Erasmus plus - Stretching and Strengthening at Work interact

Stretching and Strengthening SERGEJ M. OSTOJIC, DARINKA KOROVLJEV, VALDEMAR STAJER, NEBOJSA MAKSIMOVIC, JOHN VAN HEEL

at Work SPORT4H Network Health-Related Physical Fitness Evaluation and Prescription Manual

Novi Sad | May 1, 2020

SERGEJ M. OSTOJIC, DARINKA KOROVLJEV, VALDEMAR STAJER, NEBOJSA MAKSIMOVIC, JOHN VAN HEEL

Stretching and Strengthening at Work SPORT4H Network Health-Related Physical Fitness Evaluation and Prescription Manual

Stretching and Strengthening at Work

Foreword Having enough physical activity to advance health and wellbeing remains a challenging task for Europeans of all ages and backgrounds. Many general guidelines and educational ma- terials that promote healthy exercise are already available, yet somehow a majority of Eu- ropeans do not meet the physical activity recommendations while staying sedentary and physically inactive. Among others, members of the workforce tend to spend more time sitting while having fewer opportunities (and time) to exercise. Therefore, this sensible population requires an attentive approach of the academic community to address specific needs for physical activity and provide easy-to-digest instructions to promote healthy behaviors both at the workplace and home. The manual Stretching and Strengthening at Work has been prepared as a possible step for- ward in the right direction, being a guidebook to help testing manpower lifestyles but also to provide an illustrative document that contains many exercises for improving flexibility and muscular strength at workplace. As one of the main intellectual outputs and deliverables of SPORT4H Network , a project co-funded by the Erasmus + Programme of the European Union, the manual is intended to assist employees in improving health-related physical fitness by taking part in simple, short-term, specific and convenient exercises either at the workplace, home and during leisure. Exercises described here are primarily designed for healthy adults; always check with your health care provider before beginning exercise regimen to make sure you are medically able to participate. At the end, the authors would like to thank other members of SPORT4H Network for con- structive comments and suggestions during writing this book, and hope that Stretching and Strengthening at Work will become a handy reading for all employees (and other people too) who want to improve or maintain their health and fitness.

Sergej M. Ostojic Darinka Korovljev Valdemar Stajer Nebojsa Maksimovic John van Heel

Novi Sad | May 1, 2020

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Contents

Introduction | Getting and staying active for heath Health and lifestyle diseases

6 7 8 9

Physical activity and health

Tackling physical (in)activity at work

Physical activity interventions at workplace: open questions

Low back pain at workplace: a case study

10

Testing health and fitness at work

Measuring health-related physical fitness Healthy weight and body composition

12 12 13 14 16 17 19

Cardiorespiratory fitness

Muscular fitness: strength, endurance and flexibility Measuring physical activity and sedentary time

Additional health profiles

Exercise safely: tips and advices

Improve flexibility at workplace Start safely and smartly

21 21

General recommendations Neck and spine exercises Upper extremity stretches Lower extremity stretches

23

31 41

Improve muscular strength during working hours General recommendations

50 50

Breathing

Standing upper body exercises

51

Neck and spine exercises Lower body exercises

55 59 68

Mat exercises for glutes and back Mat exercises for abdominals Mat and office exercises for upper body Whole-body exercise at workplace

71

80 83

Being active at home and during leisure

How much physical activity is needed for good health?

86 87 88 89

Walking or cycling to job Home and leisure activities

Cut being sedentary

Exercise for special populations Older population

90 92 93

Adults with disabilities

Socially disadvantaged groups

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Introduction | Getting and Staying Active for Health Health and lifestyle diseases

Being healthy means much more than be free of disease! According to the World Health Organization (WHO), health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity ( WHO Constitution , 1946). Protecting and improving health thus requires more than straightforward access to healthcare systems; it also entails routine monitoring of health status, informing and educating the public about healthy lifestyles, and developing initiatives and policies to support health goals. Preventive measures in supporting public health in Europe appear to become of utmost importance these days since lifestyle-influenced diseases (such as obesity, diabetes, cardiovascular disease or cancer) are more prevalent than ever, as countries become more industrialized while people turn sedentary in addition to eating energy-rich diets ( Powles and co-workers, 2005; European Observatory on Health Systems and Policies , 2010; European Commission Health Promotion and Disease Prevention Knowledge Gateway , 2020). For instance, over 45% of men and women in the WHO European Region were overweight ( Figure 1 ) while there are about 60 million people with diabetes in Europe, or about 10.3% of men and 9.6% of women aged 25 years and over ( WHO Europe , 2020; WHO Europe , 2020).

Figure 1 | The prevalence of obesity across Europe Lifestyle diseases are quickly turning into the top-most economic burden on the health services across Europe. For example, cardiovascular diseases cost the European Union (EU) health care systems just under €111 billion in 2015, while cancer cost the EU €51 billion in 2009 ( European Commission Health Promotion and Disease Prevention Knowledge Gateway , 2020; United Nations , 2020). Lifestyle diseases (also known as non-communicable diseases) result in additional non- healthcare costs, for example productivity losses due to morbidity or mortality and costs of informal care. To tackle this gigantic burden of lifestyle-influenced diseases, that are mostly preventable, countries urgently require the most effective and affordable community programs to recognize health risk factors ( Figure 2 ) and positively impact wellbeing outcomes.

