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https://www.scielo.br/j/rbfis/a/GVZBFxm4ysJkYCyN3TXqXZb/?lang=en SYSTEMATIC REVIEW Evaluation of the effectiveness of workplace exercise in controlling neck, shoulder and low back pain: a systematic review Helenice J. C. G. Coury; Roberta F. C. Moreira; Natalia B. Dias Department of Physical Therapy, Universidade Federal de São Carlos (UFSCar), São Carlos (SP), Brazil Correspondence ABSTRACT BACKGROUND: Musculoskeletal disorders have been recognized as a worldwide health problem. One of the measures for controlling these disorders is workplace exercise, either at the workstation or in a separate environment within the company. However, there is controversy regarding the effectiveness and means of applying these interventions. OBJECTIVES: To assess and provide evidence of the effectiveness of workplace exercise in controlling musculoskeletal pain. METHODS: The following databases were searched: PubMed, MEDLINE, Embase, Cochrane, Pedro and Web of Science. Two independent reviewers selected the elegible studies. Possible disagreements were solved by consensus. All randomized controlled clinical trials that evaluated exercise interventions in the workplace musculoskeletal pain relief were included. The Pedro scale (range=0-10 points) was used to rate the quality of the studies included in this review. RESULTS AND CONCLUSIONS: The electronic search yielded a total of 8680 references published in English. At the end of the selection process, 18 studies were included. Strong evidence was found to support the effectiveness of physical exercise in controlling neck pain among workers who performed sedentary tasks in offices or administrative environments, while moderate evidence was found for low back pain relief among healthcare and industrial workers who performed heavy physical tasks. These positive results were reported when the training periods were longer than 10 weeks, the exercises were performed against some type of resistance and the sessions were supervised. None of the studies evaluating sedentary workers reported positive results for controlling musculoskeletal shoulder pain. Further randomized controlled trials are needed to comparatively evaluate, among other aspects, the effects of light and heavy training for shoulder pain relief. Key words: training; workplace; work-related musculoskeletal disorder; pain; prevention; ergonomics. Introduction
were checked independently by two reviewers to identify potentially relevant studies not found in the electronic search. The reviewers selected the articles to be included in the review using a standard form adapted from the Cochrane Collaboration^11. Possible disagreements during the process were solved by consensus. Inclusion criteria: Study type We selected only RCTs that included interventions involving workplace exercise and that investigated musculoskeletal symptoms. Type of participants We selected only the studies that reported results about populations of active workers, with or without musculoskeletal complaints, who performed normal work activities during the study. Intervention type We selected studies that investigated or compared interventions in the workplace or in reserved areas within the company, involving exercise for primary and/or secondary prevention of musculoskeletal pain. Types of reported results We included studies that investigated variables related to musculoskeletal pain as one of the main outcomes. Assessment of the methodological quality of the selected studies The methodological quality of the included studies was assessed using the PEDro^12 scale, which is based on the Delphi list^13. Although this scale has 11 items, only ten are scored, so the score ranges from zero to ten. Each criterion is scored according to its presence or absence in the evaluated study. Each satisfied item (except the first) contributes one point to the total score. Items that are not described in the studies are classified as "not described" are not scored. The final score is obtained by the sum of all the positive answers. The studies indexed in the Pedro database already had a rating, which was maintained, and the non-indexed studies were evaluated independently by two reviewers. In case of disagreement, a third reviewer (senior researcher) was consulted to reach a final decision. Verhagen et al.^8 , van Poppel, Hoffman and Koes^14 and Proper et al.^15 conducted previous systematic review studies to assess the effectiveness of intervention programs carried out in the workplace. They claim that, for a study to be classified as high-quality, it should have a score of more than 50% the maximum possible score. According to Maher^16 , due to the impossibility of achieving certain conditions such as blinding of therapist or subjects in the clinical trial studies in the workplace, the maximum score that can be reached by these clinical trials is 8/10. Thus, for this review, all RCTs with a score higher than or equal to five (5/8, 62%) were considered studies of high methodological quality. A minimum score of 3/8 was defined as the cutoff score for inclusion in this review.
