Journal of Occupational Rehabilitation

https://doi.org/10.1007/s10926-019-09840-7

Effectiveness of Workplace‑Based Muscle Resistance Training Exercise

Program in Preventing Musculoskeletal Dysfunction of the Upper
Limbs in Manufacturing Workers
C. Muñoz‑Poblete1 · C. Bascour‑Sandoval2 · J. Inostroza‑Quiroz2 · R. Solano‑López3 · F. Soto‑Rodríguez2

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Abstract
Aims Given the high levels of absenteeism due to musculoskeletal disorders of the upper limbs, there is a need for preven-
tive strategies to protect workers exposed to high risk levels. The purpose of this study was to determine the effect of a
workplace-based muscle resistance training exercise program in the presence of pain and musculoskeletal dysfunction of
the upper extremities in manufacturing workers exposed to repetitive movements and excessive effort in the workplace.
Method Randomized controlled trial in manufacturing workers. A sample of 120 healthy workers was allocated at random to
an experimental group, which received a resistance-based exercise program, and a control group, which performed stretch-
ing exercises. Results The muscle resistance training exercise had a protective effect on the intensity of pain perceived by
workers in their upper limbs (RR: 0.62 95% CI 0.44–0.87) compared with the group of workers who performed stretching
exercises. Conclusion A workplace-based muscle resistance training exercise program is an effective preventive strategy in
factory workers exposed to risk; however, it is necessary for companies initially to adopt mechanisms to minimize exposure
as a prevention strategy.

Keywords  Muscle exercise · Musculoskeletal disorder · Work · Prevention

Introduction work-related exposure and individual capacity [6]. The for-

Musculoskeletal disorders are among the most common
causes of occupational illness [1], representing 59% of all
work-related illness reported in European statistics. Apart
from the direct effect on employees’ health and their inca-
pacity for work, this problem imposes a considerable socio-
economic burden due to the extensive use of health services,
sick leave, disability pensions and lost productivity [2–5].
According to the World Health Organization, work-
related musculoskeletal disorders are a multifactorial
phenomenon whose contributory factors include both
* C. Muñoz‑Poblete
claudio.munoz@ufrontera.cl
1
Depto. Salud Pública, Universidad de La Frontera, Temuco,
Chile
2
Depto. Medicina Interna, Universidad de La Frontera,
Temuco, Chile
3
Depto. Especialidades Médicas, Universidad de La Frontera,
Temuco, Chile
mer includes the physical and psychosocial conditions of
the job, and the latter the worker’s physical characteristics
and general health. An integrated focus in health-at-work
programs must consider all these aspects [7].
The work-related musculoskeletal disorder most closely
associated with manual labor is injury to the upper limb [8].
The scientific evidence shows that the prevalence of this
disorder is greater in jobs involving a high rate of repetitive
work and heavy physical work [9]; therefore, interventions
in the workplace to prevent and control the problem appear
very necessary.
Although the scientific evidence is not conclusive,
the main traditional focus for managing musculoskeletal
disorders has been on ergonomics and education in the
workplace. Research [10] shows partial to moderate evi-
dence that modifications in the workplace are effective at
improving health outcomes. Another study [11] found that
interventions in the workplace can be effective at reduc-
ing sick leave, but do not produce a general improvement
in health outcomes. On this basis, it is suggested that
studies should be extended to other components of the

