J Occup Health 2017; 59: 477-494

Review

Systematic review of the association between physical

activity and burnout

Lea M. Naczenski1, Juriena D. de Vries1,2,

Madelon L. M. van Hooff1 and Michiel A. J. Kompier1

1
Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands and 2 Erasmus University Rotterdam,
Department of Work & Organizational Psychology, The Netherlands

Abstract: Objective: Burnout constitutes a health risk, (J Occup Health 2017; 59: 477-494)
and interventions are needed to reduce it. The aim of this doi: 10.1539/joh.17-0050-RA
study was to synthesize evidence regarding the relation-
ship between physical activity and burnout by conducting Key words : Burnout, Exercise, Fatigue, Intervention,
a systematic review of longitudinal and intervention stud- Longitudinal, Physical activity
ies. Methods: A literature search resulted in the identifi-
cation of a final set of ten studies: four longitudinal and
six intervention studies. In separate analyses for each Introduction
category, evidence was synthesized by extracting the
study characteristics and assessing the methodological Burnout, a severe and persistent form of fatigue that
quality of each study. The strength of evidence was cal- occurs after a long period of work stress, has become a
culated with the standardized index of convergence common phenomenon in today’s organizations. Early
(SIC). Results: In longitudinal studies, we found moder- conceptualizations of burnout define burnout “as a syn-
ately strong evidence (SIC (4) = −1) for a negative rela- drome of emotional exhaustion, depersonalization, and
tionship between physical activity and the key compo- reduced sense of personal accomplishment, that can occur
nent of burnout, i.e., exhaustion. We found strong evi- among individuals who do‘people work’ of some kind”1).
dence (SIC (6) = −0.86) for the effect of physical activity Since then, the concept has been broadened from people
on reducing exhaustion in intervention studies. As only work to all kinds of occupations. Accordingly, its dimen-
one study could be classified as a high quality study, sions were relabeled as “ exhaustion, ” “ cynicism, ” and
these results of previous studies need to be interpreted “professional efficacy.” Over time, a consensus has built
with some caution. Conclusions: This systematic review up that exhaustion is the key component of burnout 2-4) .
suggests that physical activity constitutes an effective Burnout thus mainly refers to feelings of mental and
medium for the reduction of burnout. Although consistent physical exhaustion (i.e., extreme levels of fatigue), low
evidence was found, there is a lack of high quality longi- mood, and lack of energy4).
tudinal and intervention studies considering the influence High levels of burnout are associated with substantial
of physical activity on burnout. Therefore, future re- losses for employees’ health and well-being. Employees
search should be conducted with the aim to produce high with burnout show reduced self-efficacy levels 5) , sleep
quality studies, to develop a full picture of physical activ- more poorly 6) , show decreased cognitive functioning 7,8) ,
ity as a strategy to reduce burnout. have reduced work ability9), and are at higher risk for de-
veloping cardiovascular diseases 10) . Employers, too, face
consequences such as presenteeism and lost productivity
Received February 17, 2017; Accepted July 31, 2017
Published online in J-STAGE October 7, 2017
time11-13). Estimations of the annual costs to society caused
Correspondence to: J. de Vries, Erasmus University Rotterdam, Depart- by burnout vary from 136.4 billion dollars (figures related
ment of Work & Organizational Psychology, The Burgemeester Oudlaan to the U. S. ) 12) to 200 billion euros ( figures related to
50, 3062 PA Rotterdam, Netherlands (e-mail: [email protected]) Europe) 14) . Given the high prevalence of burnout and its
Supplementary materials (Appendices) are available in the online version negative consequences, it is valuable to examine potential
of this article. approaches to reduce it.
 478 J Occup Health, Vol. 59, 2017

