 90 min day−1 at 1.6 km h−1 on the treadmill desk. Select user groups29 may average up to 90 min day−1 and up to more than 100 min day−1 in longer-term users.30 Other office-based workers more frequently average only 30 min day−1 of use, even with individually dedicated treadmill desks.9 Although these authors suggested that this was equivalent to an estimated 100 kcal day−1 increase in EE over a traditional seated working condition, the prior objectively monitored evidence indicates that this is likely closer to a 50 kcal day−1 increase.18

Although passive pedaling using chair/bedside devices is routinely used in physical therapy,31 there are only two studies10, 32 that have investigated the EE associated with a pedaling/stepping device. Office work was not performed concurrently while using the stepping device in the study conducted by McAlpine et al.,10 however, so it is not included in Figure 1. Regardless, the researchers in that study reported relatively large increases in EE (4.81 kcal min−1 over sitting) in participants ranging in size from lean to obese. Carr et al.32 measured EE to be 2.14 kcal min−1 while working at a pedal desk and pedaling at a cadence of 45 r.p.m. (estimated 2.25 km h−1) and a reported effort of 9 watts. This pace was set by the researchers so the EE of self-selected pedaling while working at a pedal desk remains unknown.

There may be a potential to realize increased EE with a pedal desk, again depending whether or not the activity could be tolerated for long durations while working. Peterman et al.21 also reported elevated EEs over seated rest with motor-driven passive pedaling (participants supplied no volitional muscle activation, rather their feet were ‘pulled’ around the cog) at both 60 r.p.m. (1.78 kcal min−1) and 90 r.p.m. (2.51 kcal min−1), but again office work was not concurrently performed. Although not a direct measure of EE, Straker et al.27 studied heart rate responses to different workstation alternatives, including pedaling at 5 and 30 watts. The slower pedaling condition elicited a similar heart rate increase over a seated working condition as a standing workstation, and the faster pedaling condition was similar to the faster walking condition (3.2 km h−1). Carr et al.32 also reported that heart rate, systolic blood pressure, oxygen consumption and leg muscle activation all increased significantly while using a pedal desk vs a seated working condition.

As evidence indicates that active workstations present the greatest opportunity for impacting workers’ energy balance, they occupy the focus of the remainder of this discourse. Other types of workstation alternatives are referred to primarily as comparative examples to place findings of active workstations in a broader context.

### Will workstation alternatives interfere with work?

While using an active workstation may decrease prolonged sedentary behavior and elevate EE typically associated with traditional seated workstations, it is not entirely clear how its use will affect performance on work tasks and ultimately productivity. Real or perceived conflicts between productivity and energy balance priorities will inevitably undermine or at least restrict the implementation of workstation alternatives in the workforce, and thus the opportunity to alter workers’ EE.

Using an active workstation is an example of a dual task performance:33 walking, pedaling or stepping while performing other tasks such as reading, thinking, speaking, typing or texting. Studies of ambulatory behavior demonstrate that gait, for example, is not an automatic process and requires considerable information processing, which may in turn reduce performance on a secondary task depending on the complexity of that task and the age of the person.34 The concern is that a worker using a treadmill desk may need to divide attentional resources between walking safely on a treadmill and performing office work, ultimately compromising productivity. There is even less understanding about how a non-weight-bearing pedaling action with a more stabilized upper body and no threat of tripping/falling may or may not affect productivity.

Productivity generally refers to both the quality of output (for example, final product) produced and the rate at which it is produced, all relative to worker input (taking into consideration time, technology and other resources, education level, managerial techniques, and so on). Measuring productivity in the workforce, especially in the service sector typified by office-based occupations, is a well-known challenge.35 Considerable heterogeneity exists within and between industries, workplaces, and even workers with similar job titles and responsibilities. It is not surprising therefore that the majority of published studies of workstation alternatives have focused primarily on controlled study of simulated task performance (for example, typing, mouse pointing and clicking, reading, math problems, speaking, and so on), which is more easily standardized and measureable (Table 2). Studies that have reported workers’ perceptions of the impact on productivity are presented later, along with other perceptions of acceptability.