13
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employer-employee relationship which could facilitate an
improvement in health, for example increasing the work-
ers’ physical capabilities.
Following the model of the National Research Council
and Institute of Medicine [12], one alternative strategy for
preventing or reducing work-related musculoskeletal pain
is the use of a workplace-based muscle resistance training
exercise program. This would give the worker sufficient
physical capacity to endure the physical demands of the
job.
According to the guidelines of the American College
of Sports Medicine [13], the most pronounced adaptations
at the level of muscle cells are obtained in response to
dynamic and progressive muscle training, which includes
high-intensity concentric and eccentric contractions and a
maximum of 8 to 12 contractions [14]. A general principle
of exercise physiology is that training should be regular
and continuous to obtain the best results. However, it has
been reported that attendance at exercise sessions is fre-
quently a serious problem [15]. Program adherence has
been recorded from 70 to 87% in programs with a follow-
up of 10 to 20 weeks [16] and from 31 to 39% at 12 weeks
[17].
Given that the effectiveness of exercise in musculoskel-
etal pain control is proportional to program adherence [18],
knowledge of prognostic factors for compliance is essential
for optimum implementation of exercise in the workplace.
The literature shows that to ensure that the interventions are
as effective as possible, they must be simple, easy to under-
stand [19] and form part of the worker’s daily routine [16].
The intensity of neck/shoulder/arm pain has been reduced
in office workers and laboratory technicians in response to
10–20 weeks of muscle training with weights, elastic bands
[19, 20, 21] or weightless exercise [22, 23]. Positive effects
have also been found in industrial workers after 20-week
interventions [24]. These findings are based on clinically
important changes in pain levels with a statistically signifi-
cant difference [20].
Most of the aforementioned studies were conducted on a
working population with low physical demand, mainly office
workers and light-load operators; it may not be possible to
transfer these results to manufacturing workers, who pre-
sent a high prevalence of musculoskeletal disorders [8]. It
is therefore pertinent to compare the inclusion of muscle
training during the working day as a prevention measure
to the traditional focus on prevention based on stretching
exercises for healthy workers.
Therefore, the purpose of this study was to determine the
effect of a workplace-based muscle resistance training exer-
cise program in the presence of pain and musculoskeletal
dysfunction of the upper extremities in manufacturing work-
ers exposed to repetitive movements and excessive effort in
the workplace.
13
Journal of Occupational Rehabilitation
Methods
Study Design
The study population consisted of manufacturing workers
exposed to excessive effort and repetitive tasks principally
with the upper limbs; they were employees of two private
companies specializing in furniture manufacturing. The
workers were identified and selected in 2016. A single-
blind controlled study was carried out with two parallel
random groups, run by duly trained personnel. The initial
and final measurements were masked. The study included
workers aged up to 40 years, asymptomatic or at most
with slight musculoskeletal pain in the upper limbs, slight
intensity on the visual analogue scale (VAS less than or
equal to 30 mm), score OCRA ≥ 7.5. Baseline, follow-up
and final measurements were taken. Workers excluded
from the study had 1 year or less at work, a history of
musculoskeletal trauma in the upper limbs or cardiovas-
cular or systemic disease.
Sample Size
The primary outcome considered in selecting the sample
size was pain intensity. To determine the number of par-
ticipants for the study we used the Epidat 3.1 ® statistics
program [25]. The significance threshold was set at 5%
(α = 0.05), with a power of 80% (β = 0.20) and variability
in the effect in each group of 1 standard deviation. For the
primary outcome, we considered a clinically important
difference of minimum 12 mm and a standard deviation
measuring 10 mm [20]. With estimated loss during follow-
up of 20%, the calculation yielded a total of 110 workers.
Participants
A total of 2400 workers belonging to the manufacturing
companies involved in the study were contacted to par-
ticipate, of which 936 did not meet the inclusion criteria.
Of the 1453 remaining workers, a correlative number was
assigned to them to obtain the sample randomly. Likewise,
the sample included an additional number of individu-
als for probable losses, consisting of 120 individuals, of
whom 11 did not consent to take part in the study (Fig. 1).
Randomization
A simple randomization was carried out, for which work-
ers were given sealed and opaque letters that included the
assignment to the group of muscle resistance training exer-
cise or to the group of stretching exercises. The control
Journal of Occupational Rehabilitation

Recruitment Potenal parcipants assessed for eligibility (n:2400)

Excluded (n:947)
• Do not comply with selecon criteria (n:936)
Included (n:1453)
• Random sample (n:120)
• Decline to parcipate (n: 11)

Randomised (n: 109)

