RESEARCH ARTICLES

Analgesic comparison of Zen Shiatsu and auricular acupuncture in back pain among nursing professionals

Thaís Dresch Eberhardt^I; Lili Marlene Hofstätter^II; Sandra Mara Silvério Lopes^III; Edson Antonio Alves da Silva ^IV; Daniela de Cassia Faglioni Boleta Ceranto^V; Anair Lazzari Nicola^VI

^I Nurse, Specialist in Acupuncture and in Nursing Management in Medical and Surgical, Master degree student in the Graduate Program in Nursing of the Federal University of Santa Maria, Rio Grande do Sul, Brazil. E-mail: thaiseberhardt@gmail.com
^II Nurse, Specialist in Acupuncture, Master degree in Fundamental Nursing, Teacher of the Nursing Course at the State University of Western Paraná. Cascavel, Paraná, Brasil. E-mail: lm_hofstatter@yahoo.com.br
^III Pharmaceutic and Biochemistry, Physiotherapist. Master in Health Technology, Teacher and Coordinator of Acupuncture Graduate Course of the Ibrate Technology School. Curitiba, Paraná, Brazil. E-mail: posgraducao@ibrate.edu.br
^IV Degree in Physics, Ph.D. in Numerical Methods in Engineering, Teacher of the State University of Western Paraná. Cascavel, Paraná, Brazil. E-mail: edsonaasilva@gmail.com
^V Surgeon Dentist, Specialist in Acupuncture, Doctor of Dentistry, Professor of Dentistry Course of University Paranaense. Cascavel, Paraná, Brazil. E-mail: dcboleta@unipar.br
^VI Nurse, Ph.D. in Nursing, Teacher of the Nursing Course at the State University of Western Paraná. Cascavel, Paraná, Brazil. E-mail: anairln@yahoo.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2015.9616

ABSTRACT

This experimental, longitudinal study used quantitative data analysis to compare the effects of Zen Shiatsu and auricular acupuncture in reducing levels of back pain in hospital nursing staff. Data was collected in October and November 2013 at a hospital in Paraná State. Completely randomized statistical design was applied to form two groups of 20 volunteers each one. Those in group 1 received a session of Zen Shiatsu and group 2 received a session of auricular acupuncture. The visual analogue scale was used to measure pain level. The effects of the two interventions were compared with nonparametric statistical methods using the R statistics program for data analysis. It was concluded that auricular acupuncture and Zen Shiatsu were equally effective in reducing levels of chronic back pain. This effect continued for seven days.

Keywords: back pain; acupressure; acupuncture, ear; complementary therapies.

INTRODUCTION

The work can be perceived as a source of happiness, recognition, fulfillment and pleasure, evidenced by the personal and economic progress provided to individuals and by causing physical and/or mental wear, illnesses and accidents related to it¹.

In Brazil, in 2007, back pain of unknown causes was the leading cause of disability among social security and accidents at work retirements, representing an incidence of 29.96 per 100,000 workers².

Regarding the nursing workers in hospitals environments, the back pain and/or low back pain are seen as more prevalent and disabling musculoskeletal disorders³, becoming a leading cause of disability or limitation for carrying out activities^4,5, as well as by health professionals demanding to problem resolution⁵.

Both acute as chronic pain can be treated with prescription drugs, but can be controlled by complementary therapies such as acupuncture, massage therapy, yoga, among others⁶.

In 2006, the Ministry of Health established the Integrative and Complementary Practices National Policy (PNPIC) in the Unified Health System (SUS), working in health promotion areas, disease prevention, maintenance and recovery of health based on model of humane care and focused on the completeness of the individual⁷.

There are two complementary therapies that point to a therapeutic possibility in reducing the level of pain, such as the Zen Shiatsu⁸ and auricular therapy or auricular acupuncture^9,10. From this, there is a question: Do both therapies (Zen Shiatsu and auricular acupuncture) promote similar reduction in the level of back pain? The hypothesis is that both can reduce similarly the level of back pain.

Comparing the analgesic effect of the two therapies is necessary because adverse events are reported after application of the auricular acupuncture, according to the literature, for example, ear pain, local bleeding, dizziness, nausea and headache. However, the frequency of occurrence of these events is rare and any serious adverse event has not been reported, according to the literature¹¹. Regarding Shiatsu, two reports describe serious adverse events - stent fracture¹² and thrombosis of the internal jugular vein¹³ - after application of the therapy. However, the Zen Shiatsu therapy has other benefits in addition to analgesia, such as improving blood circulation, physiological and energy balance⁸.

