Robson da Fonseca Neves1; Simone Pereira Aureliano Araújo1; Lílian Vieira Magalhães2; Mônica Angelim Gomes de Lima3
BACKGROUND: The increase in work-related health problems is a cause of concern for researchers worldwide. Intensification of work and the worker-work environment-illness relationship are some of the leading topics in debates on health and work. Facing this scenario, workplace physical activity (WPA) represents an option for prevention of work-related diseases.
AIM: To describe and summarize how the Brazilian literature has addressed WPA.
METHODS: A scoping review was performed based on a search on the main databases of scientific articles available in Brazil using keywords "ginástica laboral" (workplace physical activity), "labor gymnastics", "ginástica do trabalho" (workplace physical activity), "exercícios laborais" (workplace physical exercise) e "cinesioterapia laboral (workplace kinesiotherapy)". Empirical studies conducted in Brazil and published along the past 10 years were included.
RESULTS: The 44 analyzed articles applied variable, mainly quantitative methods to the study of WPA. The studies were most frequently conducted by physical educators and physical therapists. WPA was performed in both private companies and public organizations with employees who performed a wide range of functions. Six categories were detected for WPA: pain management; lifestyle behaviors; mental health components; components of human movement; quality of life; and anthropometric indicators and vital signs.
CONCLUSION: WPA has been investigated through many different methods and involving variable modalities of application. While still scarce, qualitative and multi-method studies could certainly increase the reach and potential of WPA.
Keywords: review literature as topic; primary prevention; work; gymnastics.
INTRODUÇÃO: O crescimento dos agravos relacionados ao trabalho vem preocupando pesquisadores ao redor do mundo. Isso porque a intensificação do trabalho e as relações trabalhador-ambiente de trabalho-adoecimento, entre outras, lideram o debate quando o assunto é saúde e trabalho. Nesse cenário, a ginástica laboral (GL) é uma alternativa na prevenção dos adoecimentos relacionados ao trabalho.
OBJETIVO: Descrever e sintetizar as formas pelas quais a literatura brasileira tem abordado a GL.
MÉTODOS: Uma revisão panorâmica (scooping review) foi realizada a partir de buscas nas principais bases de artigos científicos disponíveis no país, por meio dos descritores "ginástica laboral", "labor gymnastics", "ginástica do trabalho", "exercícios laborais" e "cinesioterapia laboral". Foram incluídos estudos empíricos que tratavam do contexto brasileiro e que foram publicados nos últimos 10 anos.
RESULTADOS: Nos 44 artigos analisados foi evidenciado que diversas metodologias têm sido aplicadas à GL, majoritariamente as quantitativas. Os estudos têm sido conduzidos principalmente por educadores físicos e fisioterapeutas. A GL é executada tanto em empresas privadas quanto em órgãos públicos, com trabalhadores das mais variadas funções. Seis categorias associadas à GL emergiram: manejo da dor; estilo de vida; componentes relacionados à saúde mental; componentes do movimento humano; qualidade de vida; e indicadores antropométricos e de sinais vitais.
CONCLUSÃO: A GL vem sendo investigada a partir de metodologias e formas de aplicação diversas. Estudos qualitativos e multimétodos, que são escassos, certamente garantiriam maior alcance e potencial à GL.
Palavras-chave: literatura de revisão como assunto; prevenção primária; trabalho; ginástica.
The increase in work-related health problems is a cause of concern for researchers worldwide. Work intensification and the worker-workplace-illness relationship are the leading topics on discussions on health and work1.
According to the Brazilian Social Security, poisonings and consequences of other external causes (34.82%), followed by musculoskeletal and conjunctive tissue disorders (32.5%) were the main reasons for workers to permanently leave their jobs along the period from 2009 to 2011. In turn, mental and behavioral disorders ranked third, corresponding to 4.0% of occurrences, followed by cardiovascular (3.9%) and nervous system (3.4%) problems2.
Considering Brazilian urban workers with transient or permanent work disability only as reference, the increase in sick leaves might have costed the public coffers about BRL 300 millions2. This fact clearly points to the need to address the problems originated in the work conditions and relationships, but that somehow also affect society at large, since it has to pay the cost of the resulting damages.