Assignment

Assigned to intervenon: 53 Assigned to control:56

Received intervenon: 53 Received intervenon: 56
Follow-up

Lost in follow-up: 1 Lost in follow-up:3

Intervenon interrupted: 1 Intervenon interrupted: 3

Analysed: 52
Analysis

Analysed: 53
Excluded from analysis: 0 Excluded from analysis: 0

Fig. 1  Flow chart

group was comprised of 56 individuals and the interven-
tion group 53 individuals.
During the study follow-up two participants were dis-
missed, one from the intervention group and another from
the control group; in the latter group, two women also took
maternity leave.
Interventions
The intervention took place over a period of 16 weeks. The
intervention was applied by two specially trained physi-
otherapists responsible for monitoring the whole exercise
program. Particular attention was paid to ensuring program
adherence and proper follow-up.
The program was based on muscle training with progres-
sive resistance (Fig. 2) carried out at the work stations of
each company during working hours. Training was bilat-
eral, focusing on three areas of the body: scapular waist
zone (shoulder elevator, retractor and protractor muscles),
shoulder zone (shoulder abductor and rotator muscles),
forearm-hand zone (wrist supinator and extensor muscles).
The exercises were carried out in groups, supervised by
a physiotherapist. Intervention was three times per week on
alternating days. The timetable was defined by the company
and each session lasted 15 min. The intervention was bilat-
eral and included specific locations and forces; the loads
were increased progressively following the principle of peri-
odization and progressive overload. The loads were applied
by rubber bands 20 cm wide by 2 m long with color-coded
graduations ­(Theraband®).
Prior to the change in exercise resistance, tolerance to the
next level of resistance was evaluated. The physiotherapists
focused on positive comments to maintain motivation and
program compliance.
Based on the principles of muscle training with progres-
sive resistance [13], each exercise cycle started with a pre-
tensioned rubber band, and a series was followed consisting
of concentric contraction, isometric contraction for 6 s, and

13

Fig. 2  1. Elevator muscles; 2. Retractor muscles; 3. Protractor muscles; 4. Abductor muscles; 5. Rotator muscles; 6. Supinator muscles; and 7.
Extensor muscles
finally eccentric contraction. The pause between each cycle
of exercises was 10 s.
The intervention protocol was planned for 16 weeks
of training spread across three phases, which were incor-
porated gradually. The program was standardized for
all participants making only differences between men
and women. Phase 1 (48 sessions): shoulder stabilizing
muscles with three progressive levels of resistance using
13
Journal of Occupational Rehabilitation
theTheraband of 4.6  kg, 6.3  kg and 8.5  kg for 16 ses-
sions each. Phase 2 (36 sessions): the phase 1 exercises
were augmented by strengthening of the forearm and hand
muscles, with three progressive levels of resistance using
the Theraband of 4.6 kg, 6.3 kg and 8.5 kg for 12 sessions
each. Phase 3 (24 sessions): the phase 1 and 2 exercises
were augmented by strengthening of the shoulder exter-
nal rotation and elevator muscles, with three progressive
Journal of Occupational Rehabilitation