Moreover, studies^8-10,14-20 do not present uniform techniques in the application of the two interventions and uniformity in the number of sessions. From the knowledge of the application of the two interventions, patient positioning and better intervention to reduce the level of pain, professionals applying the two treatments can opt for the best technique for this type of pathology.

The objective of this study was to compare the effect of the application of Zen shiatsu and auricular acupuncture in reducing back pain levels in nurses who work in hospitals.

LITERATURE REVIEW

The definition of pain by the International Association for the Study of Pain (IASP) was used for this research, as an unpleasant sensory and emotional experience associated with actual damage or potential tissue⁶.

Shiatsu is a Japanese massage technique with finger pressure on the body. Shiatsu name consists of the words shi, meaning finger, and atsu, pressure. Zen Shiatsu is a type of Shiatsu application technique, consisting in the application of finger pressure and the palm over the main body meridians used in acupuncture in addition to the movement of the joints⁸.

"Auricular therapy is an Acupuncture technique using the ear to make health care, using the reflection that the auricle has on the central nervous system" ^21:27. It was chosen to use the term auricular acupuncture, as best describing the technique, which involves the application of needles in order to stimulate the auricula²².

METHODOLOGY

This is an experimental, longitudinal study with a quantitative data analysis. The target population were nurses, technicians and nursing assistants of the West Paraná University Hospital (HUOP) - linked to the State University of Western Paraná (UNIOESTE) - expressing back pain feelings. To know the number of nursing professionals who felt this type of pain, active search was carried out by sending internal communication and visits to job sectors.

According to data provided by the Institution´s Human Resources Sector, in 2013, 84 nurses, 161 nursing technicians and 196 nursing assistants worked there, totaling 441 nursing professionals. Of these, 103 have expressed back pain feelings, representing 23.36% of nursing professionals working in the institution.

Nursing professionals who agreed to participate and over 18 years old who feel back pain, low back pain or back pain of any origin, acute or chronic, not using pain medications and/or anti-inflammatory every day were included in the study.

Exclusion criteria were considered for the application of auricular acupuncture in pregnant women²³ and for the application of Zen Shiatsu with the presence of bruising, bruising, skin rashes and burns on the dorsal region, fever, early postoperative, recent fractures in the spine, women in the first trimester of pregnancy, alcohol consumption and recent meal.

A completely randomized experimental design was applied to form two groups of 20 volunteers each. For the assortment, the names of the volunteers have been organized in alphabetical order and numbered. The classification was conducted by the command sample of R statistical program²⁴, associating each number assorted to a name from the list of participating employees.

Volunteers from in group 1 (SHI) received a session of Zen Shiatsu intervention group 2 (AUR), received a session of auricular acupuncture intervention. Data collection was from October and November 2013.

For the Zen Shiatsu treatment application, the volunteer was in prone position and the sequence was repeated three times^8,25,26: pressing the thumb down the first line of the Bladder Meridian on the back, one side at a time; pressing the thumb down the second line of the Bladder Meridian on the back, one side at a time; circulatory movement with the thumb around the shoulder blade, one side at a time; pressing the thumb down the first line of the Bladder Meridian on the back bilaterally; pressing the thumb down the second line of the Bladder Meridian on the back bilaterally; pressing the wrist, both hands overlaying, rising Meridian Governing Vessel or Du Mai. The location of the meridians was according to Yamamura²³ .

To put semi-permanent needles in the auricular acupuncture treatment, after proper location, the auricula was cleaned with cotton and ethyl alcohol 70%, and then there was the application of sterile needles affixed with micropore tape²⁷. The needles size selected was 1.5 mm²¹. Subjects were asked to maintain the needles for seven days without touching them and communicate the researcher in case some of them fall.

The places chosen were Shen Men, Kidney, Sympathetic, Analgesia, Muscle relaxation, Thoracic vertebrae and Lumbar vertebrae. The location of the points was carried out as indicated by Souza²¹.

To measure pain levels, the visual analog scale (VAS) - unidimensional scale was used²⁸. VAS was chosen because there is evidence about their reliability and psychometric validity as well as being more sensitive than descriptive numerical or verbal scales in the measurement of chronic low back pain²⁹.