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Poor diet

Lifestyle diseases

Physical inactivity

Alcohol use

Tobacco use

Figure 2 | The key risk factors for lifestyle diseases

Physical activity and health Being physically active appears to positively affect various health outcomes, with regular physical activity ( ≥ 150 minutes per week of moderate-intensity activity) recognized as a fundamental lifestyle behavior in tackling lifestyle diseases (EU Physical Activity Guidelines , 2008; Physical Activity Guidelines to Americans , 2015; WHO , 2020). This means that an adult person should have to be active for at least 30 minutes for 5 or more times per week to gain a number of health benefits (Exercise is Medicine, 2020), including the following:  Improved bone health, contributing to the prevention of osteoporosis and fractures in older ages,  Maintained metabolic functions, healthy weight and low incidence of obesity and type 2 diabetes,  Maintained cognitive functions and lowered risk of depression and dementia,  Increased functional capacity to carry out activities of daily living at both home and work,  Decreased sick leave fromwork,  Lowered stress levels and associated improved sleep quality, and  Improved self-image and self-esteem and increased enthusiasm and optimism. TheconceptofHealthEnhancingPhysicalActivity (HEPA) iswidelyusedtodescriberecommendations on type, duration, frequency, intensity, and total amount of physical activity for health promotion and disease prevention (EU Physical Activity Guidelines , 2008; Physical Activity Guidelines to Americans , 2015; WHO , 2020). However, it appears that achieving this goal is not an easy task. Within the EU, just under one third of adults declared spending at least 150 minutes per week being physically active in 2014; physical activity decreases with age and increases with education level ( European Commission , 2018). Additionally, 46% of the Europeans say that they never exercise or play sport, while 14% only do so seldom. The prevalence of physical inactivity has major implications for the general health of the population and the prevalence of non-communicable diseases (WHO , 2020).  Reduced risk of cardiovascular diseases, including high blood pressure,  Lowered risk of certain types of cancers (e.g. breast, prostate and colon cancer),

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It appears that a majority of Europeans do not meet the physical activity recommendations, while staying more sedentary during both leisure time and work. According to a recent report ( European Commission , 2018), nearly half of Europeans (46%) never exercise or play sport, and this proportion has increased from 2013 to 2017 for 4% ( Figure 3 ). Less than half of Europeans (44%) do some form of other physical activity (such as cycling, dancing or gardening) at least once a week, while 35% never do this kind of activity at all.

Seldom, 14

Never, 46

With some regularity, 33

Regularly, 7

Figure 3 | The proportion (%) of Europeans who exe rcise or play sport On a usual day, around two thirds of Europeans (69%) spend between 2.5 and 8.5 hours sitting, while 15% of respondents do not walk for 10 minutes at a time at all in a weekly period. The amount of regular activity that people do tends to decrease with age, with an engagement in sport and physical activity being less prevalent among people with lower levels of education and those with financial difficulties. A lack of time is by far the main reason given for not practicing sport more regularly (40%). Other factors mentioned are a lack of motivation or interest (20%) and having a disability or illness (14%) ( European Commission , 2018). Only 13% of Europeans play sport or engage in other physical activities at work ( European Commission , 2018). Considering socio-professional categories, 26% of managers never exercise or play sport, compared with 37% in other white-collar jobs, 36% of self-employed people and 49% of manual workers. Furthermore, people in white collar occupations tend to spend more time sitting down. The proportion that spends more than 8.5 hours per day sitting down is 17% among managers and 19% among other white-collar workers. In addition, it appears that the lack of time is the principal obstacle to take part in regular exercise, while informal sport settings (e.g. home, parks, outdoors, workplace) are more popular than sport clubs and health or fitness centers. This perhaps opens a window of opportunity to develop and implement specific exercise programs that are straightforward, time-efficient and highly applicable to different categories of employees for advancing physical activity at an informal setting such as workplace ( Figure 4 ). Tackling physical (in)activity at work