Workers' health involves a complexity of issues, including diseases, material and immaterial work conditions and the relationships between the various systems (health system, social security, family, etc.) that provide assistance to workers. Therefore, accurate knowledge of programs, projects and intervention actions targeting workers' health are relevant in order to estimate their impacts3.
To summarize, dealing with work-related disorders and the risks inherent to their causes is complex, as it involves measures ranging from prevention of diseases to rehabilitation and redeployment of workers. Several professionals from various field of knowledge sought to develop strategies to meet these challenges. Workplace physical activity (WPA) is one of the strategies formulated to deal with various of the problem's components, based on the belief that it is relevant for prevention and promotion of workers' health in Brazil4.
The present study sought to investigate how the Brazilian literature has approached WPA and to perform a commented synthesis. For this purpose we conducted a scoping review of the literature aiming at establishing the limits and possibilities of the current modalities of implementation of WPA, as well as eventual gaps in the knowledge about this strategy of intervention.
BEGINNINGS OF WORKPLACE PHYSICAL ACTIVITY IN BRAZIL
Historical records indicate that WPA first appeared in Poland in 1925, where it was known as "pause gymnastics." Later on it reached the Netherlands and also Russia, but only in Japan, starting 1928, it came to be considered as a routine strategy for management of health and to promote a more casual work environment5.
WPA was introduced in Brazil by Japanese executives in 1969, to progressively expand within the private and public sectors,5 being given several names, such as workplace fitness program and workplace kinesiotherapy6,7. In time, the Brazilian Portuguese term "ginástica laboral" came to be the most popular one in the country.
Brazilian authors define WPA as exercising at the workplace during the working time8-11, yet they differ as to its goals. According to Silva8, WPA promotes workers' health and prevents repetitive strain injuries. In turn, Lima9 considers that WPA seeks to relax or increase the tone of the body parts most used at the workplace, in addition to activating the ones that are less used. Finally, Freitas et al.10 and Machado Junior et al.11, assert that WPA includes measures targeting somatic and emotional disorders, while it primarily aims at the prevention of diseases caused by repetitive and monotonous work. While also mental disorders are considered within the aims of WPA-based interventions11, according to the literature it is primarily associated with movement disorders, which restricts its scope within the world of work, even though it is certainly not limited to the specificities of human movement.
As a result, WPA is applied in a variety of ways to different problems, exhibits variable characteristics and encompasses a broad scope of functions. Thus being, one may ask: how has the Brazilian literature approached WPA?
The present study investigated how the Brazilian literature approached WPA. It followed the parameters for scoping reviews formulated by Arksey and O'Malley, who suggested five steps:
1. Identification of the research question.
2. Selection of relevant studies for analysis.
3. Sample consolidation.
4. Extraction of data relevant to the research question.
5. Numerical/thematic analysis and report of results12.
This methodological matrix is intended to identify the main notions that ground a field of research and the main sources and types of knowledge available, in addition to gaps still existing within the targeted field. Scoping reviews are especially indicated for complex fields of knowledge or the ones that have not yet been sufficiently reviewed, as is the case of the topic addressed in the present study13.
The present review included empirical studies on WPA performed in Brazil and published in peer-reviewed journals from 2006 to 2016, as the selected method recommends13. The time frame was defined considering that the Brazilian scientific production on WPA is still recent, and thus a longer time frame would not have yielded a larger number of results.
Publications with theoretical discussions or systematics reviews on WPA were excluded. When analysis of titles and abstracts indicated that articles were relevant, their full text was selected for analysis. As established in the scoping review method, no criteria was adopted to analyze the quality of articles12, because our main aim was to circumscribe the full scope of the publications on the targeted subject, rather that analyzing the robustness of study designs and other methodological specific aspects. This is precisely what distinguishes scoping studies from other methods to synthesize the literature. Again, the goal in this case is to exclusively survey the scope of and gaps in knowledge, which might come to influence new studies on areas eventually identified as incipient.