We hypothesized that regular physical activity and ex- sisted of three classes of keywords: i.e., “burnout-related”
ercise may constitute an effective approach to reduce ( burnout, emotional exhaustion, occupation * stress ) ,
burnout. Physical activity is “any bodily movement pro- “physical-activity related” (physic* activ*, exercise), and
duced by skeletal muscles that requires energy expendi- “work-related” (employ*, work * ) keywords. For each
ture”15). Exercise is a subcategory of physical activity, and search operation, one search term of each class of key-
it can be defined as physical activity that is “ planned, words was combined with the operator AND, resulting in
structured, repetitive and purposeful in the sense that the 12 different search phrases with three keywords (see An-
improvement or maintenance of one or more components nex 1). This resulted in the identification of 4619 articles:
of physical fitness is the objective” 15) . Although there is 1657 from the Web of Science, 2285 from PubMed, and
reason to argue that these two concepts do overlap, yet 677 from PsycINFO. Crosschecking reference lists re-
are not the same, they are often treated interchangeably in vealed two additional articles. The citation details for all
the literature. Assets of physical activity for the reduction of these articles were transferred to EndNote X7.5.
of burnout might include its accessibility, low costs, and
positive “side effects,” such as the reduced risk for car- Selection
diovascular diseases16). After removing 2381 duplicate articles automatically
Various pathways have been proposed to explain the via EndNote X7.5 (References → Find Duplicates), the
relationship between physical activity and burnout; yet, first author and second author of this paper independently
the underlying mechanisms are still uncertain. A combi- screened 2240 articles. Three inclusion criteria were used
nation of psychological and physiological mechanisms to exclude irrelevant articles. All titles and abstracts were
may be responsible for the hypothesized positive effects. screened for relevance and for participants being adults
As to psychological working mechanisms, it has been and employees and not athletes (inclusion criterion 1), re-
proposed that regular physical activity facilitates psycho- sulting in 172 remaining records. Another two records
logical detachment from work, and in this way reduces were excluded because the articles were not peer-
the risk of prolonged stress responses such as burnout17,18). reviewed and/or the full texts were not available (inclu-
Regular physical activity may also increase people’s self- sion criterion 2). Finally, the 170 remaining articles were
efficacy19,20) that may “spill over” to the work domain. As read in full, and it was checked whether each study i) util-
a result, employees may feel more competent in coping ized burnout as an outcome measure and ii) was a longi-
with their work tasks 21,22) , and as such experience these tudinal or intervention study (inclusion criterion 3). In-
tasks as being less demanding. Lower perceived demands itial substantial agreement between the two authors was
may contribute to lower fatigue23) . As regards physiologi- reached with Kappa 0.72 and an agreement percentage of
cal working mechanisms, it has been suggested that by 73% 28) . Results and disagreements were discussed be-
means of regular physical activity one is better able to tween the two authors and resolved by consensus. This
handle psychological stress (i.e., the cardiovascular fit- resulted in a final selection of ten studies: four longitudi-
ness hypothesis)24). This may result in faster bodily recov- nal and six intervention studies (for a PRISMA flow dia-
ery after stress exposure, thus reducing the risk of burn- gram, see Fig. 1).
out25,26). Exercise may also induce changes in several neu-
rotransmitters and neuromodulators, resulting in better Data extraction
mood and increased energy25,27). The following study characteristics of all ten studies
Against this practical and theoretical background, the were extracted by the first author: study goal, design (e.g.,
aim of this study was to synthesize evidence from previ- full-panel design, randomized controlled trial ) , number
ous studies on the relationship between physical activity and type of participants, measurement method (e.g., ques-
and burnout by conducting a systematic review. Because, tionnaires, objective measures), burnout measure, type of
compared with cross-sectional studies, intervention stud- physical activity, measurement points, and results. For
ies and longitudinal studies are more appropriate for mak- longitudinal studies, the physical activity measure was
ing causal inferences, we limited our systematic review to evaluated as well. For intervention studies, besides the
intervention and longitudinal studies. In doing so, we conditions and the content of the intervention, the type of
tried to answer the question of whether physical activity prevention was extracted. That is, we indicated for each
indeed influences burnout. study whether it concerned primary (i.e., preventing burn-
out of healthy employees), secondary (i.e., reducing mild
Methods burnout symptoms and preventing these from becoming
more severe), or tertiary (i.e., reducing serious burnout)
Literature search prevention 29,30) . The second author checked all of the ex-
A systematic literature search was conducted (February tracted study characteristics. Differences were discussed
2016) within three bibliographical online databases: Web and solved.
of Science, PubMed, and PsycINFO. Search terms con-
 Lea M. Naczenski, et al.: Physical Activity and Burnout 479

Records idenƟĮed through database AddiƟonal records idenƟĮed through

IdenƟĮĐaƟon searching other sources
(n = 4619) (n = 2)

Records aŌer duplicates removed

(n = 2240)
Screening

Records excluded based

Records screened on inclusion criterion 1
(n = 2240) (n = 2068)

Records excluded based

Records considered for
on inclusion criterion 2
eligibility analysis
(n = 2)
Eligibility

(n = 172)

Full-text arƟcles
Full-text arƟcles assessed
excluded based on
for eligibility
inclusion criterion 3
(n = 170)
(n = 160)
Included

Final studies included

(n = 10): 4 longitudinal & 6
intervenƟon studies

Fig. 1. PRISMA flow diagram for systematic reviews (based on Moher, Liberati, Tezlaff, Altman, &
The PRISMA Group, 200960)).