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Convenient

Short - term

Simple

Spec ific

Figure 4 | Favorable features of work-related exercise program

The WHO’s European Policy Framework and Strategy for the 21st century prioritizes investing in health promotion programs by utilizing existing social networks such as the one in the workplace (WHO Regional Committee for Europe , 2013)). As workers generally spend more time in the workplace than any other location, the workplace can have a direct impact on workers’ physical, mental, economic and social health. The European Network for Workplace Health Promotion has defined workplace health promotion in their Luxembourg Declaration as the combined efforts of employers, employees and society to improve the health and wellbeing of people at work ( ENWHP , 2007). The European Agency for Safety and Health at Work find that well-implemented workplace health promotion can lead to improved working environment and a decrease in absenteeism (EU- EASHW , 2020), and therefore recommend that policies continue to emphasize the importance of workplace health promotion. Physical activity interventions at workplace: open questions European Commission Directorate-General for Education, Youth, Sport and Culture recently published a report containing a literature review and best practice case studies on physical activity at the workplace ( ECORYS, 2017). The report concluded that there is a large and well-developed body of knowledge on the outcomes and effectiveness of workplace physical activities ( Figure 5 ) yet there has been limited data on the effects of specific types of exercise interventions (e.g. stretching, muscle strength exercises) on specific groups of employees, including inactive individuals. Evidence on traditional interventions (e.g. walking initiatives, active travel) is more developed and robust while no studies evaluated the applicability of stretching or muscular strength exercise on physical activity behavior, health-related quality of life, healthy lifestyle profiles, or health-related physical fitness in working population.

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Most of the studies included have measured the short-term e ff ects of workplace interventions on speci fi c physical activity outcomes

Less focus on the effects of workplace interventions on physical activity using measures such as weekly levels of exercise

Limited focus on interventions for specific groups (e.g. health inequality groups)

Key findings

Evidence on some types of interventions is more developed than others

Multicomponent interventions (e.g. education, advice, counselling) have the best outcomes.

Figure 5 | A summary of the final report on physical activity at the workplace (ECORYS, 2017). In addition, no user-friendly guidelines describing alternative types of on-site exercise interventions has been developed and widely disseminated in working population, and no information is available as to whether such interventions yield an additional benefit for health profiles of inactive employees. Thus, developing and implementing a comprehensible, practical and user-friendly guidelines describing HEPA-endorsed strategies aimed to enhance different types of physical activity and counteract sedentary behaviors at workplace, with all its negative consequences, is of utmost importance to contribute to health promotion for the employees. Low back pain at workplace: a case study Sedentary behavior at workplace accompanied by other poor lifestyle behaviors often goes together with several specific health concerns, including low back pain, neck stiffness, and poor posture ( Figure 6 ). It appears that the prevalence rate of self-reported low back pain among workers in the U.S. was 25.7%, with female or older workers were at increased risk of experiencing low back pain ( Yang and co-workers, 2016). This common health problem often goes together with inadequate muscular fitness, and most workers are expected to experience symptoms of low back pain or similar musculoskeletal problems during their working life.

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Low-back pain

Muscular stiffness

Poor posture

Carpal tunnel syndrome

Tension neck syndrome

Figure 6 | Common musculoskeletal problems of workforce Employment pattern, rest break taken, reaching/overstretching, repetitive movements, job satisfaction, maintained positions, training related to health and safety and numbers of specific jobs undertaken were among the factors associated with low back pain (Wami and co-workers , 2019). While many treatment opportunities are available for an appropriate management of sedentary-driven musculoskeletal problems at work, primary efforts in the workplace should be addressed at removing or reducing possible causes of low back pain (Graveling , 2020), including poor back flexibility and core stability, or low level of muscular strength. Neuromuscular exercise at workplace appeared to effectively reduce low back pain and improve physical conditioning compared to non-exercising ( Taulaniemi and co-workers , 2019). For example, a general exercise program that combines muscular strength and flexibility (also aerobic exercise) is beneficial for tackling non-specific chronic low back pain (Gordon and Bloxham, 2016). Specifically, increasing core muscular strength can assist in supporting the lumbar spine while improving the flexibility of the muscle-tendons and ligaments in the back increases the range of motion and assists with the person’s functional movement. Even the brief programs could help in reducing low back pain symptoms in office workers, with the beneficial effects generated with small duration sessions during the working day, with only 10–15 min of adapted exercise to be performed 3–5 days per week (Gobbo and co-workers , 2019).

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Testing health and fitness at work Measuring health-related physical fitness

The definition of health-related physical fitness involves exercise activities that a person can do in order to try to improve her or his physical health and stay healthy. The evaluation of health-related physical fitness in different populations, including workforce, is a fairly common practice by a sport-for-health professional. There are several reasons to evaluate each component of health- related physical fitness. Some of the reasons may include:  Education of employees about their current level of health-related physical fitness,  Utilizing data from the evaluation to personalize physical activity programs,  Provide baseline and follow-up data to evaluate exercise programs at workplace, and  Motivate employees towards more specific action. Appropriate evaluation includes the assessment of several elements of health-related physical fitness, including body composition, cardiorespiratory endurance, muscular fitness, and flexibility. Advanced assessment could incorporate the level of physical activity at home and work, health- related quality of life, and health-promoting lifestyle habits of workforce ( Figure 7 ), with additional outcomes may include biochemical profiling, blood pressure, sleep quality and many other variables.