levels of resistance using the Theraband of 4.6 kg, 6.3 kg Measurement of Physical Risk
and 8.5 kg for 8 sessions each.
Women carried out the same protocol as men, but with The risk associated with repetitive movements was
a lower resistance, using the Theraband of 3.2 kg, 4.6 kg assessed by applying the OCRA checklist, which measures
and 6.3 kg. the risk level in terms of the likelihood of musculoskeletal
The control group maintained a daily routine established disorders presenting in a given time, focusing on the risk
by both companies consisting of stretching exercises. These to the upper limbs [31].
exercises consisted of limb movements to stretch muscu-
loskeletal tissues, carried out by workers under the partial
Statistical Methods
supervision of a monitor from the work section who had
been trained by the supervising physiotherapists.
A mask was constructed for data entry using the statistical
software EpiData and Stata15.1 for analysis [32]. A bivari-
ate analysis based on Fisher’s exact test for categorical
Baseline Measurements
variables and a t test for continuous variables were used;
if these could not be applied, the Wilcoxon signed-rank
On enrolment into the study and based on the current causal
test was used. Statistical significance tests were included
model of work-related musculoskeletal pain [12], all the
to identify in an exploratory way those variables that may
workers were asked to complete a standardized questionnaire
be influencing the appearance of musculoskeletal pain
giving information about their sociodemographic, individual
considered in the model. The main analysis consisted of
and work characteristics. These included questions about
estimating the effect of the workplace-based muscle resist-
their age, anthropometric details, gender, family situation,
ance training exercise program through a multiple regres-
education level, time in employment, work organization,
sion model, which included the variables that showed a
level of physical activity and whether they smoked. The fol-
statistically significant association in unadjusted models.
lowing measurements were also included:
The evaluation of the model included goodness-of-fit tests
using the likelihood ratio test.
Information on Clinical and Functional History and Pain
Ethical Approval
At the start and end of the study, information was collected
on pain intensity using the VAS for pain, graduated on a The study protocol was notified, registered and approved
continuum from 0 to 100 mm. The reliability and validity of by the Ethics Committee of the Universidad de La Frontera
this instrument have been described and tested in numerous (Decision 031/2015).
studies [26]. Additional information on the participants’ his-
tory of musculoskeletal pain was obtained using the Nordic
Questionnaire, the DASH (Disabilities of the Arm, Shoul-
der and Hand) Questionnaire [27] and by clinical tests [28,
Results
29] to detect muscle and tendon conditions in the shoulder
The sample contained 80.7% men, the mean age was
(subacromial impaction test, supraspinatus muscle test and
28.7 years ( x standard deviation (SD) 5.4 years. 71.6%
painful arch test) and forearm (epicondylitis test: stretching
completed secondary education, 54.12% were married or
method and resisted contraction method).
in a stable relationship, and 53.2% were principal wage-
earner of the family. Of the whole sample, 45.9% reported
carrying out recreational physical exercise, such as run-
Measurement of Psychosocial Risk
ning, cycling or football, and 62.4% were non-smokers.
34% presented a normal body mass index and 24% were
On enrollment into the study the workers answered the
overweight (Table 1).
SUSESO ISTA 21 Questionnaire, which provides informa-
In organizational terms, the workers had been employed
tion on five dimensions: psychological demands, active work
on average for 4 years; most share their work stations
and skills development, social support in the company and
(76.2%) and half (51.2%) rotate between work stations
leadership quality, compensation, and double presence (e.g.
within the company. They are employed at different tasks
paid work and domestic-family work). This questionnaire
in the furniture manufacturing chain. Evaluation of occu-
reveals the workers’ level of psychosocial risk, which may
pational risk measured by OCRA produced a x score of
affect their health. All the items are marked with a score that
15.4 (± 11.5) for the right upper limb and 11.7 (± 6.0) for
increases with the risk level [30].

13
 Journal of Occupational Rehabilitation

Table 1  Baseline characteristics
Control (n = 53) Intervention (n = 52) p value

Age ( x, SD) 28.36 (5.42) 29.03 (5.38) 0.5125

Sex (%) 0.3463
 Male 78.6 83.02
 Female 21.4 16.98
Educational level (%) 0.939
 Primary 5.4 7.6
 Secondary 82.1 79.2
 Higher 12.5 13.2
Marital status (%) 0.954
 Single 46.4 45.3
 Long term relationship 26.8 28.3
 Married 23.2 24.5
 Divorced, widowed 3.6 1.9
Principal wage-earner (%) 48.2 58.5 0.283
Practice recreational exercise (%) 0.121
 Never 30.4 18.9
 Occasionally 25.0 33.9
 Frequently 37.5 28.3
 Always 7.14 18.9
Smoker (%) 0.644
 No. 66.1 58.5
 Occasional 26.8 30.2
 Smoker 7.1 11.3
Weight ( x , SD) 76.9 (12.8) 79.0 (14.5) 0.411
Height (mean, SD) 169.6 (7.8) 169.1 (6.9) 0.749
BMI (%) 26.8 (4.2) 27.6 (4.9) 0.370
BMI (%) 0.622
 Low weight – –
 Normal 32.7 34.6
 Overweight 45.5 36.5
 Obesity 20.0 28.9
Pain intensity initial VAS 0–100 mm ( x , SD)
 Upper limb 9.7 (10.4) 8.0 (7.1) 0.161
 Neck 9.9 (18.9) 5.8 (15.1) 0.105
 Right shoulder 12.4 (23.9) 10.9 (21.1) 0.373
 Left shoulder 7.4 (16.7) 8.8 (21.2) 0.654
 Right elbow-forearm 10.4 (19.9) 6.7 (12.9) 0.124
 Left elbow-forearm 5.6 (16.7) 4.8 (13.2) 0.394
 Right wrist-hand 13.9 (26.0) 10.6 (19.7) 0.231
 Left wrist-hand 8.7 (21.8) 6.2 (16.4) 0.247
 Functionality initial DASH: 0–105 points ( x , SD) 27.2 (8.9) 29.8 (8.4) 0.401
Everyday functional difficulties in the last week (%) 0.112
 None 56.4 54.7
 Few 21.3 17.1
 Moderate 22.3 28.2
 Substantial – –
 A lot – –