Study quality evaluation ity) for each criterion it was classified as an overall high
When drawing conclusions about the relationship be- quality study31).
tween physical activity and burnout, one should rely more
strongly on findings from high quality studies. Therefore, Synthesis of evidence
we assessed study quality with a criteria list for assessing Due to the variety of measurement methods, timing of
the methodological quality of each study that was based measurements, and statistical analyses used in the studies,
on the list of Van Laethem, Beckers, Kompier, Dijkster- a meta-analysis was considered inappropriate. To avoid
huis, and Geurts (2013) 31) . We used two different sets of mere “vote-counting” and to quantify the strength of evi-
quality criteria, i.e., for longitudinal studies (see Table 1) dence for the relationship between physical activity and
and for intervention studies (see Table 2). The first author burnout, a standardized index of convergence (SIC) value
and second author rated the six longitudinal studies for was calculated according to a method of Wielenga-
five criteria and the four intervention studies for seven Meijer, Taris, Kompier, and Wigboldus (2010)32). The for-
criteria with zero (“insufficient”), two (“sufficient”), or mula of SIC is
three (“good”) stars. Uncertainties were discussed and
consensus was reached between the first two authors.
Only when a study had at least two stars (sufficient qual-
 480 J Occup Health, Vol. 59, 2017

Table 1. Quality evaluation criteria for longitudinal studies

Criteria 0 stars (insufficient) 2 stars (sufficient) 3 stars (good)

1.
Applied design Incomplete panel design (2 TP, Incomplete panel design (>2 TP, Complete panel design (all
≥1 central research variables ≥1 central research variables variables measured at each TP)
measured only at 1 TP) measured more than once but
not on all TP)
2.
Measures: Burnout Burnout (dimensions) not Burnout (dimensions) measured
measured validly (i.e, no correct validly (i.e, correct use of
use of validated [sub]scales of validated [sub]scales of the
the MBI, MBI-NL, UBOS, MBI, MBI-NL, UBOS, SMBQ,
SMBQ, C-CBI) C-CBI)
3.
Measures: PA/exercise PA/exercise not measured PA/exercise measured validly PA/exercise measured validly
validly (i.e, no correct use of (i.e, correct use of validated (i.e, correct use of validated
validated scale such as the scale such as the GPAQ, IPAQ, scales such as the GPAQ,
GPAQ, IPAQ, SGPALS OR no SGPALS but scale does not take IPAQ, SGPALS including the
use of objective measures such frequency, duration, intensity of frequency, duration, intensity of
as accelerometers, pedometers) PA/exercise into account) PA/exercise, OR use of objec-
tive measures such as acceler-
ometers, pedometers)
4.
Non-response analysis No check on selectivity of the Check on selectivity of the Check on selectivity of the
sample sample either at baseline or sample at both baseline and
follow-up follow-up
5.
Statistical adjustment Either no adjustment for: Adjustment for potential con- Adjustment for potential con-
–Potential confounders, and founders, AND adjustment for: founders,
–T1 dependent variables, and –T1 dependent variables, or AND adjustmen for:
–Potential change of indepen- –Potential change of some –T1 dependent variables, and
dent variables independent variables –Potential change of indepen-
OR adjustment for potential dent variables
confounders,
but no adjustment for:
–T1 dependent variables, and
–Potential change of indepen-
dent variables
TP=Time Point(s); PA=Physical Activity; MBI=Maslach Burnout Inventory; MBI-NL=Maslach Burnout Inventory (Dutch version);
UBOS=Utrechtse Burnout Scale; SMBQ=Shirom-Melamed Burnout Questionnaire; C-CBI=Copenhagen Burnout Inventory;
GPAQ=Global Physical Activity Questionnaire; IPAQ=International Physical Activity Questionnaire; SGPALS=Saltin-Grimby
Physical Activity Scale

that the studies either report inconsistent results or did not

n (positive) –n (negative)
SIC = find a significant relationship at all. By combining the
n (total)
SIC value with the corresponding number of studies as-
with n (positive) as the number of studies reporting a sig- sessing this relationship, the strength of evidence can be
nificant positive relationship, n (negative) as the number determined (see Table 3).
of studies reporting a significant negative relationship, SIC calculations were conducted separately for longitu-
and n (total) as the total number of studies examining dinal and intervention studies. For the intervention stud-
this relationship. The values can therefore range from ies, the main and most advanced analysis concerning the
−1, with all articles presenting a significant negative re- relationship between physical activity and burnout was
lationship, to +1, with all articles presenting a significant used for the calculation of SIC (e.g., no analyses concern-
positive relationship. A SIC value close to zero means ing depression or other outcome measures were consid-
ered; analyses with statistical adjustments were preferred
 Lea M. Naczenski, et al.: Physical Activity and Burnout 481

Table 2. Quality evaluation criteria for intervention studies

Criteria 0 stars (insufficient) 2 stars (sufficient) 3 stars (good)