A search was conducted on electronic databases available at CAPES Portal (Brazilian Federal Agency of Evaluation and Support of Graduate Education/Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) and also in SciELO (Scientific Electronic Library Online), which is an indisputably relevant medium for scientific communication on health. SciELO is linked to BVS (Virtual Health Library/ Biblioteca Virtual de Saúde) and LILACS (Latin American and Caribbean Literature Health Sciences Literature/ Literatura Latino-americana e do Caribe em Ciências da Saúde) both of which are also highly relevant media for communication of information on health in Brazil. In addition, we also performed a manual search based on cross references cited in the selected articles in order to locate and include significant studies. Selection was performed by the first two authors; the third author solved eventual instances of doubt relative to the inclusion of studies.
To make sure the scope of the survey would be adequately broad, we employed five keywords highly prevalent in journals published in Brazil: "ginástica laboral" (workplace physical activity), "ginástica do trabalho" (workplace physical activity), "exercícios laborais" (workplace physical exercise), "cinesioterapia laboral" (workplace kinesiotherapy) and "labor gymnastics". The latter was included because it appears in several Brazilian publications, even though the expression most widely used in English is "workplace physical activity"4.
The extracted information was organized in a matrix model14. Next we clustered the most frequent topics together to define the prevalent thematic units. The final results of this process are described in Chart 1.
Figure 1 depicts the results of the search conducted at SciELO and CAPES Portal. Initially we located 149 articles; 37 were excluded for being duplicates and further 82 for being theoretical studies or addressing other types of physical exercise (performed at gyms, rhythmic gymnastics) or quality of life at work. Checking of cross references allowed locating further 14 articles. Therefore, 44 articles were included for analysis.
The remainder of the results are described in two separate sections: one devoted to an overall view of the analyzed studies, and the other to the main applications of interventions using WPA.
OVERALL OVERVIEW OF THE ANALYZED STUDIES ON WORKPLACE PHYSICAL ACTIVITY
Most of the analyzed studies employed quantitative and descriptive methods, as well as variable nomenclature, as shown in Chart 1.
CHARACTERISTICS OF INSTITUTIONS WHERE STUDIES WERE CONDUCTED
WPA was investigated at private industrial6,7,16,18,22,35,30,34-36,38,40-42,44,45,48,49,52,53,civil construction7, call center28,43 and service25 companies. For the public sector, studies targeted universities15,19,23,24,27,29,32,33,46,54, financial institutions11,26 and several other institutions of variable nature20,21,31,39,55.
Most participants in studies on WPA were engaged in administrative functions in either the public15,19-21,23,24,26,27,29,32,39,46,55 or the private sector7,18,38,40,41,44,45,47,50,52,53. The remainder of the samples included employees working in industrial production6,18,34,36,41,42,48,52, civil construction17, storage18,36,50, general services27,32,33, call centers28,43, as urban public transport drivers51, and also university students52. The latter was an experimental study, for this reason the participants were not workers as in the other studies.
WHO STUDIES PHYSICAL EXERCISE AT THE WORKPLACE?
While WPA is mainly investigated by educators and physical therapists, also other professionals approached this subject, which indicates that it is of multidisciplinary interest (Chart 1).
FREQUENCY AND LENGTH OF PHYSICAL EXERCISE AT THE WORKPLACE
The weekly frequency of WPA was quite variable: twice per week in 7 seven studies11,19,33,40,46,51,55; three times per week in 12 studies7,30,32,35,37-40,44,45,47,53; four times per week in 2 studies43,55; 5 times per week in 5 studies24,26,40,41,48; and every day of the week in 5 studies6,20,28,34,52. One only study assessed the effects of one single session of WPA54. The length of sessions varied from 10 to 30 minutes7,19,33,46; however, most studies did not provide this information.