13
Journal of Occupational Rehabilitation

Table 1  (continued)
Control (n = 53) Intervention (n = 52) p value

Everyday working difficulties in the last week (%) 0.223

 None 32.3 34.7
 Few 28.1 25.2
 Moderate 19.4 23.1
 Substantial 20.2 17.0
 A lot – –
Difficulty in performing work (%) 0.303
 None 48.3 49.1
 Little difficulty 12.2 14.2
 Moderate difficulty 11.5 9.8
 Great difficulty 28.1 26.9
 Incapable – –
Difficulty in performing work as well as you would wish (%) 0.282
 None 33.6 31.5
 Little difficulty 17.8 19.2
 Moderate difficulty 22.4 21.2
 Great difficulty 26.2 28.1
 Incapable – –

OCRA​ Occupational repetitive action

*p value: < 0.05 (T-test, Fisher’s exact test)

Table 2  Baseline organizational Control (n = 53) Intervention (n = 52) p value

characteristics
Employment history (months, x , SD) 48.9 (53.3) 48.2 (45.7) 0.935
Employment in the same company 46.6 (40.2) 41.8 (32.6) 0.497
(months, x , SD)
Shared work station (%) 73.2 79.3 0.460
Replaced when absent (%) 78.6 83.0 0.556
Rotation through different tasks (%) 44.6 58.5 0.148
Monthly remuneration (U$) 518 493 0.219
OCRA (0–22.5) ( x , SD)
Right 14.8 (11.2) 15.9 (11.8) 0.597
Left 11.4 (5.5) 11.9 (6.5) 0.624

*p value: < 0.05 (T-test)

Table 3  Baseline psychosocial Control (n = 53) Intervention (n = 52) p value

factors x (SD) x (SD)

Psychological demands (0–20) 8.9 (2.9) 8.1 (2.7) 0.127

Social support and leadership quality (0–20) 6.9 (3.4) 6.8 (3.3) 0.721
Active work and skills development (0–20) 5.7 (3.2) 5.2 (2.9) 0.375
Compensation (0–12) 4.5 (2.7) 4.2 (2.8) 0.512
Double presence (0–8) 4.8 (2.4) 3.8 (2.6) 0.036*

*p value: < 0.05 (Fisher’s exact test)