Sample sizes for studies evaluating performance while using workstation alternatives have generally been small and participants are typically novices in terms of their previous exposure to working while using workstation alternatives. Assessed tasks are diverse, as are use parameters (for example, walking speed). Little is known about how continued use and practice affects performance, whether users eventually adapt to workstation alternatives, what factors may affect this process, and/or how long it may take.

### Will workers use workstation alternatives? How long will they use them?

An acceptable workstation alternative can generally be described as one that is perceived as tolerable by the worker (not being unduly burdensome, inconvenient, inaccessible or uncomfortable) and innocuous (non-distracting from the task at hand, not tiring). Assessment of acceptability is frequently a part of formative evaluation before larger scale study or implementation.41 There is no standardized approach to the measurement of acceptability and researchers frequently report exploratory findings derived from their own constructed and delivered questionnaires, interviews and/or focus groups. For example, Thompson et al.9 reported acceptability results and provided the questions they constructed based on a Likert scale. In general, reported study findings may reflect study-specific instrument design; if there are no questions solicited about negative perceptions, then none are captured. Confronted with no easy way to summarize these diverse findings, we only offer here a brief summary of those reported for the different types of workstation alternatives.

The few studies that have been conducted comparing sitting on an office chair with sitting on a stability ball have generally reported that sitting on a ball was associated with increased discomfort.42, 43, 44 An exception is the study by Beers et al.16 that reported no difference in sensations of comfort or of ‘liking’ between the two seated conditions.

Both users (workers) and purchasers (employers) have been generally positive about the introduction of sit–stand desks into workplaces.45 Study participants have reported that sit–stand/standing workstation alternatives were easy to use,46 enjoyable,46 comfortable,46, 47 did not negatively affect productivity9, 47 or were perceived as having improved productivity by at least some of the workers sampled,46 and improved perceptions of energy,47 health,47 happiness47 and stress.47 Open-ended comments solicited by Pronk et al.47 at the end of a sit–stand desk intervention included perceptions of less low back pain and shoulder tension, posture improvement, decreased wrist and elbow pain and increased comfort. Others have also noted perceived benefits for good posture and potential for reduced musculoskeletal soreness associated with all-day sitting.26 There is some evidence that a sit–stand desk may be preferred to the traditional seated workstation.27, 46 In particular, Alkhajah et al.46 reported that 83% of the workers engaged in their study of sit–stand desks indicated that they disagreed or strongly disagreed with a statement indicating that they would prefer to return to their original workstation set-up. The ability to alternate freely between sitting and standing postures, rather than being confined to either posture, is associated with the reduced discomfort and increased preference.48 On the negative side, there have been reports that it is less comfortable than traditional seated work,16, 26, 36 less comfortable and less ‘likable’ than working while sitting on a stability ball,16 more fatiguing,16 hands and wrists are insufficiently supported,46 there is insufficient room to navigate a mouse,46 there is leg discomfort,27 and the need to change footwear to comfortably use the sit–stand desk is a burden.46 Alkhajah et al.46 also reported that some workers experiencing the sit–stand desk perceived that it reduced their productivity.

Edelson and Danoff15 reported that typists felt less stressed while working on a treadmill desk vs a traditional seated condition, but otherwise there were no statistical differences in perceived arousal or body complaints. Positive user perceptions have also included the ability to ‘break up the day,’ and that use ‘may help creativity.’27 Thompson et al.9 reported that workers believed treadmill desks were not too noisy, did not negatively affect productivity and did not induce undue fatigue. The authors reported that a question regarding fatigue at the end of the day generated the greatest disagreement among participants; some felt less tired while an equal number felt more tired. They also reported that participants with back pain indicated that it was improved while using the treadmill desk. Straker et al.27 reported that some study participants perceived decreases in both typing and mouse speeds and increases in associated error rates, regardless of walking speed tested (1.6 and 3.2 km h−1), relative to a seated condition. Specific concerns included diminished fine motor coordination, a dizzying effect of the head movement relative to the computer monitor, slight wrist and/or leg discomfort, and a perception of an increased need for concentration on tasks. Funk et al.38 reported that of three treadmill speeds tested, 17% of study participants preferred the 1.3 km h−1 speed for typing, 46% preferred 2.25 km h−1 and 37% preferred 3.2 km h−1. Straker et al.27 noted that some users commented that a 1.5 km h−1 walking condition was ‘uncomfortably slow.’ Thirteen of 17 physicians completing a treadmill desk intervention indicated that they would be interested in continuing to use this workstation alternative if it were available.29