TYPES OF EXERCISE
Stretching was the main type of exercise among the studies that sought to improve the range of motion of joints11,12,15,23,24,35,39,47. Active exercises to gain strength or resistance training combined with stretching and massages or relaxing were cited in several studies6,7,19,30,33,34,38,40,44,45,50,54,55. Some studies combined the latter with recreational activities43,48,51,53. Also posture alignment7 and breathing exercises19 and techniques for segmental stabilization and muscle chain stretching46 were combined with some of the aforementioned types of exercise.
WORKER AND MANAGERS' ASSESSMENT OF PHYSICAL EXERCISE AT THE WORKPLACE
Workers and managers' assessment of WPA considered the following aspects: adherence to WPA17,28,31,32,36,40; workers' perception of WPA benefits21,22,27,28,37,55; managers' perception of WPA21; satisfaction with and relevance of WPA21,30,41; and satisfaction with the professionals who lead WPA sessions18. Authors did not systematically describe the strategies used for assessment17,21,27,31,36,37,40,41,55. Nevertheless, some studies applied qualitative approaches; in such case application of semi-structured interviews stood out18,22,28,30,32.
MAIN APPLICATIONS OF INTERVENTIONS USING PHYSICAL EXERCISE AT THE WORKPLACE
The selected studies were also classified as to the applications of interventions using WPA into the following categories: pain management; lifestyle; mental health components; components of human movement; quality of life; and anthropometric indicators and vital signs.
This type of studies sought to analyze the impact of WPA to reduce the intensity of musculoskeletal pain, as well as to detect changes in the characteristics of pain following performance of WPA.
The instruments applied in intervention studies with WPA to assess the intensity and characteristics of pain were: Self-Perceived Pain Scale19; Wisconsin Brief Pain Inventory40,53; Pain Topography and Intensity questionnaire42,43; the Corlett diagram adapted by Guimarães37,46; and ad hoc, non-validated questionnaires and interview scripts7,11,18,23,32,33,35,38,39,55.
According to 17 studies, the eventual benefits of WPA reported by participants were related to improvement of musculoskeletal pain. In the attempt to establish causal hypotheses for the detected phenomenon, authors sought to find a relationship between length of exercise and outcomes. In most studies, WPA sessions were conducted 3 times per week, usually on alternate days, and lasted 10 to 20 minutes7,32,35,38-41,53. In the remainder of the studies, sessions were performed twice per week11,19,33,40,46,55, 4 times per week43,55, 5 times per week or every day34,40. Machado Junior et al.11 found that performance of WPA twice per week was insufficient to discriminate the intensity of musculoskeletal pain, and thus they were not able to establish causal relationships for the improvement of pain following intervention with WPA. The sample size of the studies that found favorable effects on pain was usually small, 50 participants, on average11,19,23,32-34,38-41,42,43,46,50,53,55. We should notice that the studies with larger numbers of participants did not find sufficient elements to associate WPA with improvement of musculoskeletal pain18,35. Therefore, the present review evidenced a need for studies on the relationship between WPA and intensity of musculoskeletal pain to be continued.
About 15 studies analyzed the impacts of WPA on the participants' lifestyle behaviors. For this purpose, the authors employed questionnaire "Lifestyles and Leisure-Time Habits of Workers at Brazilian Industrial Companies"16; adapted Buckle and Echternach's questionnaire42; exploratory interviews and questionnaire SF-366; questionnaire "Lifestyle Profile"49; and ad hoc questionnaires and interview scripts7,15,18,23,24,26,29,35,37,39,55.
The authors who investigated the relationship between lifestyle and WPA are divided among the ones who believe that WPA favors the adoption of healthy lifestyles6,7,15,18,24,26,29,33,35,37,39,42,55, and the ones who consider there is not conclusive evidence in this regard16,49.
MENTAL HEALTH COMPONENTS
The scope of mental health conditions considered in WPA interventions was quite broad, among which stress, mood disorders, fatigue and anxiety stood out. In the attempt to investigate these aspects, some studies applied instruments, such as Work Stress Test (WST)46 and Bipolar Fatigue Questionnaire48 or ad hoc instruments33.
We detected a trend among authors indicating that WPA has clear benefits on mental health7,17,18,32,33,35,42,43,48,53. However, other authors observe that the effects were not fully favorable, especially when stress-related conditions were considered16,46.