13

the left, meaning that both are classified as an unaccepta-
ble risk (Table 2).
The five psychosocial risk factors evaluated presented a
moderate level of occupational health risk (Table 3).
Due to the exposure of the individuals to tasks of high
repetition and overstrain of the upper extremities, which
supposes a greater risk of musculoskeletal affectations, the
evaluation of the pain and clinical tests was considered.
The mean value of pain intensity at the start of the study
did not differ significantly between the intervention group
and the control group; the predominant issues were pain in
the right hand-wrist ( x:12.3 mm, SD: 23.1) and right shoul-
der ( x ∶ 11.7 mm, SD: 22.4). Although employed in active
work, they reported varying intensities of pain. The mean
baseline pain intensity for all upper limb areas was 8.9 mm
(SD: 8.9).
The clinical tests [28, 29], carried out at the beginning of
the study, consisted of provocation tests and helped detect
muscle and tendon conditions in the shoulder and forearm,
which made it possible to rule out individuals with subclini-
cal conditions. These tests were the subacromial impaction
test and the epicondylitis test. These were positive 19% for
the shoulder and 10% for the forearm.
The musculoskeletal symptoms persisted for 177 days on
average, with the highest number of days in the shoulder area
( x ∶ 219 days, SD: 535); there were no statistically signifi-
cant differences between the groups.
Mean attendance at exercise sessions was 40.6 sessions
(SD: 7.4) with a minimum of 10 sessions by a participant
who abandoned the study and a maximum of 48 sessions by
those who completed the entire program. On conclusion of
the study, 90% of the workers in both the experimental and
control groups had attended at least 46 sessions, while the
overall attendance was 75%.
At the start of the study, the workers presented mean
upper limb pain ( EVA∶ x 8.9 ). The results of the final pain
level measurements are shown at Table 4. The group which
carried out muscle resistance training exercise presented a
lower mean pain level than the control group; the difference
between groups was statistically significant in the follow-
ing regions: neck, right elbow-forearm, and both right and
left wrist-hand. The difference between the groups was also
significant when the overall pain of shoulder elbow and hand
was considered. Other musculoskeletal symptoms such as
tingling and muscle weakness were absent in the interven-
tion group.
The mean baseline measurement of work functionality of
the workers was DASHx28.5. The final results for the work-
ers’ functionality are given in Table 4. The value attached
to the upper limb as a functional unit was measured with
the DASH questionnaire, which quantifies and compares
the repercussions of the different processes affecting differ-
ent regions of the limb. The groups presented statistically
13
Journal of Occupational Rehabilitation
significant differences in the sum of their capacities to per-
form 21 activities; the workers presented a mean score of 27
points on a scale of 0 to 105. In the report of functional dif-
ficulties in the last week, members of the intervention group
related fewer difficulties in everyday and work activities (p
value: < 0.05). In the survey of “difficulty in performing
work”, 70% of the workers exposed to the muscle resist-
ance training exercise presented no functional difficulties.
The muscle resistance training exercise had a protective
effect on the intensity of pain perceived by workers in their
upper limbs (RR 0.62 95% CI 0.44–0.87) compared with the
group of workers who performed stretching exercises. Like-
wise, the workers engaged in the experimental intervention
also had a positive effect with respect to work functionality
(RR 0.51 95% CI 0.32–0.83).
Discussion
This study showed that the intervention of a workplace-
based muscle resistance training exercise program for manu-
facturing workers reduces musculoskeletal pain in the upper
limb more than the stretching exercises they habitually carry
out at work. Their work functionality was also improved.
In general, the results are in line with those of another
clinical trial [33], which also confirmed the positive effect
of the exercise program on painful symptoms in the neck,
shoulder, forearm and hand, as well as producing every-
day functional and work improvements. The differences
observed in this study are related to the administration peri-
ods of the programs; for example, an intervention of 6 to
9 months with two sessions per week is described, as com-
pared to 16 weeks in the present study with similar results.
Another difference is that in the study mentioned above, the
control group did not perform preventive physical activity
at work [33], in contrast to the activity done in this study.
In a systematic review [34], 30 different types of inter-
vention to prevent musculoskeletal disorders of the upper
limb in the workplace were evaluated. Strength exercise pro-
grams presented the strongest evidence of prevention, while
stretching exercises presented moderate evidence. In the pre-
sent study, as in those described in the systematic review, the
interventions were applied in the workplace, allowing their
potential benefits to be included in preventive management
and control.
The muscle resistance training exercise programs in the
systematic review did not have the same effect in the differ-
ent regions of the body; the greatest effect of pain reduc-
tion and control was found in the elbow, forearm and wrist,
principally on the dominant side. This variability was also
shown in another study [34], in which the pain reduction and
functional improvement were concentrated in the shoulders
and wrists.
Journal of Occupational Rehabilitation

Table 4  Symptomatology and functionality on completion of the intervention

 Pain intensity final, VAS (0-100 mm) Control (n = 53) Intervention (n = 52) p value
x (SD) x (SD)