Workers experiencing an under-desk pedaling device reported that it was easy to use, did not affect productivity or quality of work and was an acceptable alternative to activity during bad weather.11 More recently, Carr et al.32reported that pedal desk users believed that they could be easily used in a typical office work setting, would reduce sedentary behavior at work and improve health. Participants also reported that they felt comfortable maintaining a professional phone call, typing on a keyboard and using a computer mouse. Some pedal desk users have noted that it is an improvement over the treadmill desk in terms of balance and producing less upper body movement than what occurs during walking.27 However, some users have also reported minor leg or gluteal discomfort related to the seat27 and others have reported that having their knees hit against the underside of a conventional desk was problematic.49 Both of these concerns seem to be remediable design issues.

There has only been one study thus far that has compared worker perceptions across seated, standing, treadmill and pedal desk workstation alternatives.27 The study design required participants to walk at speeds controlled externally by treadmill settings during that condition; however, they needed to actively and consciously maintain pedaling speeds required for the research application. This latter requisite was considered to be distracting by some, but it is unlikely that real workplace implementation would continue such a rigid requirement. Straker et al.27 did note that a number of participants suggested that a self-selected speed would be more comfortable than the set speeds used to standardize the investigation. Compared with the traditional seated working condition, however, the standing workstation was ranked highest in terms of perceived feasibility (83%) for workplace implementation, followed by the pedal desk (63% thought it feasible, 13% thought it may be feasible) and finally the treadmill desk (50% thought it feasible, 13% thought it may be feasible). In terms of overall preference, the standing desk and pedal desk were equally preferred, and the treadmill desk was least frequently preferred.

Evidence of adherence to use can also be interpreted as an indicator of acceptability of workstation alternatives. Beers et al.16 reported that having been required to perform word-processing tasks for 20 min each while seated in an office chair, seated on a stability ball or while standing, participants preferentially chose to do additional word-processing tasks in the traditional condition, followed by the stability ball condition and lastly in the standing condition. Self-reported use of shared standing desk ranges from high frequencies (for example, daily) and durations (up to 3+ hours at a time), to infrequent and short durations (0.2 h), to not at all.50 Wilks et al.45 reported low usage patterns of sit–stand desks after their introduction to four different companies, with modest increases in utilization with education.

In a study of unrestricted access to individually dedicated treadmill desks,30 accelerometer-determined walking during working hours increased 128 min day−1 over baseline values at 6 months and decreased somewhat to 109 min day−1 over baselines values at 12 months (suggesting some waning of behavior). Thompson et al.9 reported that even the most avid user did not use the treadmill desk more than 4 h day−1; as indicated above, the modal duration of use was 30 min day−1. Carr et al.32 asked novice pedal desk users following 30 min of use to estimate their potential workplace usage under dedicated use or shared use paradigms; 95.6% reported they would use it daily if they could have one in their private office whereas only 11.1% reported they would use it daily if access was shared in a common area. Despite this optimism, however, in a 4-week study of workers’ use of individually dedicated under-desk pedaling devices,11 participants only pedaled an average of 12.2 days (range 2–20 days) out of a possible 20 working days (61% compliance), and an average of 23.4 min at a ‘somewhat hard’ intensity on days that they did use the device. The researchers reported that although average pedal time was maintained over the course of the study, the number of participants who actually used the devices declined over the same time frame. Participants also perceived that their sedentary time at work decreased as a result of using the device; however, there were no associated significant differences in self-reported time spent sitting, standing or walking. More recently, Carr et al.49 reported usage of the same type of dedicated under-desk pedaling device averaging 31 min day−1 on 22.6 days used (37.7% compliance) as part of a 12-week behaviorally enhanced multi-component intervention that also prescribed daily increases in pedometer-monitored steps per day. In these latter two studies it appears that usage was mostly confined to breaks (that is, lunch time) rather than concurrent use while working, which may also explain the relatively lower compliance and use patterns compared with at least some of the treadmill desk studies. The tendency towards 30 min day−1 duration suggests that workers may be disposed to adopting a usage pattern reminiscent of public health recommendations for exercise, regardless of the clear differences in intended purpose and executed intensity.