Data extraction All authors worked independently, using a standard form adapted from the Cochrane^11 collaboration model for the data extraction, considering: 1) aspects of the study population, such as occupational activity, mean age and gender; 2) aspects of intervention, such as sample size, type of exercise, presence of supervision, frequency and duration of training sessions; 3) follow-up; 4) follow-up loss; 5) evaluated pain variables and 6) reported results. Data analysis A scoring system including five levels of evidence was used to synthesize the evidence in this review. This system considers the number, the methodological quality and the results of studies regarding the variable of interest, and it has been used in previous systematic reviews involving workplace interventionsl8,14,15, as follows: Strong evidence: provided by consistent findings in two or more high-quality RCTs; Moderate evidence: provided by consistent findings in one high-quality RCT and one or more low-quality RCTs, or by consistent findings in multiple low-quality RCTs; Limited evidence: only one high-quality RCT or multiple low-quality RCTs; Conflicting evidence: inconsistent findings in multiple RCTs; Absent evidence: no RCT. Results Search strategy The literature review included titles published until December 2008. The electronic search resulted in a total of 8680 references published in English. The final selection was defined by consensus and resulted in 19 studies, two17,18^ of which were duplicated. Therefore 18 studies were selected, including six high-quality studies (Figure 1). Assessment of the quality of the studies Among the eighteen relevant studies, 17 were indexed in the Pedro database^12 , while one non- indexed study^19 was evaluated by consensus of three reviewers, using the Pedro scale. The scores of each one of the included studies are shown in the last column of Table 1. Two20,21^ of the eighteen studies included in this review describe their methods of randomization, but these methods were considered inappropriate by the Pedro raters^12. This was due to the existence of different specific methods to generate the random allocation sequence. Some methods such as computer randomization, random number tables and randomization cards are considered more suitable, while others are considered less appropriate, such as alternate allocation, or allocation based on medical chart numbers or birth date^22. Given the difficulty in performing
analysis based only on the methodological quality of the included studies could lead to imprecise interpretations regarding the evidence on the effectiveness of physical exercise practice in the workplace, because it is possible to identify particular trends when the results are analyzed according to the specificities of each protocol. Thus, we opted for a detailed analysis focusing on the exercised body region and the characteristics of the exercise protocols, such as: total duration of training, type of training, presence of supervision, population and duration of the sessions. The studies by Jorgen et al.28,36^ were conducted with the same group of workers using a similar exercise protocol in terms of the frequency of sessions, duration of training and application of sessions. However, each study focused on different body regions, which were independently evaluated. In order to avoid potentialization of the results of a single exercise program, both studies were evaluated jointly and described in the tables as no. 28 and no. 36. Effects of the training duration Table 3 shows the results of exercise per body region and duration of the exercise program over time. The studies that showed effective results, including three17,19,28,36^ high-quality studies, were those in which the time of application of the protocol was equal to or greater than ten weeks, providing strong evidence for the effectiveness of long-term exercise programs. None of the programs lasting less than ten weeks resulted in positive effects for any of the regions studied. Among the ineffective programs, there is one reported in a high-quality^29 study, thus reinforcing the evidence regarding the ineffectiveness of short-term exercise programs. Considering the body regions, eight studies investigated the low back area, of which six reported positive results after long-term exercise programs and one28,36^ was a high-quality study, indicating moderate evidence of the effectiveness of long-term training to control low back pain. The results for the shoulder region were not positive for the control of symptoms neither after short- or long-term programs. The effectiveness of exercise for the neck region was investigated in eight studies. Of the four studies that showed positive results for interventions lasting ten weeks or more, three19,17,28,36^ were high-quality studies, providing strong evidence of the effectiveness of long-term exercise programs for that region. Among the three studies that applied long-term training programs and were ineffective for neck pain, one^23 was a
high-quality study, however the protocol of this study included light training, which may also have contributed to the ineffectiveness of the result as analyzed below. Effects of types of training The exercises performed during training sessions were classified into two categories: light or heavy training (Table 4). A protocol was considered light if it involved stretching, relaxation, light aerobic and dynamic exercise, i.e. without resistance. In contrast, a protocol was considered heavy if it included some type of resistance to perform the exercise resulting in increased intensity of the eccentric and concentric contractions, i.e. dumbbells, isokinetic equipment, elastic bands and exercises against gravity. In general, light training in the workplace was shown to be ineffective for the control of musculoskeletal symptoms23,25-27,29. Only one study^17 , despite being a high-quality study, demonstrated positive results for the control of neck pain after light training, indicating conflicting evidence for the effectiveness of light training for the neck region. Conversely, heavy training was effective in controlling symptoms of the neck region, with strong evidence17,19,28^ for this type of training. All eight studies on the low back area applied heavy training. Six of them, including one of high quality^36 , were effective in controlling pain. Thus, there is moderate