Cardiorespiratory fitness

Health - promoting lifestyles

Body composition

SPORT4H

Muscular strength and endurance

Health -related quality of life

Physical activity

Flexibility

Figure 7 | Health and fitness profiling for SPORT4H

Healthy weight and body composition Maintaining optimal body weight is strongly corelated to miscellaneous health benefits. From reducing risks from various lifestyle diseases to improving performance at home and work, a healthy weight is an upshot of healthy behaviors in many cases, including taking part in regular physical activity and/or choosing right low-energy foods. Besides weight in kilograms a person

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can measure with bathroom scale, several other indicators can tell much more about health and fitness. For example, body mass index (BMI) is an indirect measure of body composition used to assess weight relative to height. Body composition is defined as the relative proportion of fat and fat-free tissue in the body. Calculating BMI compares an individual’s weight to their height, and categorize each person as normal-weight, underweight or overweight ( Figure 8 ). The formula is BMI = kg/m 2 where kg is a person’s weight in kilograms and m 2 is their height in meters squared.

Underweight < 18.5 kg/m 2

Optimal 18.5 - 25 kg/m 2

Overweight 25 - 30 kg/m 2

Obese > 30 kg/m 2

BMI

BMI

BMI

BMI

Figure 8 | Body mass index (BMI) classification. Thewaist circumference (WC) is another indirectmeasure of body composition. Excessive abdominal fat may be a serious issue because it places a person at greater risk for developing obesity-related conditions, such as type 2 diabetes, high blood pressure, and coronary artery disease ( National Center for Chronic Disease Prevention and Health Promotion , 2020). WC is measured with a simple non-stretching tape as the smallest waist circumference above the umbilicus or navel. Sex- specific cutoffs for WC ( Figure 9 ) can be used to identify increased risk associated with abdominal fat, particularly in adults with BMI > 25 kg/m 2 . An increase in waist circumference may also be associated with increased risk in persons of normal weight.

Men

Waist circumference > 102 cm

Women

Waist circumference > 88 cm

Figure 9 | Waist circumference cut-off points.

Cardiorespiratory fitness Cardiorespiratory fitness (CRF) is related to the ability to perform large muscle, dynamic, moderate- to-high intensity exercise for prolonged periods. CRF reflects the functional capabilities of the heart, blood vessels, blood, lungs, and relevant muscles during various types of exercise demands. Specifically, CRF affects numerous responses at rest, in response to moderate and maximal exercise, and during prolonged work. It can be assessed by various techniques and has many synonyms, including maximal aerobic capacity, functional capacity, maximal oxygen consumption or cardiorespiratory endurance. Lower levels of CRF are related with poor metabolic health, increased prevalence of lifestyle disease and other disadvantageous health outcomes ( Figure 10 ) (Myers and co-workers , 2019).

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MEN

18 – 25 yrs

26 – 35 yrs

36 – 45 yrs

46 – 55 yrs

56 – 65 yrs

65 +

Excellent

> 60

> 56

> 51

> 45

> 41

> 37

Good

52-60

49-56 43-48 40-42 35-39 30-34

43-51

39-45 36-38 32-35

36-41

33-37 29-32 26-28 22-25

Above average

47-51

39-42 35-38

32-35

Average

42-46

30-31

Below average

37-41

31-34

29-31

26-29 22-25

Poor

30-36

26-30

25-28

20-21

Very poor

< 30

< 30

< 26

< 25

< 22

< 20

WOMEN

18 – 25 yrs

26 – 35 yrs

36 – 45 yrs

46 – 55 yrs

56 – 65 yrs

65 +

Excellent

> 56

> 52

> 45

> 40

> 37

> 32

Good

47-56 42-46 38-41 33-37 28-32

45-52 39-44 35-38

38-45 34-37

34-40

32-37 28-31 25-27 22-24

28-32 25-27 22-24

Above average

31-33

Average

31-33

28-30 25-27 20-24

Below average

31-34

27-30 22-26

19-21 17-18

Poor

26-30

18-21

Very poor

< 28

< 26

< 22

< 20

< 18

< 17

Figure 10 | Reference values for cardiorespiratory fitness (ml/kg/min) for men and women This component of health-related physical fitness can be measured or predicted using different methods. Field tests are probably the most convenient techniques that require little equipment, space and time to accurately predict CRF at workplace. The Queens College Step Test is among the most popular methods to evaluate CRF since minimal equipment and costs are involved in executing the test, with little time required, and test can be administered at workplace. The person steps up and down on the platform at a rate of 22 steps per minute (women) or at 24 steps per minute (men), with rhythm directed by a metronome. The person is stepping up using a four-step cadence, ‘up-up-down- down’ for 3 minutes. Immediately after the end of 3-min period, the heart rate was evaluated from 5-20 seconds of recovery and CRD was determined according to following equations:

CRF (men) = 111.33 - (0.42 x heart rate) CRF (women) = 65.81 - (0.1847 x heart rate)

Muscular fitness: strength, endurance and flexibility Muscular fitness is a fundamental component of health-related physical fitness since it highly correlates with several health outcomes. Poor muscular fitness is recognized as an important marker of nutritional status and a predictor of metabolic complications, cancer, cardiovascular disease and all-cause mortality (Ramirez-Velez and co-workers , 2016). Muscular fitness comprises three domains: muscular strength, muscular endurance and flexibility. Muscular strength refers to the maximal force that can be generated by a specific muscle or muscle group. Muscular strength could be measured by many methods, with handgrip strength test perhaps being the most convenient, simple, commonly used and accurate method to evaluate general strength

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of workforce, with reference norms widely available ( Figure 11 ). In short, a person squeezes the dynamometer with maximum effort, which is maintained for about 3 seconds. The best result from three trials for each hand is recorded, with at least 15 seconds recovery between each effort.