1.
Control group & No control group or randomiza- One control group, but no At least one control group and
randomization tion randomization randomization
2.
Measuring TP: Pre or post intervention only Pre and post intervention At least 1 pre and >1 post
Burnout intervention
3.
Intervention content The initial problem The initial problem The initial problem
(regarding burnout) is not clear (regarding burnout) is insuffi- (regarding burnout) is clear and
and/or intervention does not fit ciently presented and/or inter- intervention fits initial problem
initial problem vention does fit initial problem
4.
Intervention process No information about the imple- Information about the imple- Information about the imple-
mentation process is presented mentation process is presented, mentation process is presented
but insufficient
5.
Measures: Burnout Burnout (dimensions) not Burnout (dimensions) measured
measured validly (i.e, no correct validly (i.e, correct use of
use of validated [sub] scales of validated [sub] scales of the
the MBI, MBI-NL, UBOS, MBI, MBI-NL, UBOS, SMBQ,
SMBQ, C-CBI) C-CBI)
6.
Non-response analysis No check on selectivity of the Check on selectivity of the Check on selectivity of the
sample sample either at baseline or sample at both baseline and
follow-up follow-up
7.
Intention-to-treat No intention-to-treat analysis Use of intention-to-treat analysis
Note. TP=Time Point(s); MBI=Maslach Burnout Inventory; MBI-NL=Maslach Burnout Inventory (Dutch version);
UBOS=Utrechtse Burnout Scale; SMBQ=Shirom-Melamed Burnout Questionnaire; C-CBI=Copenhagen Burnout Inventory

Table 3. Strength of evidence for the relationship between physical activity and burn-
out based on the number of studies assessing this relationship and its corre-
sponding SIC value

SIC value
Number
–1.00 - –.60 –0.59 - –.30 –0.29 - 0.29 0.30 - 0.59 0.60 - 1.00
of
studies Strength of Strength of Strength of Strength of Strength of
evidence evidence evidence evidence evidence
1-2 Insufficient Insufficient Insufficient Insufficient Insufficient
3-5 –– – 0 + ++
≥6 ––– –– 0 ++ +++
Note. 0=inconsistent evidence; –/+=limited evidence for negative/positive relationship; –
–/++=moderately strong evidence for negative/positive relationship; – – –/+++=strong
evidence for negative/positive relationship

over analyses without statistical adjustments). A)33-36). Two studies were conducted in the Netherlands33,34)
and two were conducted in Sweden 35,36) . Sample sizes
Results ranged from 1747 to 3717 for a heterogeneous group of
employees with mixed gender who were employed in
Longitudinal studies business services, public administration, industry, educa-
We identified four longitudinal studies ( see Table 4 tion, health care, and social insurance.
 482
Table 4A. Study characteristics of longitudinal studies

Measurement Burnout mea- Physical activ- Type of physi- Measurement

Study Study goal Design Participants Results
Methods sure ity measure cal activity times
1. Bernaards et al. Investigating Longitudinal 1747 Dutch em- Questionnaires MBI-NL 1 item: ‘How Strenuous 4 times, in Once or twice
(2006) 33) the longitudinal prospective ployees from 34 exhaustion often within the leisure time PA 1994, 1995, strenuous leisure
relation be- design with 3 companies subscale past four 1997 and 1998 time PA a week
tween strenuous times follow up (blue-, white- (7 items) months did you was associated
leisure time PA collar, caring participate in with lower risk of
and psychologi- profession): strenuous sports future exhaustion
cal complaints - mixed gender activities or compared to no
(depression and - ≥1 year work strenuous or ≥3 times a
emotional in current job physical activi- week. This result
exhaustion) in a - working hours ties that last was only found in
Dutch working ≥24h/week long enough to workers with sed-
population to become entary jobs.
find evidence sweaty?’
for preventive
role of PA
2. De Vries et al. Examining ’ Two-wave 2275 Dutch em- Questionnaires UBOS exhaus- 1 item: ‘On how Moderate- 2 times, in 2008 Support for recip-
(2016) 34) ‘normal’, longitudinal full ployees (busi- tion subscale many days a intensity PA and 2009 rocal relation
‘reversed’ and panel (with a ness services, (5 items) week are you (i.e., activities between PA and
‘reciprocal’ one-year time public adminis- normally that require a work-related
relationships interval) tration, indus- physically moderate fatigue:
between PA and try, education): active during at amount of effort - Increase PA
work-related - mixed gender least 30 mins. a and noticeably associated with
fatigue (i.e., - full time (36h/ day (only count accelerate the decrease work-
exhaustion week) PA that is heart rate) related fatigue.
component of - no physically equally de- - Increase work-
burnout); and demanding jobs manding as related fatigue
between PA and brisk walking or associated with
task demands biking. Activi- decrease PA
ties shorter than
10 minutes do
not count) - dur-
ing your work
and free time
together?’
J Occup Health, Vol. 59, 2017
Table 4A. Study characteristics of longitudinal studies (continued)