Upper limb 10.4 (11.3) 5.4 (8.8) 0.007*

Neck 6.6 (17.6) 1.1 (5.4) 0.045*
Right shoulder 11.1 (21.9) 8.5 (20.3) 0.259
Left shoulder 6.6 (17.6) 6.5 (15.9) 0.481
Right elbow-forearm 12.8 (24.6) 4.3 (14.2) 0.016*
Left elbow-forearm 8.7 (21.5) 5.3 (16.4) 0.182
Right wrist-hand 12.2 (25.5) 4.5 (16.4) 0.034*
Left wrist-hand 10.9 (20.8) 1.1 (5.4) 0.013*
Functionality final, DASH (0–105 points) 28.7 (9.1) 25.8 (8.7) 0.037*
Everyday functional difficulties in the last week (%) 0.018*
 None 71.7 86.54
 Few 9.43 11.54
 Moderate 18.87 1.92
 Substantial – –
 A lot – –
Everyday working difficulties in the last week (%) 0.065
 None 43.40 71.15
 Few 32.0 17.31
 Moderate 16.98 9.62
 Substantial 5.66 1.92
 A lot 1.89 –
Difficulty in performing work (%) 0.041*
 None 64.15 78.85
 Little difficulty 1.89 3.85
 Moderate difficulty 13.21 3.85
 Great difficulty 18.87 9.62
 Incapable 1.89 3.85
Difficulty in performing work as well as you would wish (%) 0.021*
 None 45.28 71.15
 Little difficulty 26.42 13.46
 Moderate difficulty 20.75 5.77
 Great difficulty 7.55 9.62
 Incapable – –

*p value: < 0.05 (t-test)

The study participants were healthy, active workers; how-
ever, they presented variable magnitudes of pain at the start
of the study. The intervention produced reductions in pain
intensity in the workers despite the same physical and work
requirements. Although the pain reduction was not clini-
cally relevant, it was important in view of the high physical
demands to which the workers are exposed, and the higher
risk of triggering a more serious situation of dysfunction or
pain. The functionality reported was improved in the inter-
vention group, either because of its relation with reduced
pain or as a result of the positive effect of the exercise.
It should be noted that when exercises are carried out
with the upper limbs, beneficial effects are also found in
the cervical area; this occurs particularly when the aim is
to develop strength in muscles which share their function
between the two area. In this study in particular, a reduction
in cervical pain close to the clinically important difference
defined for this study was observed [35].
In the randomization process, the distribution of the work-
ers between the control and intervention groups resulted in
quite similar patterns of sociodemographic and individual
characteristics, work station risk and psychosocial factors.
The analysis of these aspects showed that the sample was
representative of young workers. Given that the average age
of the sample is young, it is not possible to extrapolate the
findings to older populations.