MALES

FEMALES

Excellent

> 64

> 38

Very good

56-64 52-55 48-51 44-47 40-43

34-38 30-33 26-29 23-25 20-22

Above average

Average

Below average

Poor

Very poor

< 40

< 20

Figure 11 | Reference values for handgrip test (kg) in men and women

Muscular endurance is the ability of a muscle group to execute repeated contractions over a period of time sufficient to cause muscular fatigue, or to maintain a specific percentage of the maximum voluntary contraction for a prolonged period of time (ACSM , 2017). This element of health-related fitness is incorporated in various every-day activities at both job and home, including carrying boxes, chopping woods, washing car or walking up a flight of stairs in the office. Specifically, abdominal muscle endurance is important for core stability and back support of a employee, and this can be evaluated by a modified sit-up test ( ACSM , 2017). An employee lies supine on mat with knees bent at 90° and feet on floor, with arms extended to sides with fingers touching a piece of masking tape. A second piece of tape is placed beyond the first piece at 12 cm apart for subjects less than 45 years of age, or at 8 cm apart for employees 45 years or older. The subject slowly lifts the shoulder blades off the mat by flexing spine until finger tips reach the second piece of tape by following a rhythm set up by a metronome (40 beats per minute). Subject performs as many curl-ups as possible without stopping, up to a maximum of 75 repetitions ( Figure 12 ). MEN

20 – 29 yrs

30 – 39 yrs

40 – 49 yrs

50 – 59 yrs

60 – 59 yrs

Well above average

75

75

75

74

53

Above average

41 – 56 27 – 31 20 – 24

46 – 69 31 – 36 19 – 26

67 – 75 39 – 51 26 – 31

45 – 60 27 – 35

26 – 33

Average

16 – 19

Below average

19 – 23

6 – 9

Well below average

4 – 13

0 – 13

13 – 21

0 – 13

0

WOMEN

20 – 29 yrs

30 – 39 yrs

40 – 49 yrs

50 – 59 yrs

60 – 59 yrs

Well above average

70

55

55

48

50

Above average

37 – 45 27 – 32

34 – 43 21 – 28

33 – 42 25 – 28

23 – 30

24 – 30

Average

9 – 16

13 – 19

Below average

17 – 21

12 – 15

14 – 20

0 – 2

3 – 9

Well below average

5 – 12

0

0 – 5

0

0

Figure 12 | Reference values for modified sit-up test

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Flexibility is the ability to move a joint through its complete range of movement. Flexibility is dependent upon which muscle and joint is being evaluated; therefore, it is joint specific. Poor flexibility at workplace is often related with many musculoskeletal disorders, including low-back pain. One of the most popular flexibility assessment procedures is the sit and reach test ( ACSM , 2017). This test involves sitting on the floor with legs stretched out straight ahead and shoes removed. The soles of the feet are placed flat against the box. With the palms facing downwards, and hands on top of each other, the employee should reach forward along the measuring line as far as possible and hold that position for at one-two seconds while the distance is recorded, with score recorded to the nearest centimeter ( Figure 13 ).

MEN

WOMEN

Super

> +27

> +30

Excellent

+17 to +27

+21 to +30 +11 to +20

Good

+6 to +16

Average

0 to +5

+1 to +10

Fair

-8 to -1

-7 to 0

Poor

-20 to -9

-15 to -8

Very poor

< -20

< -15

Figure 13 | Reference values for sit and reach test (cm) in men and women

Measuring physical activity and sedentary time Several methods are available to measure sedentary behavior and the level of physical activity among different populations, including workforce. This includes indirect methods, which are surrogate markers of physical activity (such as body composition, cardiorespiratory fitness, and surveys or questionnaires), and direct methods, which reflect actual bodily movement or energy expenditure (including direct calorimetry, doubly labeled water, and accelerometers) ( Kelly and co-workers , 2017). Various surveys and questionnaires are perhaps the easiest and fairly effective tools to assess the types of intensity of physical activity and sitting time that people do as part of their daily lives, including work. The International Physical Activity Questionnaire (IPAQ) was developed to measure health-related physical activity in various populations as part of their everyday lives (Hagströmer and co-workers , 2006)). A short IPAQ version for use by either telephone or self-administered is widely available and valid tool to assess individuals’ last 7-day recall of physical activity. The purpose of IPAQ is to provide a common instrument that can be used to obtain internationally comparable data on health–related physical activity a person spent in the last week at work, as part of house and yard work, to get from place to place, and in spare time for recreation, exercise or sport. IPAQ allows estimating total physical activity in MET-min/week and time spent sitting by 7-item open-ended questionnaire ( Figure 14 ).