Measurement Burnout mea- Physical activ- Type of physi- Measurement

Study Study goal Design Participants Results
Methods sure ity measure cal activity times
3. Jonsdottir et al. Analyzing Longitudinal 3114 Swedish Questionnaires SMBQ (22 Adapted 4-level Leisure time PA 2 times, in 2004 Workers report-
(2010) 35) longitudinal prospective employees items), i.e.,SGPALS and 2006 ing light PA,
associations design with two (mainly health physical fa- PA in the last moderate, or
between self- year follow up care, social three months:
tigue, emotional vigorous PA at
reported lei- insurance): 1) mostly
exhaustion and baseline are less
sure-time PA - mixed gender sedentary; 2)
cognitive weari- likely to report
and burnout - ≥1 year work ness light PA, such burnout at
among working - ≥50% full- as walking for ≥ follow-up com-
individuals. time 2 hours a week; pared to seden-
Lea M. Naczenski, et al.: Physical Activity and Burnout

3) moderate PA, tary workers.

such as swim-
ming for ≥ 2
hours a week; 4)
vigorous, high
intensity PA ≥5
hours a week
4. Lindwall et al. Examine Longitudinal 3717 Swedish Questionnaires SMBQ (22 4-level Leisure time PA 4 times, in Changes in PA
(2014) 36) whether intra- prospective health care items) i.e., SGPALS. PA in 2004, 2006, were associated
individual design with 3 workers: physical fa- the last three 2008 and 2010 with, and trav-
changes in PA follow up - mixed gender tigue, emotional months elled together
are correlated measures ->/=1 year work exhaustion and with, changes in
with intra- ->/=50% cognitive weari- burnout across
individual full-time ness time.
changes in men-
tal health across
four measure-
ment time-point
over 6 years,
both from
between- and
within-person
perspectives.
Note. PA=physical activity; MBI=Maslach Burnout Inventory; MBI-NL=Maslach Burnout Inventory (Dutch version); UBOS=Utrechtse Burnout Scale; SMBQ=Shirom-Melamed
Burnout Questionnaire; C-CBI=Copenhagen Burnout Inventory; GPAQ=Global Physical Activity Questionnaire; IPAQ=International Physical Activity Questionnaire;
SGPALS=Saltin-Grimby Physical Activity Scale; mins=minutes
483
 484

Table 4B. Study characteristics of intervention studies

Method of Burnout Prevention Intervention Measurement Intervention

Study Study goal Design Participants Conditions Results
measurement measure type content times dose
1. Bretland & Comparing Randomized 49 Australian Flexibility & Question- MBI (22 Primary Flexibility & Baseline, 4 weeks, 3 Both types of
Thorsteinsson aerobic with controlled employees strength naires, items) i.e., prevention strength after 2 weeks times a week, exercise
(2015) 40) flexibility & trial (education, exercisea exercise emotional exercisea and at 30 mins reduced
strength government, (n=9), diary exhaustion, (e.g. yoga, post-inter- emotional
exercise to medical): aerobic depersonali- pilates & vention exhaustion.
assess mixed gender exerciseb zation and body bal- Flexibility &
relative ->18 years (n=20), personal ance) partly strength
effectiveness old control accomplish- supervised exercise also
against - no medical (n=20) ment improved
well-being, issues Aerobic professional
perceived - not hyper- exericseb: efficacy. No
stress and tensive - no both super- change in
burnout. regular vised group cynicism.
exercise fitness
classes and
individual
aerobic
exercise
2. Freitas et Assessing the Pretest- 21 Brazilian WPA Pro- Question- MBI (22 Primary WPA (not Baseline, 12 weeks, 5 WPA did not
al. (2014) 41) effects of a posttest palliative gram. No naires items) i.e., prevention further post-inter- times a week, decrease
workplace intervention care nursing control group emotional specified) vention 10 mins burnout (i.e.,
physical study without profession- exhaustion, emotional
activity control als: depersonali- exhaustion,
(WPA) condition. - gender not zation and depersonali-
program on No random- specified personal zation and
levels ization - ≥1 year in accomplish- personal
ofburnout of current job ment accomplish-
a nursing ment).
team in a pal-
liative care
unit.
J Occup Health, Vol. 59, 2017
Table 4B. Study characteristics of intervention studies (continued)

Method of Burnout Prevention Intervention Measurement Intervention

Study Study goal Design Participants Conditions Results
measurement measure type content times dose
3. Gerber et Explore Pilot study. 12 Swiss Exercise Question- MBI (22 Secondary Aerobic Baseline, and 12 weeks, At post-inter-
Lea M. Naczenski, et al.: Physical Activity and Burnout

al. (2013) 42) whether a Pretest- male em- (n=12); naires items) i.e., prevention exerciseb post-inter- 2/3 times a vention,
12-week posttest ployees: No control emotional (e.g., cross vention week, 60 emotional
aerobic design - male group exhaustion, trainers, mins exhaustion,
exerciseb without - age 30-65 depersonali- running, and deper-
training control - non-smok- zation and bicycle) at a sonalization.
program condition. ing personal private were signifi-
results in No random- - good accomplish- fitness cantly
reduced ization physical ment center, super- reduced No
levels of health vised by sign. change
burnout. - no regular exercise in personal
exercise coaches. accomplish-
during last 2 ment.
years
- high scores
on MBI
exhaustion or
cynicism
485
 486