Although merely replacing sitting with standing is believed to engender a new set of musculoskeletal complaints,51 no studies have reported acute/overuse injuries or other reportable events associated with the use of active workstation alternatives. This should not be surprising as the typical use patterns9, 11 cannot be described as physically stressful (biomechanically or physiologically demanding8), especially considering the low-intensity nature of the PA enacted using active workstation alternatives in real-world workplaces.

### Are interventions designed around workstation alternatives successful?

At this time there are four peer-reviewed standing/sit–stand desk interventions (Table 3), four treadmill desk interventions (Table 4) and two multi-component interventions32, 52 that have included active workstations. As cataloged in Tables 3 and 4 and below, interventions have varied considerably on design, duration, outcome measures and reported significant findings. There has been only one randomized cross-over controlled trial.29 The two multi-component interventions32, 52 have been randomized controlled trials, but the actual effect of the active workstations included in these studies is obscured within the intervention design. Across interventions, there have been 304 participants, of whom 114 (37.5%) have been men and 190 (62.5%) have been women.

Focusing on the standing desk/sit–stand interventions, two46, 47 have studied individually dedicated sit–stand workstations and described significant findings in objectively monitored behavior and other outcomes. The third50 studied access to shared height-adjustable desks and noted no observed significant differences in objectively monitored behavior (no other outcomes measured).

All four treadmill desk interventions9, 30, 53 have studied installation of individually dedicated workstations and documented significant increases in objectively monitored PA (variably measured and defined) and/or decreased time spent in sedentary behaviors. Somewhat confusingly, Thompson et al.29 reported that physicians averaged 90 min day−1 walking on the treadmill at 1.6 km h−1 (which is considered light activity54); however, accelerometer data indicated that moderate intensity activity increased (exact amount not reported), which suggests either a measurement error or a change in behavior beyond the use of the treadmill desk. In this randomized cross-over controlled study, Thompson et al.54 also showed that physician use of treadmill desks produced a small but significant weight reduction of 1.85 kg over 12 weeks. They further reported a significant weight gain (exact amount not reported) over the same time period in those physicians who ceased to use the treadmill desk as part of the study cross-over design. A significant difference in body fat percent between treadmill desk and control (usual seated work) behaviors was attributed primarily to a gain in body fat percent during the latter condition. The two studies of longer term use (9 months53 and 12 months30) have also tracked and reported changes in indicators of body habitus, namely, weight (−1.4 kg on average)30 waist (−4 to 5.5 cm)30, 53 and hip (−4.8 cm)53 circumferences. John et al.53 reported significant improvements in LDL (−8 mg dl−1), total cholesterol (−11 mg dl−1) and HbA1c (−0.4%), whereas Koepp et al.30 reported significant improvements in HDL (+4 mg dl−1).