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Figure 14 | The short form of International Physical Activity Questionnaire (IPAQ)

Additional health profiles Besides traditional profiles for health-related physical fitness and physical activity, other domains could also be evaluated to better describe the health status of an employee. These include health- related quality of life (SF-12) and health-promoting lifestyle profiles. SF-12 is a multipurpose, generic 12-item questionnaire of health status, all selected from the SF-36 Health Survey ( Figure 15 ). The questions were combined, scored, and weighted to create two scales that provide glimpses into mental and physical functioning and overall health-related-quality of life.

Figure 15 | SF12 Questionnaire

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Health-Promoting Lifestyle Profile (HPLP-II) is another self-administered questionnaire with 52- item self-report of health-promoting lifestyle habits in six domains, with PA and diet subscale scores separately analyzed in this study ( Figure 16 ). Participants indicate how often they engage in certain health-promoting behavior on a four-point Likert scale ranging from 1 (never) to 4 (routinely). Mean scores are calculated for both subscales, with higher scores indicating more frequent health-promoting behavior.

Figure 16 | HPLP-II Questionnaire

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Exercise safely: tips and advices

Taking part in exercise can have many health benefits. However, to enjoy it safely it’s necessary to adhere to several recommendations. For example, several populations should consult a doctor before beginning a physical activity program. That includes pregnant or nursing women; persons suffering from chronic diseases (e.g. cardiovascular diseases, lung and kidney diseases, diabetes, arthritis, osteoporosis) or cancer; persons who experience pain or discomfort in the chest, neck, jaw or arms during physical activity; a person with dizziness, fainting or shortness of breath during mild effort or at rest; people who have problems with joints, muscles, and/or bones that worsen when exercising. Prior to engaging in intense physical activity, consultation with a doctor are recommended for people aged over 35 years, as for people who have a family history of heart diseases, also for active smokers and those who have stopped smoking in the last 6 months, physically inactive adults, people who are overweight and obese, or those who have high blood pressure or raised cholesterol. The risk of injury during exercise depends more on the type and intensity of the activity, than the total amount of activity (e.g. duration of exercise). Walking and activities of moderate intensity are generally safe, whereas running and competitive activities (e.g. tennis, football) are associated with a higher risk of injury. In the case of an acute infection (e.g., inflammation of the ear, throat or sinuses; herpes, diarrhea), physical activity is not recommended . Pregnant women should not take part in activities at high risk of falling or hitting the abdomen (e.g. horse riding, basketball, skiing, skating, martial arts), while high altitude activities and competitive activities require special caution. Warm up is required before engaging in any physical activity, particularly for intense activities. Warm up typically consists of slower-paced aerobic activities (e.g. light walking, slow running) and calisthenics (e.g. arm swings, lunges) to prepare the large joints and muscle groups for the main exercise. Warm up lasts ~ 5 to 10 minutes, with the duration depends on the intensity of the main exercise; higher intensity requires longer warm up. After the main activity is over, it is recommended that the body cools down . Cool down typically takes low-intensity running followed by stretching exercises. Ensure sufficient fluid intake (water is probably the best choice) during physical activity; exercise in warm conditions enhances sweating and loss of fluid and electrolytes, requiring more fluid intake. A dry mouth and thirst are the main signals of dehydration (loss water and electrolytes in the body) that requires fluid replenishment. Use the necessary protective equipment during physical activity: elbow and knee pads, special hiking shoes, hat or cap for sun protection, swimming goggles if you have sensitive eyes, etc. Activities in extreme weather conditions (e.g. high environmental temperature with high humidity; low temperature followed by strong wind and precipitation etc.) require adequate clothing, careful monitoring of exercise load and additional protection (e.g. high-protection cream factor when exposed to strong sun; hat and gloves when very cold, etc.). A list of tips for safe physical activities has been presented in Figure 23 .

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Activity

Safety measures

All activities

Always do a warm up

• •

Always do a cool down routine

• Gradually increase the intensity and duration of exercise • Keep fluid intake optimal