Table 4B. Study characteristics of intervention studies (continued)

Method of Burnout Prevention Intervention Measurement Intervention

Study Study goal Design Participants Conditions Results
measurement measure type content times dose
4. Lindegard Investigating Pretest and 69 Swedish Multimodal Question- SMBQ Tertiary MMT: Baseline, 18 weeks, All partici-
et al. (2015) 43) whether posttest patients of treatment naires (22-items) prevention program after 6 once a week, pants report-
initially design stress clinic (MMT; i.e., physical tailored months, after 60 mins ed a decrease
physically without due to n=69). No fatigue, according 12 months, in burnout
inactive control stress-related control emotional individual after 18 symptoms
patients diag- condition. No exhaustion: group. exhaustion needs; months over time. At
nosed with randomiza- - mixed and cognitive 8-week 18 months,
exhaustion tion gender weariness group stress Participants
disorder - physically management who com-
differ at inactive program; plied mildly
6-month, - diagnostic comprehen- or strongly
12-month criteria sive info with the PA
and exhaustion about PA; showed
18-month disorder self-selection larger and
follow-up in of 18-week more sus-
burnout participation tained
levels de- in coached improve-
pending on group-exer- ments in
whether they cise program burnout
complied during the
with PA follow-up
recommen- period than
dations. non-compli-
ers.
J Occup Health, Vol. 59, 2017
Table 4B. Study characteristics of intervention studies (continued)

Method of Burnout Prevention Intervention Measurement Intervention

Study Study goal Design Participants Conditions Results
measurement measure type content times dose
5. Tsai et al. Explore the Non-ran- 89 Chinese Control Question- C-CBI (10 Primary Worksite Baseline, 12 weeks Personal and
(2013) 44) effectiveness domized banking and (n=38; no naires, digital items) i.e., prevention exercise post-inter- Low inten- work-related
of exercise quasi-experi- insurance intervention), sphygmoma- work-related program, vention sity: once a burnout was
program on mental workers: low (n=36) nometer, and personal after work, week, 60 significantly
burnout and design with - mixed and high waistlines burnout gymnastics, mins. High reduced by
metabolic control gender (n=35) aerobic, intensity: exercise.
syndrome condition intensity stretching to twice a week, High inten-
components. exercise increase 60 mins. sity exercise
muscle resulted in
strength, with greater
music and improve-
Lea M. Naczenski, et al.: Physical Activity and Burnout

trainer ments
compared to
low-intensi-
ty.
6. Van Investigate Randomized 75 Dutch Exercise and Question- UBOS (16 Secondary FYS: pro- Baseline, FYS: 4 Both inter-
Rhenen et al. the short- and controlled telecommu- relaxation naires items), i.e., prevention gressive post-inter- exercise ventions
(2005) 45) long-term trial nications program emotional muscle vention, and sessions in 8 revealed
effectiveness company (FYS; n=71), exhaustion, relaxationc & at 6 months weeks, 60 positive
of two brief employees: cognitive professional Fitness follow-up mins COG: 4 impact on
preventive - mixed intervention efficacy, (aerobicb & sessions in 8 burnout (i.e.,
work stress gender (COG; n=59 cynicism non-aerobic weeks, 60 emotional
management - high rate of exercised) mins. exhaustion
programs. distress during work. and profes-
(4DSQ> .32) Individually sional
conducted. efficacy). No
COG: decrease in
restructuring cynicism.
of irrational
beliefs
Note. PA=Physical Activity; MBI=Maslach Burnout Inventory; MBI-NL=Maslach Burnout Inventory (Dutch version); UBOS=Utrecht Burnout Scale; SMBQ=Shirom-Melamed
Burnout Questionnaire; C-CBI=Copenhagen Burnout Inventory; GPAQ=Global Physical Activity Questionnaire; IPAQ=International Physical Activity Questionnaire;
SGPALS=Saltin-Grimby Physical Activity Scale; mins=minutes
a
Physical activities in which muscles are stretched and strengthened.
b
Physical activities involving large muscle groups that are used for extended periods of time in activities that are rhythmic in nature, such as walking, running, or cycling.
c
Relaxation technique used to learn to monitor and to control the state of muscle tension.
d
Brief intense bursts of physical activity, such as weightlifting.
487
 488 J Occup Health, Vol. 59, 2017

Table 5. Quality evaluation of longitudinal studies

1 2 3 4 5
Study Applied Measures: Measures: Non-response Statistical
design burnout PA/exercise analysis adjustment
1.
Bernaards et al. (2006)33) ** *** 0 *** **
2.
De Vries et al. (2016)34) *** *** 0 0 ***
3.
Jonsdottir et al. (2010)35) 0 *** *** ** **
4.
Lindwall et al. (2014)36) *** *** *** *** **
Note. 0=insufficient; **=sufficient; ***=good; PA=physical activity