The volunteer filled up a spreadsheet, a score about his pain in the seven days before treatment, immediately after treatment and seven days after, where zero means no pain and ten was the maximum pain felt. Arithmetic average of the three moments of pain measures was calculated, and coded as follows: the moment before - the average of the scores given to pain by VAS in the last seven days prior to application of the treatment; post-immediate moment - average scores given to pain by VAS immediately after applying the treatment; moment later - the average of scores given to pain by VAS seven days after applying the treatment.

The application of the two interventions were performed by the same therapist, who was the researcher, being responsible for the data collection on measuring pain.

The effects of the two interventions were compared with non-parametric statistical methods by the nature of the measures. The 95% confidence interval was adopted for the results, using the R²⁴ statistical program for data analysis.

This study was approved by the Ethics Committee in Research involving human beings of the State University of Western Paraná (UNIOESTE) under Opinion Number 125/2013. All subjects were informed of the study objectives and signed a free and informed consent form before the enrollment in the trial. In addition, the research met the ethical aspects recommended by National Health Council (CNS) Number 466 of 2012. In order to preserve the anonymity of the participants, they were identified with numbers in ascending order, starting at number one, as the development of data collection.

RESULTS AND DISCUSSION

Of the 40 individuals selected after randomization, 35 were within the inclusion criteria and agreed to participate, 17 of the SHI Group and 18 of the AUR Group. One SHI group volunteer could not participate in the research, because he had recent spinal injury and the other four were excluded from the sample because they did not agree to participate.

The sample participants were average of 41 years old, ranging between 24 and 58 years old. This average age is compatible with a study that found the same average among individuals with back pain in southern Brazil³⁰. Most people - 33 (94.29%) - were female and 2 (5.71%) were male. What is observed is that the woman, in addition to being inserted into the working world, she did not abandon her house chores (children´s education, home cleaning, paying bills, care for sick family members), resulting in double or triple workday and this leads to a potential risk of illness to them⁴.

Women are at greater risk for back pain compared to men because the female has some anatomical features, such as smaller stature, smaller muscle mass, decreased bone mass, more fragile joints and less adapted to strenuous physical effort, greater fat weight, which can contribute mainly to the emergence of low back pain³¹. Therefore, the findings in this study are similar to the literature.

Concerning the work, individuals had an average of 15.43 years of working time in nursing, 15 (42.86%) volunteers worked in the institution as nursing assistants, 15 (42.86%) as nursing technicians and five (14.28%) as nurses.

Regarding back pain, the average time of subjects feeling this type of pain was 7.86 years. Among the volunteers, 17 (48.57%) felt pain of unknown cause, 8 (22.86%) reported receiving medical diagnosis and the cause of pain was work-related and 10 (28.57%) had medical diagnosis, but with different causes of pain.

A study indicates a positive relationship between pain and sociodemographic and labor characteristics of hospital nursing staff³².

The region in which pain more occurs is lumbar - 22 (62.86%) - two of which (5.71%) only experience pain in the chest, and 11 (31.43%) in both regions. All subjects felt chronic pain, 29 (82.86%) intermittent and 6 (17.14%) continued pain.

A study found high prevalence of musculoskeletal disorders in nursing technicians and assistants of a public hospital in Salvador - BA (83.7%) and the result found was the pain in the lower back is the most present in this population group. This type of disorder can be related to the physical demands to which these professionals are more exposed in their work, including performing repetitive hand movements, adoption of posture and walking most of the time, weight lifting and carrying out a lot of muscle strength³.

A study that evaluated the prevalence of low back pain in nursing professionals in a hospital in Belo Horizonte - MG with 80 assistants, nursing technicians and nurses, observed occurring musculoskeletal symptoms in several body regions, affecting mainly the region of the spine (lumbar, thoracic and cervical)³.

Most of the volunteers - 30 (85.71%) - reported that back pain began while working in care sectors, 3 (8.57%) were farmers, 1 (2.86%) worked in administrative sector and 1 (2 , 86%) practiced sports.

A study showed that low back pain was one of the physical repercussions of nursing workers from the action in cardiopulmonary resuscitation in medical wards³³.

Other authors point out that the mobilization in bed, transporting patients, bathing in the bed were the main factors related to cases of low back pain among nursing professionals of a hospital in Rio de Janeiro³⁴.

The effects of two interventions were performed by applying Spearman Correlation Test three times. The test measures the level of correlation between two variables³⁵. First, the test was applied in order to compare if the averages of pain levels were similar between groups. Second, the paired test was applied, comparing if there was difference (decrease) in average pain levels, within each group, after application of the intervention. In the third step, the test was applied in order to compare if the effect of two interventions were similar.