COMPONENTS OF HUMAN MOVEMENT
The components of human movement assessed following WPA sessions include: flexibility, strength, posture and motor coordination. The tools used for this purpose were: International Physical Activity Questionnaire (IPAQ)50; static muscle strength tests52; semi-structured interviews23; electromyography54; Flexitest41,55; Wells bench35,55; dynamometry49; and ad hoc questionnaires38,55.
All the authors who analyzed components of human movement reported significant improvement following WPA. These findings suggest that these aspects possibly are the ones that best respond to interventions based on WPA.
QUALITY OF LIFE
Seven studies analyzed the quality of life of workers. For this purpose 2 studies applied QVS-8044,45; 3 studies SF-366,25,53; and 2 ad hoc, non-validated questionnaires31,35.
However, although most studies applied validated questionnaires, some did not actually analyze quality of life (QoL)6,34,44,53. Instead, they focused on some topics, such as daily well-being and general health, selecting some isolated items from instruments traditionally used for QoL assessment. Only two studies found improvement of QoL following WPA25,31. Both are descriptive studies that analyzed frequencies of variables, but did not establish any relationship between them. This fact notwithstanding, Grande et al.45 assert that 3-month intervention might not suffice to detect significant improvements in health domains or perceived quality of life.
ANTHROPOMETRIC INDICATORS AND VITAL SIGNS
Four studies prioritized anthropometric indicators – body weight, height, body fat percentage, body mass index (BMI) and waist circumference (WC) – and/or vital signs – systemic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP) and heart rate (HR).
For this purpose, the tools used included: bioimpedance scales; electronic blood pressure and HR monitors47; electronic scales; electronic stadiometer and fat caliper49; and ad hoc questionnaires for anthropometric assessment35,52. In none of the studies the results indicated improvement of anthropometric indicators or vital signs as being WPA-derived benefits.
The analyzed literature shows that WPA is a rather recent subject, being scarcely addressed by Brazilian researchers.
Most studies employed quantitative and descriptive methods, while very few had resource to qualitative or qualitative-quantitative approaches, which fact hinders any attempt at a more subjective understanding of the impact of WPA on workers' well-being.
While WPA has been more widely investigated by physical educators and physical therapists, it was also approached by other categories of professionals, which indicates that the field exhibits a multidisciplinary trend. Nevertheless, one may easily notice that the biomechanical view still prevails in interventions, and consequently, that its multi-professional nature did not suffice to broaden the scope of WPA. As a result, as applied in Brazil, the focus of WPA is still limited to musculoskeletal disorders. This seems to restrict its indication to conditions that respond well to physical activity, such as disorders of the respiratory and peripheral nervous systems, attention and memory deficit, sedentary behavior, obesity, and eventually some gastrointestinal and urinary problems present in the world of work4.
By contrast, the international literature points to a broader scope for WPA, as its benefits have been investigated for several outcomes, as e.g.: blood pressure and blood sugar levels; productivity; absenteeism; use of health services; reduction of obesity; perceived well-being; and satisfaction with work56. There is a need to widen the comprehension of WPA in its articulation with other actions, such as workplace surveillance, disability prevention and promotion of workers' health57.
Analysis showed that some studies included the results of assessments of WPA performed by workers and managers. However, some such measurements are unspecific and do not clarify the main difficulties and potential of this type of intervention21,22,27,30,42.
It is worth noticing that, as a rule, the studies neglected organizational and political determinants that might influence the outcomes of WPA. The exception is the study by Andrade and Veiga21, who addressed dissatisfaction with the care for technical aspects of WPA, such as the place allocated to activities, embarrassment induced by exercising in front of colleagues, the music selection and length of sessions. Also Soares et al.28 called the attention to the influence of issues related with the capital-work relationship on lack of adherence to WPA, as e.g. excessive job demands, lack of reorganization of work to make room for WPA and inability of workers to control their rest time, since WPA is allocated to this time slot without any reflection whatsoever on the actual needs of workers. Curiously, one study performed in the Netherlands by Robroek et al.58 addressed the ethical and moral tension derived from the interference of employers and workplace demands with the private life of employees. According to these authors, lifestyle behaviors (including drinking and smoking), use of free time and interpersonal relationships should remain outside the scope of influence of employers. Here one might also add that Brazilian authors have neither considered cultural or religious aspects in the assessment of the results of WPA.