Walking

• Use comfortable shoes of appropriate size • Do not eat immediately before exercise • Refrain from doing exercise outside during the hottest time of the day in summer • Keep yourself visible, use headphones carefully during exercise • Take your cell phone with you • Always inform somebody about your whereabouts during exercise • Avoid exercising in unsafe areas, during a rush hour or traffic jams • Consider using sunglasses or protective creams during sunny days • Wear layered clothes • Choose cycle of appropriate size (e.g. being able to touch the ground with feet) • Learn arm signals for cyclists • Follow the traffic rules • Maintain your cycle on a regular basis • Check the cycle before every ride (e.g. breaks, lights, chain) • Always wear a helmet • Do not use headphones or cell phone during a ride • Choose rollers of appropriate size and check them before every ride • Learn the safe techniques, focus to stopping • Always wear a helmet, knee and elbow pads, also wrist suspensors • Choose plain, wide and safe terrains, with no obstacles and crowd • Avoid rides in roadways or sidewalks • Keep the right side during a ride • Ride with a fellow in case of need • Do not hook up to a bicycle, motor bike or other vehicles • Do not use headphones or cell phone during a ride • Avoid rides at night or through poorly-lit streets • Choose a fitness club who employees licensed professionals • Choose a gym with safe, well lighted, ventilated and spacious rooms • Always wear an appropriate fitness gear (e.g. remove jewelry, buckles) • Select a fitness program that suits your level of fitness and affinities • If you exercise at home, check the reputation of the author of the video • Follow the program as closely as possible • It is mandatory to have fundamental swimming skills • Do not use alcohol before or during an exercise session • Follow the rules at the swimming site (e.g. pool, lake, see beach) • Use googles • Do not swim if feeling tired, cold or after spending too much time sunbathing • Avoid swallowing water from a swimming pool • Use swimming cap, ear plugs or remove water from the ears after swimming • Do not swim in crowdy sections of a pool • Always take a shower before and after a swimming session • Do not swim while having diarrhea • Never swim alone in open water • Check the water quality and temperature • Do not jump into the water • Consider using protective cream during sunny days • Use life jacket when being active on water (e.g. sailing, rowing, fishing)

Running

Cycling

Skate rollers

Group exercise

Swimming

Figure 23 | Tips for safe physical activities

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Stretching and Strengthening at Work

Improve flexibility at workplace

Start safely and smartly A proper warm-up is the first step in starting any exercise program at workplace. This is a necessary preparatory measure to allow for a safe, efficient and well-executed physical activity program. Warm-up prepares the body for exercise by increasing heart rate and blood flow to working muscles, and raises skeletal muscles temperature for optimal flexibility and efficiency. Warming up before exercise is also critical for preventing injury during a workout. Several recommendations are listed below to do a warm up routine appropriately:

Warm up for at least 1 to 3 minutes



 Do whatever activity you plan on doing at a slower pace  Do dynamic exercises (e.g. butt kicks, arm circles, lunges)  Use your entire body

When warm up routines are over, you are ready to follow the main program.

General recommendations Stretching your muscles and joints is known to bring many positive health benefits, including increased flexibility and range of motion, upgraded performance in daily activities at home and work, and improved posture, stress relief and back pain ( Figure 17 ). Specifically, stretching can help reducing muscle soreness, aches, and pains. Simple daily tasks such as bending over and tying shoes or rotating trunk during functional daily activities at work are accomplished better with flexibility. Many leading health authorities are recommending stretching as part of regular exercise routine, with flexibility exercise is recommended to be performed at least 2-3 days per week ( EU Physical Activity Guidelines , 2008; Physical Activity Guidelines to Americans , 2015; WHO , 2020).

Figure 17 | Stretching improves workplace tasks

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Stretching and Strengthening at Work

The optimal flexibility program requires conducting stretching relevant muscles and joints, including neck and spine, upper and lower body. Preferably, a good program for improving flexibility at workplace includes all the major muscle groups, tends to be a very brief routine (~ 5 min) while concentrating on the sensible muscle groups of the neck and spine. The stretching programs should be prescribed for any employee who is interested in improving range-of motion or preventing health outcomes of poor flexibility (e.g. low back pain, muscular stiffness, neck ache). However, to get a result, an employee needs to be involved in a regular stretching program for at least several weeks, preferably as a daily routine or as close to that as possible. Stretching can accompany other exercise programs or executed as an individual routine. In addition, any employee can adapt the stretching exercises to fit his or her individual needs, focusing stretching routine to a particular muscle with soreness or stiffness. General recommendations for stretching exercises are enlisted below.  Hold the stretching position for 10 to 30 seconds  Hold the end-position to the point of tightness or mild discomfort  Rest for 5 to 10 seconds between each exercise  Repeat each exercise two to four times, accumulating 60 seconds per stretch  Stretch at least two or three times per week at workplace The following exercises are enlisted as specific stretching routines that are focused to improve the range of motion for specific body segments, including neck, spine and trunk, along with exercises for arms and legs. All stretching exercises depicted require no additional equipment or extra room, are appropriate to various work environments and easy to learn and perform at both work and at home.

Before starting stretch exercises at work:

1. consult your doctor or physiotherapist first if you have complaints about the musculoskeletal system or you feel sick; 2. when feeling pain: tingling, dizziness, stop the exercise; and 3. never use force when performing the exercise.

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Stretching and Strengthening at Work

Neck and spine exercises Poor neck and spine flexibility usually appear due to prolonged sitting at work and/or holding the head in a constant stable position, like during a continued looking at the screen. The following exercises can help employees to keep the neck from stiffening up during sitting at work, but also for preventing low-back pain, inadequate postures, or awkward working positions. Follow the general recommendations for each exercise and adhere to specific instructions.