All of the interventions presented in Tables 3 and 4 are focused just on providing access (primarily dedicated) to workstation alternatives. Straker et al.55 have stated that access may be insufficient to encourage optimal use; education and behavioral support is likely also needed. Robertson et al.56 demonstrated that workers assigned to ergonomics training with their sit–stand desks reported fewer musculoskeletal and visual discomfort and had significantly higher performance scores (quantity and quality of faxes sent) over a 15-day period than workers provided sit–stand desks with minimal training. One study reported that participants received behavioral counseling and accelerometer-based behavioral feedback, but few other details were provided.29 None of the studies presented in Tables 3 and 4 have rigorously evaluated methods of behavioral counseling, automated prompts or managed behavior tracking.

Two studies49, 52 of multi-component interventions including active workstations have been conducted. Parry et al.52 took a participative approach, taking into consideration physical and psychosocial features of organizations, to engage government clerical, call center and data processing workers in the design, implementation and evaluation of three different workplace interventions. One intervention included either treadmill desks or pedal desks and promotion of incidental office activity, another used pedometer challenges to increase activity outside of work and a third focused on re-designing office ergonomics and breaking up computer tasks. Participants included in the final analysis (31 men, 31 women; mean age 43.5 years; mean BMI 28 kg m−2) experienced significant reductions in sedentary behavior (both on work days and during working hours), increased number of breaks per sedentary hour (again both on work days and during working hours), increases in light activity during works hours and increases in moderate-to-vigorous PA on work days. No significant differences were observed between groups; however, the authors noted that the participatory nature results in overlapping strategies between intervention groups.

Carr et al.49 provided 3 men and 20 women (mean age 42.6 years; mean BMI 31.7 kg m−2) access to a motivational website and sent email prompts and messages to encourage use of an under-desk pedal device as part of a 12-week multi-component study that also included a pedometer-based program. Objectively measured sedentary behavior significantly increased within the waiting list control condition (1 man, 16 women; mean age 47.6 years, mean BMI 33.2 kg m−2) and significantly decreased in the multi-component intervention, producing a significant between-group difference. There was also a significant between-group difference in waist circumference change in favor of the multi-component intervention. No other within or between-group differences in objectively measured PA (any intensity) or cardiometabolic parameters were apparent. It is difficult to attribute the differences in sedentary behavior and waist circumference to the pedaling device in this multi-component intervention, especially given the somewhat limited compliance ascribed specifically to this specific component (described above).

### Limitations and future directions

Changing the way we work by incorporating active workstation alternatives presents an opportunity to re-balance the EE equation that has been insidiously disrupted by modern conventions. There are, however, limitations and potential barriers to consider. Foremost is the fact that although active workstations uniquely provide the opportunity to raise EE relative to seated or standing-based workstations, they are also generally more expensive. Although the internet is rife with homemade versions, many commercially available treadmill desks (for example, SteelCase WalkStation, approximately $4000) and elliptical pedal desks (for example, LifeBalance Station, originally$8000, now described as $2795 for the pedaling device and$900–1500 for an accompanying height-adjustable desk32) are too expensive for wide-spread worksite adoption beyond niche individual use. These units also take up a large ‘footprint’ that may or may not fit into the confined individual space allocations of existing office designs other than more spacious executive suites. A lack of portability is also a barrier to managing physical resources by easily or quickly moving such workstation alternatives between offices, meeting rooms and other workplace facilities. These cost and convenience factors likely underlie the fact that all of the interventions studied to date have necessarily been focused on relatively small sample sizes. For example, John et al.53 divulged that their sample size of 12 was determined by the number of individual treadmill desks they could afford for their study. Further, their presence does not necessarily eliminate the need for a separate seated working area located in the same office space that is also fully supported by requisite work equipment. Under such requirements, executives, eccentrics, self-employed workers and those with occupations that allow a great degree of autonomy and disposable income appear to be the primary commercial target for users.