The average pain by VAS before and after the application of different treatments and the p-value obtained after applying the Spearman correlation test, in order to compare the averages of the pain levels were similar between groups, presented in Table 1.

TABLE 1: Moments measures the levels of pain and medium levels of pain, according to the therapies. Cascavel, PR, Brazil, 2013.

It is observed that, for all pain levels (before, immediately after and after), was obtained p-value> 0.05, not being significant for the difference, at a significance level of 5%.

The p-values found after application of the Spearman Correlation Test compared by comparing whether there was difference between the pain levels in the moments before and after immediately before and after are shown in Table 2.

TABLE 2: Comparison of pain levels in the moments before, immediately after and after the application of their interventions. Cascavel, PR, Brazil, 2013.

For all comparisons, p-values <0.05 were found, being significant for the hypothesis of difference at a 5% significance level. In other words, it is possible to say that there was a significant reduction in pain levels average after the implementation of interventions and this effect was maintained for seven days.

Finally, the Spearman Correlation Test was applied, testing the average differences between the levels of pain between the moments before and after immediately before and after, between groups. Both results obtained p-values> 0.05, not significant in the event that the difference, at a 5% significance level according to Table 3. Therefore, it can be inferred that both had the same analgesic interventions.

TABLE 3: Average differences between the levels of pain in the moments before, immediately after and after the application of interventions. Cascavel, PR, Brazil, 2013.

Regarding Zen Shiatsu, there were not found similar results in literature, in which the same application methodology of therapy was used. Furthermore, no study presents evidence level 1³⁶. However, studies that applied Shiatsu techniques found significant results in reducing pain.

One example was a study with two weekly sessions of Shiatsu applied, for 16 weeks in 10 patients with carpal tunnel syndrome, diagnosed as suffering from work-related musculoskeletal disorders (MSDs). It was found that there was a statistically significant difference in pain relief and improved functionality, but there was no statistically significant difference when the results are compared to those obtained by conventional therapy¹⁴.

A research analyzed the effect of relaxation induced by Shiatsu on the distribution of power of alpha waves through electroencephalography (EEG) in women aged up to 35 years old. It is believed that the presence of alpha waves are related to the specific mental state, characterized tranquility and better tolerance to pain. It was noticed that the frontal and temporal areas showed a significant increase in alpha standard potential, that is, individuals who showed these changes could have a higher pain tolerance¹⁵.

Another study described the use of two Shiatsu cases, through acupressure in side meridian (Kidney Meridian) to treat pain in the shoulder end, after laparoscopic cholecystectomy. Both patients reported immediate pain relief¹⁶. Massage with acupressure proved to be an effective complementary therapy for the reduction of occupational low back pain in nursing staff³⁷.

Regarding the auricular acupuncture and auricular therapy, studies with higher levels of evidence³⁶ in the literature indicating that intervention reduces pain; however, also they have different methodologies of application for intervention.

A systematic review and meta-analysis on the effects of auricular therapy in pain management concluded that auricular therapy is effective for the treatment of a variety of types of pain, especially in postoperative pain¹¹.

An experimental study applied auricular therapy with Vaccaria seeds in 74 patients for chronic back pain, using Shen Men, Sub-cortex, and Lumbar Vertebrae. The results suggest that auricular therapy seems to reduce levels of chronic low back pain¹⁷. For the treatment of MSDs, auricular therapy has also been shown effective in reducing pain levels¹⁸.

Other studies that applied auricular therapy in elderly patients with low back pain also found a reduction in pain levels. Out of htem, two used magnetic inserts to show that the effect of reducing the level of pain remained for up to four weeks after application of the intervention^19,20. It was also confirmed that auricular therapy with needles could reduce back pain in pregnant women during a week⁹, although this is recommended with caution in this population group.

Thus, when comparing the analgesic effect of auricular acupuncture, Yamamoto skull acupuncture, electro-acupuncture and therapeutic exercise in treating low back pain, it is concluded that both complementary therapies are similar in reducing this type of pain, but auricular acupuncture has a small advantage over the other¹⁰.

From this, it can be seen that the results obtained in this study are similar with the findings reported in the literature. However, the studies used different methodologies of application of auricular acupuncture or auricular technique, with materials and various places.

However, one study found different results in that although the present auricular acupuncture was effective in reducing pain systemic acupuncture was more beneficial³⁸.

Considering women are at higher risk for developing back pain, it is suggested to the institution the development of alternatives to reduce occupational causes for this problem.