All four studies assessed physical activity and burnout was applied in three studies. Two studies checked the se-
with questionnaires. They all measured exhaustion as the lectivity of the sample at baseline and follow-up33,36). Jons-
main dimension of burnout. These four studies did not dottir et al. (2010) 35) did so only at follow-up, and De
measure depersonalization (cynicism) or reduced sense of Vries et al. (2016) 34) did not do so at all. One study ad-
personal accomplishment ( professional efficacy ) . To justed for potential confounders (criterion 5) (e.g., gen-
measure exhaustion, two studies used the subscale “ex- der, age, education, working overtime, and working ir-
haustion” of Dutch versions of the Maslach Burnout In- regular hours), time point one (T1) -dependent variables,
ventory: the Maslach Burnout Inventory-NL ( MBI-NL, and the potential change of independent variables35) . Ber-
seven items)33,37) and the “Utrecht Burnout Scale” (UBOS, naards et al. ( 2006 ) 33) also adjusted for potential con-
five items)34,37). The other two studies35,36) used the Shirom- founders and a potential change of independent variables,
Melamed Burnout Questionnaire ( SMBQ ) with 22 but adjustments for T1 measurements were conducted for
items 38) . In the two Dutch studies, physical activity was exhaustion only and not for physical activity, as physical
investigated with one item, whereas the two Swedish activity was measured at baseline and not at follow-up.
studies used the Saltin-Grimby Physical Activity Scale Lindwall et al. (2014)36) and Jonsdottir et al. (2010) 35) ad-
(SGPALS) 39) to assess participants’ frequency, duration, justed only for age, gender, and T1 physical activity and
and intensity of physical activity. Burnout (exhaustion) exhaustion but not for potential changes of independent
and physical activity were measured at four33,36), or at two, variables.
different measurement points 34,35) . The time between the Altogether, the study by Lindwall et al. (2014)36) could
measurements points lasted 1 year33,34) or 2 years35,36). be classified as a high quality study (two or three stars on
Study quality evaluation each quality criterion). The other three studies can be con-
Two studies used a complete panel design with physi- sidered as studies of moderate quality.
cal activity and burnout measured at each time point (see Synthesis of evidence
Table 5, criterion 1)34,36). An incomplete panel design was All four studies demonstrated a significant negative re-
used by Bernaards et al. (2006)33), who measured burnout lationship between physical activity and the key burnout
at four measurement points but physical activity only at component, i.e., exhaustion. Three of these studies inves-
baseline. Jonsdottir et al. (2010) 35) also used an incom- tigated only a “normal” relationship (i.e., physical activity
plete panel design with two time points, measuring burn- → exhaustion)33,35,36), whereas one study examined a “nor-
out at both time points but physical activity only at base- mal” but also a “reversed” relationship between physical
line. In all four studies, burnout was defined as “exhaus- activity and exhaustion (i.e., also exhaustion → physical
tion only.” All four studies used validated (sub) scales to activity)34).
measure exhaustion (criterion 2). In two studies, a full Specifically, it was shown that participants who en-
questionnaire was used (i.e., SMBQ)35,36) , and the remain- gaged in strenuous physical activity once or twice a week
ing two studies used one subscale (i.e., MBI) 33,35) . In two were at significantly lower risk for ( future ) exhaustion
studies, physical activity was measured with a validated than participants who were physically active more than
scale, including the frequency, duration, and intensity of twice a week or between one and three times a month.
physical activity (criterion 3) 35,36) , while in the other two This association was stronger for workers with sedentary
studies physical activity was measured with a single item rather than non-sedentary jobs 33) . Furthermore, partici-
(see Table 4A33,34) ). A non-response analysis (criterion 4) pants who became more physically active over a 6-year
 Lea M. Naczenski, et al.: Physical Activity and Burnout 489

Table 6. Quality evaluation of intervention studies

1 2 3 4 5 6 7
Control
Study Non-
group & Measuring Intervention Intervention Measures: Intention-
response
randomiza- TP: burnout content process burnout to-treat
analysis
tion
1.
Bretland & *** *** *** *** *** 0 0
Thorsteinsson (2015) 40)
2.
Freitas et al. (2014) 41) 0 ** ** ** *** 0 0
3.
Gerber et al. (2013) 42) 0 ** *** *** *** 0 0
4.
Lindegard et al. (2015) 43) 0 *** *** *** *** ** 0
5.
Tsai et al. (2013) 44) ** ** *** *** *** 0 0
6.
Van Rhenen et al. (2005) a45) *** *** *** *** *** ** 0
Note. 0=insufficient; **=sufficient; ***=good; TP=time points
a
The aim of this study was to test the hypothesis that a newly developed, combined physical intervention is more ef-
fective in reducing psychological complaints than a cognitive intervention. The cognitive intervention can be consid-
ered as control condition.