Besides expense, the purchase of multiple units presents a human resource management challenge to employers who must then plan how to equitably distribute such workstation alternatives among employees. Equipment may also come with user size limitations, including weight restrictions, and thus employers must also consider this in terms of workplace equity. The need to safely ambulate precludes some use by workers who are susceptible to motion-related imbalance or have orthopedic limitations or joint pain. Access to an electrical power source is necessary to operate treadmill workstations, and although this is arguably trivial for individual use, it can become a cost and resource management consideration for larger-scale adoption in corporate workplaces. Gender-related preference for active workstations cannot be inferred from intervention participation at this time; apparent imbalances may only reflect study recruitment strategies (for example, targeting traditionally stereo-typical male or female occupations). The need for appropriate footwear (that is, athletic or other type of comfortable shoe) for extended standing and/or treadmill desk use (both in terms of comfort but also noise control on treadmills) may also seem frivolous but is likely a real barrier to some people’s uptake.46 The need for such footwear while using a pedal desk has not been explicitly evaluated, but may be unnecessary as it is a non-weight-bearing activity. For women, the decision to wear a skirt or dress while using an active workstation likely remains a personal choice within their unique workplace culture. A layered upper body (for example, shirt and sweater and/or jacket) will provide the opportunity to quickly adjust body temperature as needed, depending on workplace air conditioning or heating conventions and personal tolerance/preference. If active workstations are used as intended (for example, the top end of the SteelCase WalkStation is 3.2 km h−1 and the top end of the LifeBalance Station is 65 r.p.m.), then sweating should not be a problem.57 Cox et al.22 reported that the oxygen uptake of using a treadmill desk at 1.6 km h−1 was 7–8 ml kg−1 min−1 and Carr et al.32 reported that using a pedal desk at 40 r.p.m. was almost 6 ml kg−1 min−1. As 1 MET (metabolic equivalent of resting oxygen consumption) is 3.5 ml kg−1 min−1, then these studies indicate that active workstations represent approximately 2–2.5 MET activities, considered light intensity.54 None of the studies reviewed herein mentioned any concerns with sweating.

Although no study has reported injury related to use at this time, tripping/falling while using a treadmill desk remains a plausible low risk and therefore employers must consider and weigh the potential for insurance and litigation issues. Walking on a treadmill is likely a common enough experience for most people to be able to judge their personal comfort and safety. The SteelCase WalkStation has an emergency stopping feature in the event of a trip/fall. If advanced age and/or disease/disability compromise gait and increase the potential for tripping/falling, then a treadmill desk may not be a prudent choice. Obviously the risk of tripping/falling would be less for pedal desk users. However, as all active workstation alternatives have moving parts, lifetime maintenance and replacement of the equipment must be considered. John et al.53 pointed out that some commercially available treadmills were not designed for slow walking over prolonged durations and that such limited motors can become overloaded and lead to mechanical problems.

At least one of the solutions to some of the access/cost-based limitations is to provide shared desks, that is, allowing multiple users access to a centrally located workstation alternative. Although shared access in a common area may introduce perceived embarrassment/discomfort using the active workstation in the presence of co-workers, this was directly queried and ultimately not considered a concern by novice pedal desk users.49 However, shared access to active workstations does present other unique logistical and human resource management problems including personal inconvenience, equity of scheduling and shared responsibility of maintenance. For example, a worker may shut down their usual desktop computer to maintain confidential files and move to the workstation alternative only to find another worker there. Attempting to maximize use by allocating scheduled use requires active management and also may be too rigid for workers who must respond to others’ (including clients’) impromptu requests. Supervisors may or may not view time away from dedicated work areas to use the workstation alternatives as productive time for individual workers, which may lead to workplace friction. The repeated frustration of such scenarios could undermine use entirely. Finally, even the quietest active workstations will likely make some degree of noise. Shared multiple units may or may not present a distraction in an open office design.

With regard to future directions, more studies of EE are needed directly comparing the different types of workstation alternatives currently available, and especially under conditions of real use, including at self-selected speeds. In addition, studies are needed to compare the relative acceptability of workstation alternatives in real-world workplaces; this should include tracked measures of actual use as an estimate of workers’ tolerance for the behavior. As sit–stand/standing desks do not appear to offer an advantage over traditional seated work, at least in terms of EE, then their impact on other health outcomes must be candidly evaluated to determine their relative utility and set the stage for comparative cost-effectiveness studies.