CONCLUSION

Both auricular acupuncture - with application of semi-permanent needles for seven days in Shen Men, Kidney, Sympathetic, Analgesia, Muscle relaxation, Thoracic vertebrae and Lumbar vertebrae - as the Zen Shiatsu technique, in the methodology applied in the study, are effective in reducing levels of back pain when are used for nursing professionals. This effect is maintained for seven days.

Both treatments achieved similar effects in reducing the average level of pain, that is, a treatment is no better than the other.

One limitation of this study is that it was not used pain measurement at the time of application of the treatments, since most of the individuals had mild pain or without pain at the exact time of therapeutic application. In addition, measurements of pain levels were not held at the same time of day, gender differences nor the factors involved in pain thresholds within the genre itself (as the premenstrual period) were not considered. However, the researcher who measured pain levels knew the type of intervention applied. These factors characterize the weaknesses of the study.

REFERENCES

1.Beck CLC, Prestes FC, Tavares JP, Silva RM, Prochonow AG, Nonnenmacher CQ. Identidade profissional dos enfermeiros de serviços de saúde municipal. Cogitare enferm. 2009;14: 114-9.

2.Meziat Filho N, Silva GA. Disability pension from back pain among social security beneficiaries, Brazil. Rev saúde pública. 2011;45:494-502.

3.Ribeiro NF, Fernandes RCP, Solla DVF, Santos Junior AC, Sena Junior AS. Prevalência de distúrbios osteomusculares relacionados ao trabalho em profissionais de enfermagem. Rev bras epidemiol. 2012;15:429-38.

4.Carvalho LSF, Matos RCS, Souza NVDO, Ferreira REDS. Motivos de afastamento por licença de saúde dos trabalhadores de enfermagem. Cienc cuid saúde. 2010;9:60-6.

5.Schmidt DRC, Dantas RAS. Quality of work life and work-related musculoskeletal disorders among nursing professionals. Acta Paul Enferm. 2012;25:701-7.

6.Kopf A, Patel NP, editores. Guia para o tratamento da dor em contextos de poucos recursos. Seattle (DW): International Association for the Study of Pain; 2010.

7.Ministério da Saúde (Br). Política Nacional de Práticas Integrativas e Complementares no SUS – PNPIC-SUS. Brasília (DF): Ministério da Saúde; 2006.

8.Souza W. Shiatsu dos meridianos: um guia passo a passo. 3ª ed. São Paulo: Editora Senac São Paulo; 2010.

9.Wang SM, Dezinno P, Lin EC, Lin H, Yue JJ, Berman MR, et al. Auricular acupuncture as a treatment for pregnant women who have low back and posterior pelvic pain: a pilot study. Am j obstet gynecol. 2009; 201:271.e1–271.e9.

10.Mehret MOC, Colombo CCG, Silvério-Lopes S. Estudo comparativo entre as técnicas de a acupuntura auricular, craneoacupuntura de Yamamoto, eletroacupintura e cinesioterapia no tratamento da lombalgia crônica. Rev Bras Terap e Saude. 2010;1:1-12.

11.Asher GN, Jonas DE, Coeytaux RR, Reilly AC, Loh YL, Motsinger-Reif AA, et al. Auriculotherapy for pain management: a systematic review and meta-analysis of randomizes controlled trials. J altern complement med. 2010;16:1097-108.

12.Ichihashi S, Higashiura W, Itoh H, Sakaguchi S, Kichikawa K. Fracture and collapse of ballon-expandable stents in the bilateral common iliac arteries due to shiatsu massage. Cardiovas Intervent Radiol. 2012;35:1500-4.

13.Wada Y, Yanagihara C, Nishimura Y. Internal jugular vein thrombosis associated with shiatsu massage of the neck. J Neurol Neurosug Psychiatry. 2005;76:142-3.

14.Masselli MR, Turatti TF, Cruz CM, Silvestre MR, Pereira JDAS. O Shiatsu como terapêutica alternativa em portadores de distúrbio osteomusculares relacionados ao trabalho. Rev dor. 2010; 11:197-202.

15.Pernambuco CS, Pires VNL, Maulaz MB, Mesquita MG, Caetano LF, Novaes JF, et al. A inferência do shiatsu na distribuição de potência das ondas alfas no córtex cerebral em mulheres adultas. Fit Perf J. 2003; 2:178-82.