1. Back neck stretches

Starting position: Sitting (or standing) with a straight back  Put hands together on the back of the head  Slowly press the head straight down  Try to go to the chest with the chin, but don’t go further when you feel the stretch

 Keep this position for at least 10 seconds  Keep the spine as straight as possible

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Stretching and Strengthening at Work

2. Back-side neck and rotation stretch

Starting position: Stretch either while sitting or standing  Stretch either while sitting or standing the head  The other arm is hanging or put on the low back for better stretchSlowly pull the head down toward the right armpit  Try to touch the shoulder with the chin, but don’t go further when you feel the stretchKeep this position for at least 10 seconds  Repeat stretching on the other side

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Stretching and Strengthening at Work

3. Front-side neck and rotation stretch

Starting position: Stretch either while standing or sitting  Put the left hand on the side of the head  Slowly pull the head toward the left shoulder  Keep the spine straight  Try to touch the shoulder with the left ear, but don’t go further when you feel the stretch  Keep this position for at least 10 seconds  Repeat exercise on the other side

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Stretching and Strengthening at Work

4. Seated lower-trunk stretch

Starting position: Sit upright in a chair with legs set apart and feet on the ground  Slowly round the upper back and begin to lean forward.  Continue to bend at the waist as much as possible, but don’t go further when  you feel the stretch  Lower the head and abdomen between the legs and below the thighs  Keep feet on the ground

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Stretching and Strengthening at Work

5. Standing lower-trunk stretch

Starting position: Stand upright with the feet together  Turn the left side of the body to an office wall  Keep the distance at about an arm’s length away  Place the left hand on the wall at shoulder height  Put the right hand at the hip joint  Contract the buttocks and slightly rotate the hips in toward the wall.  Use the right hand to push the right hip toward the wall  Keep this position for at least 10 seconds  Repeat stretching on the other side

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Stretching and Strengthening at Work

6. Seated lower-trunk back-side stretch

Starting position: Sit upright in a chair  Keep your spine straight  Join the hands behind the head  Keep the elbows in a straight line across the shoulders  Slowly band the waist at right side while moving the elbow toward the right hip  Keep this position for at least 10 seconds  Repeat stretching on the other side

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Stretching and Strengthening at Work

7. Standing lower-trunk back stretch

Starting position: Stand upright with legs ~ 40 cm apart  Put your hands on the back of your thighs  Slowly arch the back while contracting the buttocks and pushing the hips forward  Continue the movement while releasing the head backward  Slowly slide the hands past the buttocks and down the legs, but don’t go further when you feel the stretch or feel pain in your back  Keep this position for at least 10 seconds

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Stretching and Strengthening at Work

8. Lower-trunk rotational stretch

Starting position: Stand upright with legs ~ 30 cm apart  Put the right foot about 10 cm ahead of the left foot  Place both hands near the right hip.  Slowly arch the back, contracting the buttocks and pushing the hips forward.  Continue the movement while rotating the trunk clockwise  Slowly drop the head back toward the right side  Slide the hands past the right buttock and down the right leg  Repeat stretching on the other side

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Stretching and Strengthening at Work

Upper extremity stretches Upper arm extremity stretches are effective in people who experience inactivity-related stiffness in upper arm and forearm, and for employees who often feel frozen hand due to prolonged working in front of computer or other similar conditions. Please follow the general recommendations for each exercise and adhere to specific instructions.

1. Front shoulder stretches

Starting position: Stand upright  Place feet shoulder-width apart

 Put one foot slightly in front of the other  With bent arms hands behind the head  Gently pull the elbows back  Keep this position for at least 10 seconds

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Stretching and Strengthening at Work

2. Back and upper shoulder stretch

Starting position: Stand upright with the feet shoulder-width apart  Bring the left arm across the front of the body,  Grab hold of the left elbow with your right hand

 Try to move the left elbow to your body  Keep this position for at least 10 seconds  Repeat stretching on the other side

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Stretching and Strengthening at Work

3. Touch the shoulder blade

Starting position: Stand upright  Keep the spine straight  Put the left arm behind the back  Keep the left elbow bent at about 90 degrees  Grasp the left elbow with the right hand  Slightly pull the left arm across the back  Push it up more toward the right shoulder  Keep this position for at least 10 seconds  Repeat exercise on the other side

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Stretching and Strengthening at Work

4. Shoulder stretch

Starting position: Take a squatting position while facing a doorway  Keep your feet next to each other  Keep the right shoulder in the line with the left side of the door jamb  Grab the inside of the doorjamb with the right hand  Lower the buttocks toward the floor  Keep the right arm straight and feet firmly planted  Keep this position for at least 10 seconds  Repeat exercise on the other side

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Stretching and Strengthening at Work

5. Elbow / chest stretches

Starting position: Take a standing position in a doorway  Keep feet shoulder apart and arms straight  Raise the left arm to shoulder level and place it against the wall

 Rotate the trunk backward toward the wall  Keep this position for at least 10 seconds  Repeat exercise on the other side

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