13

Another important point is that the result of the meas-
urements taken showed that the workers suffered unsat-
isfactory health in various respects. Nevertheless, and
despite being exposed to a high risk of musculoskeletal
disorders and in some cases suffering slight pain, they
remained active at their work stations. The functionality
of the upper limb also appears to be reduced; this result is
an important consideration, since it may be a consequence
of the cumulative effects of exposure, and may also affect
the worker’s ability to carry out their work in the optimum
manner.
In recognition of their different morphological charac-
teristics, women carried out the progressive stages of the
training program with a series of lower resistance than
men. The program was less beneficial for them in terms of
symptomatology and functionality; however, these results
may be due to the low number of women participating in
the study compared to men. Nonetheless, it has been shown
that female workers have benefited from interventions of this
type even considering that the risks associated with exposure
to physical loads are substantially lower for them, in addition
to the differences attributable to their sex [36].
The psychosocial factors assessed showed a moderate
health risk, and this must be taken into account for an inte-
grated approach to prevention in the workplace. The litera-
ture recognizes that these factors may partially explain the
presence of symptomatology [37], particularly in the ser-
vices industry. They also appear to have an impact on manu-
facturing workers [38]. In the present study, social support
and leadership were risk factors for symptomatology and
functional alteration of the upper limbs; nevertheless, the
workers benefited from the implementation of the program.
It may be supposed that without this unfavorable condition,
the results of the intervention could have been better.
Given that the physical work performed in this study was
highly demanding, particularly in the upper limbs, and that
the literature [39] shows that exposure to repetitive physical
work with excessive effort in the upper limbs causes pain
and functional problems, it may be supposed that the pre-
ventive measures and ergonomic modifications implemented
previously have been insufficient.
Many interventions have been described in the literature
[40] and adapted to the work environment to prevent mus-
culoskeletal disorders with varying results. The intervention
evaluated in this study was aimed at producing muscle work
through regular and progressive training under supervision,
working on the assumption that this improves their condi-
tion. As a result of the program, the ability of workers to
tolerate external loads was increased by greater tolerance
to exposure to repetitive movements and excessive muscu-
loskeletal stress. This demonstrated its effectiveness as a
mechanism to prevent and control pain and musculoskeletal
dysfunction.
13
Journal of Occupational Rehabilitation
Another study [41] analyzed the effect of muscle training
with a variety of protocols in employees in different types
of work, such as office workers or teachers; the results were
similar, but they lacked statistical significance and important
clinical improvements were found in neck and shoulder pain.
In the work environment, one of the most commonly
used interventions consists of self-administered stretching
exercises; however, their proven effectiveness for managing
musculoskeletal disorders is low [31]. These exercises are
used mainly because they are easy to apply and of low com-
plexity; nevertheless, the present study showed that it is pos-
sible to apply a different exercise program, which although
it requires pre-training, supervision and follow-up, has a
preventive effect. Implementation is facilitated by the coop-
eration of the company and its risk prevention management
structure, making the time and space available to carry it out.
The findings of this study allowed us to contrast a work-
place-based muscle resistance training exercise program
and a workplace-based stretching exercise, although both
produced positive effects when implemented under supervi-
sion and with good adherence to the routine, the resistance-
based exercise program produced better protective effects
after 16 weeks.
It should be noted in this context that the two types of
program pursued different physical objectives: first, the
stretching exercises produce modifications in the flexibility
of musculoskeletal tissue, countering muscle reactions to
prolonged, repetitive or excessive effort. If this is the goal,
the exercises should be repeated before, during and after the
working day. Second, the resistance-based exercise program
is intended to affect the physiology of the muscles, modify-
ing the metabolism, contractile capacity and resistance to
fatigue of muscles used in the work [13]; this would help
improve a specific aspect of the worker’s physical capability
to respond to the particular demands of their work.
Another interesting point arising from this study is that
it allowed us to observe the variable effect in the areas that
comprise the upper limbs. The best results were found in
the distal parts, such as the forearm and wrist. This may be
due in part to the training technique used or the relation-
ship established between the biomechanical requirements
of the task and the use of anatomical areas. This element
needs to be evaluated in more detail in future studies by
analyzing individuals with more homogeneous biomechani-
cal requirements.
The first limitation of this study was the impossibility of
blinding the interventions due to their nature, and because
they were carried out by workers at their work stations. Sec-
ond, the effect of the intervention was measured immedi-
ately on conclusion of the study, so the long-term effects
are unknown. Third, the sample size and selection method
did not allow for a differentiated analysis of specific tasks
within the companies. And finally, given the small number
Journal of Occupational Rehabilitation
of women who participated in the study, the estimation of
the effect of the sex variable should be considered with cau-
tion and the results of this study applied mainly to young
men.
As a final point, doing exercises in the workplace proved
to be a modality which was easily accepted by the workers,
aided by the fact that the company established a time dedi-
cated to the purpose. This contributes to the opportunity to
implement similar programs with the support of the workers
themselves. Thus, workers in manufacturing companies can
benefit from a muscle resistance training exercise program,
which may complement or replace traditional prevention
activities.
Conclusion
In conclusion, the younger manufacturing sector workers
exposed to repetitive movements and excessive effort on the
job can benefit from the intervention of a muscle resistance
training exercise program in the workplace to prevent mus-
cle pain and dysfunction of the upper limb; however, it is
necessary for companies initially to adopt mechanisms to
minimize exposure as a prevention strategy.
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