evidence for the effectiveness of heavy training on low back pain. For the shoulder region, despite high-quality studies using both forms of training, none of the programs resulted in symptom control, indicating that light training and especially heavy training were ineffective in that region. Effects of supervision The effect of supervision on the training sessions was considered for the neck and low back regions because the studies on the shoulder region did not show any positive results. Of the 12 studies that included supervision, eight were positive, including two17,19^ high-quality studies. In contrast, four of the five studies that investigated unsupervised training were ineffective. Of these, two23,29^ were high-quality studies, and only one^28 obtained a positive result. Thus, the joint analysis of the studies indicated strong evidence of ineffectiveness for unsupervised trainings. Influence of the type of job The type of job performed by the participants was classified as sedentary work or physical work. Activities carried out in offices and administrative departments and industrial work involving light physical demand were considered sedentary work. The job was classified as physical work if it was performed by nurses, nursing assistants, home care workers and by the employees of a kitchen cabinet manufacturer who handled heavy loads^31. One of the studies^30 included hospital employees from administrative and clinical professions who performed both types of activity (sedentary and physical work). The study by Larsen et al.^21 was developed with military conscripts and did not specify the activities they performed, therefore this study was excluded from this part of the analysis. Table 6 shows that most studies assessed sedentary activities and investigated especially the neck, shoulder and neck/shoulder regions. The studies that evaluated physical work studied mainly the effects of the training on the low back region. Seven studies assessed the neck
results of this review^38 showed that a gain in muscle strength was associated with a decrease in chronic neck pain. In another review article about low back pain, Pope, Goh and Magnusson^39 also observed that the increase in muscle strength of the spine had a preventive effect on pain. Reviews by Ylinen^38 and Pope, Goh and Magnusson^39 included the evaluation of clinical studies, while the present results evaluated only the effect of exercise in relieving symptoms in the workplace. Thus, the interpretation of the present results, in light of those reviews, must be taken with reservation. Nevertheless, there seems to be a common physiological basis to heavy training programs that influences the pain, as discussed below. The association of resistance exercise with a reduction in symptoms can be explained, at least in part, by the fact that strong muscle contractions activate the muscle's tension receptors, whose afferents trigger the release of endogenous opioids that stimulate endorphin production by the pituitary gland^40. Thus, the increased level of endorphins at the end of the training supposedly reduces central and peripheral pain^40. Another hypothesis, according to Waling et al.^41 , is related to the fact that strength and/or resistance training would stimulate the growth of blood capillaries, optimizing oxygen supply, eliminating algogenic metabolic residue and promoting better nutrition of the muscle tissue. With regard to light training applied in the workplace, the results showed no evidence of effectiveness for any of the evaluated regions. These results support those previously described, suggesting that light training does not provide enough muscle stimulus to promote substantial physiologic changes in the mechanism of chronic neck pain. Light training involving relaxation, socialization, etc. may positively affect productivity and promote healthier habits or even improve moods and the company's standing with employees^42 , but it is not sufficient to promote improvement in muscle function^43. Due to the lack of studies on the effectiveness of light training for the low back region, it was not possible to reach a conclusion about this type of training in the control of low back pain. Thus, further studies are needed to comparatively evaluate the effectiveness of light and heavy training in the workplace. Duration, intensity and supervision of the exercise programs The present study found strong evidence that long-term training, lasting ten weeks or more, is effective in reducing musculoskeletal pain in workers. In the literature, there are no studies evaluating this aspect of training in the workplace, but according to Wilmore and Costill 44 , studies with athletes have already shown that muscular adaptation to strength training, expressed as increased voluntary strength, starts eight weeks after the beginning of training. Neural factors, which lead to an increase in voluntary muscle activation, seem to be involved in this process^44. Thus, although the parameters observed for the training of athletes cannot be directly extrapolated to the worker population, it is likely that a minimum time of training for muscle disorders is also necessary for obtaining benefits in the exercises performed in the workplace. With regard to training intensity, there was lack of evidence related to the specific frequency and duration of sessions needed to provide relief of symptoms. In general, the longer sessions (40 minutes to 1 hour) were associated with lower frequencies (two to three times a week), and shorter sessions (5 to 6 minutes) were associated with higher frequency (daily), with positive