Exercise as recommended by public health authorities58 should be of at least moderate intensity. None of the workstation alternatives described herein meets that threshold, nor are they intended to do this. Active workstations are not intended to replace exercise; they are intended to replace sedentary behavior. To emphasize by inculcation, although 30 min (Thompson et al. 9) or even 90 min (Thompson et al.29) of daily walking on a treadmill desk at 1.6 km h−1 or even 3.2 km h−127 should increase EE over the seated working condition,18 it does not obviate public health recommendations for PA that is of at least moderate intensity. The benefits of a physically active lifestyle extend beyond energy balance. Therefore, researchers should consider the impact of workstation alternatives on other PA and sedentary behaviors performed (for example, priming or compensating) both at work and also in non-work time. As active workstations do elevate EE, however, and thus represent a feasible strategy for addressing obesity (and related chronic diseases including cardiovascular disease and type 2 diabetes1), mechanistic studies of the impact of their use on heart health indicators and glycemic control are also needed. Finally, implementation and process-oriented research is desperately needed in addition to outcome-based research conducted under real-world conditions to better inform employers and workers about what works best for whom and under what conditions.41

## Conclusions

Sedentary behavior is now recognized as a potential health threat.51, 59 Although there have long been occupations recognized as sedentary in nature (for example, seamstress/seamster, accountants, and so on),60 modern technological advances (for example, computer hardware), task automation facilitated by increasingly sophisticated software, increasing forms and numbers of electronic communication modes, individually dedicated office equipment (for example, desktop printers) and office furniture (for example, ergonomically comfortable chairs that actually increase sedentary behavior15) and design trends (for example, cubicle-based pods supported by their own kitchenettes, restrooms) have each likely contributed to the increasingly sedentary nature of more and more types of occupations over the last 50 years.4 Workstation alternatives that include sitting on a stability ball or engaging in standing-based work technically reduce sitting behaviors associated with traditional office work; however, the evidence clearly shows that they do not generate a meaningful difference in EE. As the work day takes up a large amount of a full-time employed individual’s day, the health-based need to obtain sufficient amounts of regular PA has shifted almost entirely to the non-work committed time of the day, which is already strewn with other competing personal, family, home and community obligations. Confronted with this sedentary behavior-prompting and supporting milieu, it makes sense to enrich or fortify the contemporary workplace with multiple opportunities to replace sedentary behavior with low-intensity non-exercise PA that does not distract the workers from their primary task. Active workstations are potentially important strategies for mitigating the diminished EE inherent to contemporary office-based workplaces, but only if use is optimized and devices are affordable and thus scalable. The science supporting active workstations is young and heterogeneous; this means that there are many research gaps and opportunities, including those focused on implementation issues related to optimizing both employers’ and workers’ uptake.

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## Author information

Authors

### Corresponding author

Correspondence to C Tudor-Locke.

## Ethics declarations

### Competing interests

Dr Tudor-Locke and her husband, Mr Gerald R Locke, co-invented and thus own intellectual property for a workstation alternative device that is not presented in this review of published literature. We are currently conducting research with the device. The remaining authors declare no conflict of interest.

Author contributions

All authors contributed to this manuscript and approved its final content. CT-L led the writing of this manuscript while alternating between a treadmill desk (3.2 km h−1 as indicated by device display, no incline; wearing business attire and athletic shoes) and a pedal desk (52–56 r.p.m. and 40–44 watts as indicated by Garmin Vector Power Meter Pedals, no resistance; wearing business attire and a range of footwear including high heels). She says she doesn’t sweat.

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Reprints and Permissions

Tudor-Locke, C., Schuna, J., Frensham, L. et al. Changing the way we work: elevating energy expenditure with workstation alternatives. Int J Obes 38, 755–765 (2014). https://doi.org/10.1038/ijo.2013.223

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### Keywords

• occupation
• sedentary behavior
• sitting
• workplace
• physical activity

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