16.Yeh C-C, Ko SC, Huh BK, Kuo CP, Wu CT, Cherng CH, et al. Shoulder tip pain after laparoscopic surgery analgesia by collateral meridian acupressure (shiatsu) therapy: a report of 2 cases. J Manipulative Physiol Ther. 2008;31:484-8.

17.Yeh C-H, Chien L-C, Chiang Y-C, Huang L-C. Auricular point acupressure for chronic low back pain: a feasibility study for 1-week treatment. Evid Based Complement Alternat Med. 2012;.1-9.

18.Araújo APS, Silvério-Lopes S. Auriculotherapy in the treatment of individuals bearing work - related osteomuscular distubances (WRMD)/ repetitive effort injuries (RSI): one retrospective assement. FIEP Bulletin. 2009;79:133-7.

19.Suen LKP, Wong TKS, Chung JWY. Auriculotherapy on low back pain in the elderly. Complement Ther Clin Pract. 2007;13:63-9.

20.Suen LKP, Wong EMC. Longitudinal changes in the disability level of the elders with low back pain after auriculotherapy. Complement Ther Med. 2008;16:28-35.

21.Souza MP. Tratado de auriculoterapia. Brasília (DF): Med Center; 2007.

22.Silvério-Lopes S, Seroiska MA. Auriculoterapia para analgesia. In: Silvério-Lopes S, editor. Analgesia por acupuntura. Curitiba (PR): Omnipax; 2013. p. 1-22.

23.Yamamura Y. Acupuntura tradicional: a arte de inserir. 2ª ed. São Paulo: Roca; 2001.

24.R Core Team. R: A language and environment for statistical computing. Vienna (Austria): R Foundation for Statistical Computing; 2012. [cited in 2015 Apr 12] Available in: http://www.R-project.org/.

25.Jarmey C, Mojay G. Shiatsu: um guia completo. São Paulo: Pensamento; 1991.

26.Martins ES, Lconclli LB. A prática do Shiatsu – na visão tradicionalista chinesa. São Paulo: Roca; 2002.

27.Prado JM, Kurebayashi LFS, Silva MJP. Auriculotherapy effectiveness in the reduction of anxiety in nursing students. Rev esc enferm USP. 2012;46:1200-6.

28.Ministério da Saúde (Br). Cuidados paliativos oncológicos: controle da dor. Rio de Janeiro: INCA; 2001.

29.Souza FAEF, Hortense P. Mensuração da dor. In: Chaves LD, Leão ER, organizadores. Dor: 5º sinal vital: reflexões e intervenções de enfermagem. 2ª ed. São Paulo: Martinari; 2007. p. 99-117.

30.Ferreira GD, Silva MC, Rombaldi AJ, Wrege ED, Siqueira FV, Hallal PC. Prevalence and associated factors of back pain in adults from southern Brazil: a population-based study. Braz j phys ther. 2011;15:31-6.

31.Silva MC, Fassa AG, Valle NCJ. Dor lombar crônica em uma população adulta do Sul do Brasil: prevalência e fatores associados. Cad saúde pública. 2004;20:377-85.

32. Lima ACS, Magnago TSB, Prochnow A, Ceron MDS, Schardong AC, Scalcon CB. Factors associated with musculoskeletal pain in hospital nursing workers. Rev enferm UERJ. 2014;22:526-32.

33.Sá CMS, Souza NVDO, Lisboa MTL, Tavares KFA. Organização do trabalho e seus reflexos na atuação dos trabalhadores de enfermagem em ressuscitação cardiopulmonar. Rev enferm UERJ. 2012;20:50-5.

34.Hipolito RL, Mauro MIC, Mauricio VC, Mendevil, CL, Silva LA, Gomes SR. A incidência de distúrbios musculoesqueléticos em trabalhadores da equipe de enfermagem em Campos dos Goytacazes. Rev pesqui cuid fundam. 2011;3:2015-23.

35.Vieira S. Bioestatística: tópicos avançados. 3ª ed. Rio de Janeiro: Elsevier; 2010.

36.Stetler CB, Morsi D, Rucki S, Broughton S, Corrigan B, Fitzgerald J, et al. Utilization – focused integrative reviews in a nursing service. Appl nurs res. 1998;11:195-206.

37.Borges TP, Kurebayashi LFS, Silva MJP. Occupational low back pain in nursing workers: massage versus pain. Rev esc enferm USP. 2014;48:670-6.

38.Silva E, Silvério-Lopes S. Lombalgia e lombociatalgia: estudo comparativo de tratamento com acupuntura sistêmica e auricular. FIEP Bulletin. 2010;80 (esp).