results in both cases. Thus, new studies are still needed to obtain more useful results on these aspects of training protocol. The positive results of the high-quality clinical trials that included supervision and the negative results of the studies that did not include supervision demonstrate evidence of the effectiveness of supervised workplace exercise. This finding may be related to the presence of a professional prepared to provide guidance, monitor the sessions and assist in achieving the correct performance of the exercise. Type of occupational activity performed by the participants Strong evidence was observed for the effectiveness of exercise in controlling neck symptoms in workers who performed sedentary or light tasks. Sedentary tasks are usually performed in the sitting position and require concentration and precision. Direct consequences of this condition are anterior flexion of the neck and neck immobility to maintain visual acuity^45. Over time, the flexed position can lead to weakness of the neck extensors, and static muscle work can lead to fatigue and pain^46. Strengthening exercises involving dynamic muscle contractions can benefit blood flow and relieve pain in that region, as discussed earlier. Although the risks of the sitting posture for the low back are already known^45 , this region was evaluated in only two of ten studies involving sedentary activities, limiting more conclusive interpretation of these results. New methodological quality studies are needed to investigate the effects of exercise on the control of low back pain in sedentary activities. Most of the studies conducted in physical work environments evaluated the low back region. Exercises for low back symptoms in workers who perform heavy activities showed moderate evidence of effectiveness. In patients, the exercises have been used to relieve low back symptoms due to their physiological effects. Among these effects is the improvement of nutrition of the intervertebral disc, which occurs by diffusion, as a result of increased pumping and mechanical flow generated by exercise^47. Furthermore, the muscle strength of the low back region reduces lumbar lordosis, intradiscal pressure and the tension in the intervertebral joints. However, muscle strengthening in the workplace should not be seen as a resource to enable the worker to exert more strength at work, because it is always more advisable to reduce the physical demands of the task and the risks of new or recurrent episodes of low back pain^48. Ineffectiveness of shoulder exercise None of the workplace exercise programs had positive effects on shoulder symptoms. The authors did not provide a specific explanation for these negative results or an exact clinical diagnosis for the symptomatic workers who participated in the study. The only diagnosis mentioned was trapezius syndrome, and only in one study^16. The studies included in this review evaluated the shoulder symptoms only in workers who performed sedentary activities. According to Thorn et al.^49 , there is a high prevalence of trapezius myalgia among workers who perform sedentary tasks with low levels of muscular activity. According to Westgaard and Winkel^46 , epidemiological studies show a clear association between adverse psychosocial factors and muscle pain syndromes, and this association is likely to be permeated by physiological aspects. Although psychological factors may influence the development of painful symptoms in all regions of the spine, the shoulder girdle seems to
The most critical points regarding the quality of the studies were related to blinding. Only four studies17,23,28,33^ used blinding of the examiners. Still, in this context, only two studies20,28^ reported concealment allocation of the subjects into the groups and only seven of the 18 studies17,21,28- 30,34,36 (^) provided information about intention-to-treat. Those factors were responsible for reducing the methodological quality of the studies. Given the impossibility of blinding of subjects and therapists in preventive workplace interventions, this condition was accepted and adjustments were made in the Pedro scale. However, there is still a need to conduct new studies that minimize the main methodological faults mentioned here and to provide better evidence to clinical practice. Although the Pedro scale is widely used in evaluations of clinical trials, it has limitations such as lack of evaluation of the external validity of clinical trials and fails to evaluate the magnitude of the effect of the intervention^12 , which hinders a more reliable evaluation of the methodological quality of the studies. Another limitation concerns the criterion adopted for synthesis of the evidence, based on the five levels of evidence. Although this criterion has been used in previous reviews8,14,15, it has not been validated for use in occupational interventions. Thus, there is a need for further high-quality RCTs to better assess the effectiveness of some characteristics of workplace physical activity and control pain in the neck, low back, and especially, the shoulder region. Conclusions Workplace exercise can reduce musculoskeletal pain, although this beneficial effect depends on the characteristics of the exercise programs. There is evidence that exercise reduces musculoskeletal pain when it includes resistance, supervision and duration of at least ten weeks. This effectiveness was observed for neck and low back pain control. No high-quality studies on training to reduce shoulder symptoms achieved positive results, although this region was evaluated only in workers who performed sedentary or light activities. Finally, there is strong evidence for the control of neck pain in sedentary work environments and moderate evidence for the control of low back pain in physical work environments.
Musculoskeletal injuries include bone fractures or joint dislocations, sprains, strains, ligament tears, tendon lacerations. Repetitive movements at work cause small joint injuries that eventually become chronic and lead to permanent damage. They are mainly located in the wrists, elbows and shoulders, cause severe pain and prevent normal joint mobility.
Occupational exercise reduces musculoskeletal pain, although this beneficial effect depends on Characteristics of the exercise program. Evidence that exercise can reduce musculoskeletal pain. Include resistance, supervision and a duration of at least ten weeks. observed this effect Controls neck and low back pain. No high quality studies on training to reduce shoulder symptoms. Positive results, although this area was only evaluated in sedentary or inactive workers. Activity. Finally, there is strong evidence that neck pain can be managed in a sedentary work environment, and Moderate evidence for the management of low back pain in physical work settings. It can be seen in the results where they show that exercising in the workplace can reduce symptoms and neck pain back, but in the shoulders, two light workers showed little improvement in symptoms or sedentary activities, such as strenuous or physical activity. However, the effectiveness of these programs depends on the characteristics of the training and the type of exercise.