The analyzed studies included several complex variables, such as pain, lifestyle behaviors, mental health components and quality of life, among others, which were associated to the results of WPA intervention. However, one may ask whether objective quantitative study designs are able to provide the complex data required for analysis of the effectiveness and efficacy of WPA. Indeed, for this type of subject the literature suggests qualitative and participative approaches, allowing for the workers' opinions to be heard in a widely encompassing and inclusive manner59.
For instance, pain is a genuinely subjective unpleasant emotional and sensory experience of multidimensional nature60. Lifestyle is the set of habits and customs that is influenced, modified, encouraged or constrained by the lifelong process of socialization61. In turn, mental health involves a complex interaction of biological, psychological and social factors62, and might be considered as the dynamic balance of the interactions of individuals with their various ecosystems63. Quality of life includes physical, mental, psychological and emotional well-being, in addition to social relationships, such as the ones with family and friends, health, education and purchasing power, among other life circumstances61.
Anthropometric indicators assess the nutritional status of populations and also metabolic disorders64. Vital signs are indicators of the state of health and status of the circulatory, respiratory, neural and endocrine functions of the body65. A causal relationship between improvement in these and the abovementioned aspects and WPA could not be systematically established.
Differently, when WPA was correlated with components of human movement, such as flexibility, strength, posture and motor coordination, its benefits were compelling35,41,52,54. Perhaps such results were unequivocal because these factors might be objectively measured, and as a rule only depend on the examiner's expertise. Flexibility, muscle strength, posture and motor coordination, all of them frequently considered in studies on WPA, demonstrate in a simple and replicable manner the gains obtained with WPA intervention66-67, whence its undisputable usefulness.
IMPLICATIONS FOR FUTURE STUDIES
We emphasize the aspect of inclusiveness68,69 for future studies, which lacked in the reviewed literature. The influence of factors such as gender, age range, presence or not of physical or mental disabilities or other disorders, incentive and freedom to adhere to WPA, among others, are still largely neglected by researchers. In addition, the type of employment relationship involving workers and WPA promoters, productive sector areas and hierarchical models at companies were practically fully absent in the analyzed studies. These are contextual elements that should be considered in the design of any study performed at the workplace so as not to pass over several aspects that have a role in the health-disease-work process at the so-called "factory floor."57,59
Despite all the care in the formulation of the study design and in article selection, the present review might have limitations derived from the access to Brazilian databases, which is not always consistent and stable. In addition, the use of keywords in the Portuguese language might have hindered locating articles published by Brazilian authors in international journals. In the same line, term "labor gymnastics", selected as keyword, seems to be frequently used in studies published by Brazilian authors, but very seldom occurs in the international literature, which brings again the concern with the difficulties inherent to international scientific dialogue.
Within the scope devised for the present review, we conclude that WPA has been investigated through many different methods and involving variable modalities of application. The number of qualitative and multi-method studies was small, while these methods could certainly elucidate the reach and potential of WPA.
Finally, the reviewed studies showed that WPA alone does not seem able to induce changes as deep in individuals as to modify parameters of their quality of life, mental status and other aspects inherent to the relationship between workers and their environment, organizations and work process. Nevertheless, the present review reaffirms the need to maintain close relations between production of democratic, inclusive and emancipatory knowledge and articulation of interventions in the world of work, as they will result in concrete benefits not only for the productive sector, but for society at large.
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15 de Agosto de 2017.
Aceito em 26 de Dezembro de 2017.
Trabalho realizado no Laboratório de Estudos e Práticas em Saúde Coletiva (LEPASC) da Universidade Federal da Paraíba (UFPB) – João Pessoa (PB), Brasil.
Fonte de financiamento: nenhuma