period showed a larger decrease in exhaustion than par- One study was conducted as a one-condition pilot study42).
ticipants who did not become more active. Lindwall et al. Sample sizes ranged from 12 to 89 in a heterogeneous
( 2014 ) 36) showed that exhaustion and physical activity group of participants who were employed in education,
changed together over time, from both a between-person government, medicine, telecommunications, banking, and
and a within-person perspective (i.e., increasing physical insurance. Five studies used a sample of mixed gender,
activity levels were associated with decreasing exhaustion whereas one study examined only male employees42). Two
levels). Jonsdottir et al. (2010) 35) found participants re- studies selected subclinical samples of participants with
porting performance of light, moderate, or vigorous high burnout or stress symptoms 42,45) , which therefore
physical activity to be less likely to report exhaustion at were considered as secondary prevention studies 29,30) . In
follow-up compared with participants with a sedentary one study, patients attending a stress clinic and who were
lifestyle. Only De Vries et al. (2016) 34) investigated, and diagnosed with stress-related exhaustion were investi-
found supportive evidence for, a reciprocal relationship gated 43) , and this study was accordingly considered as
between physical activity and exhaustion. An increase in concerning tertiary prevention 29,30) . Three studies selected
physical activity was related to a decrease in exhaustion healthy employees40,41,44) and were considered to cover pri-
at follow-up, and an increase in exhaustion was associ- mary prevention 29,30) . Three studies selected participants
ated with a decrease in physical activity at follow-up. who were not physically active40,42,43).
Based on the four longitudinal studies reviewed in this All six studies measured exhaustion, i. e. , the main
paper, the SIC value was: SIC (4) = (0−4)/4 = −1. This burnout dimension. Lindegard et al. (2015) 43) and Tsai et
indicates moderately strong evidence for a negative rela- al. (2013)44) measured exhaustion only. Lindegard and co-
tionship between physical activity and the key component workers used the SMBQ, whereas Tsai et al. used the Co-
of burnout, i.e., exhaustion (see Table 3). penhagen Burnout Inventory ( C-CBI ) . The four other
studies 40-42,45) additionally included measures of cynicism
Intervention studies and professional efficacy, using the MBI. Internal consis-
The main study characteristics of the six identified in- tency was good in all studies, except for the MBI in the
tervention studies 40-45) are presented in Table 4B. These study of Freitas et al. (2014)41). Participants were asked to
studies were conducted in Australia, Brazil, Switzerland, fill out the questionnaire at baseline and at one follow-up
Sweden, China, and the Netherlands. Two studies had a point in three studies 41,42,44) . Two intervention studies used
randomized controlled trial design40,45). Three other studies three time points 40,45) whereas one study had four time
had a non-randomized quasi-experimental design 41,43,45) . points 43) . Intervals between time points ranged from 2
 490 J Occup Health, Vol. 59, 2017

weeks to 6 months. Most interventions comprised in- was insufficient. The corresponding SIC value for ex-
structed group fitness sessions, during or after work, haustion is as follows: SIC (6) = (0−5)/6 = −0.83. This
sometimes combined with individual workouts. All stud- indicates that there is strong consistent evidence for a
ies operationalized physical activity as aerobic exercise, negative relationship between physical activity and ex-
to which two studies also added flexibility, strength, and haustion (see Table 3). Two40,45) out of four studies that in-
relaxation exercises, i.e., yoga and pilates 44) , and progres- vestigated the burnout component “professional efficacy”
sive muscle relaxation 45) . Intervention program durations (or personal accomplishment), found a significant effect
ranged from 4 to 18 weeks, with two to five weekly on this outcome. The SIC value for professional efficacy
physical activity sessions, and a duration of 10-60 min is as follows: SIC (4) = (2−0)/4 = 0.50, indicating lim-
per session. The most frequently applied duration was 12 ited evidence for a positive relationship between physical
weeks, twice each week, for 60 min. Two studies adjusted activity and professional efficacy. One42) out of four stud-
the level of physical activity based on individual skills ies that studied “cynicism” (or depersonalization) showed
and fitness of the participants43,45). a significant effect on this outcome. Hence, the corre-
Study quality evaluation sponding SIC value for cynicism is as follows: SIC (4) =
As to criterion 1, i.e., applied design (Table 6), two in- (0−1)/4 = −0.25. This means that there is inconsistent
tervention studies had at least one control condition and evidence for a negative relationship between physical ac-
applied randomization for the different conditions 40,45) . tivity and cynicism.
Tsai et al. (2013) 44) used a control condition but did not
randomize the participants. The three remaining studies Discussion
had neither a control condition nor randomization 41-43) . In
three studies, burnout was measured (criterion 2) at base- Burnout constitutes a serious risk to sustainable health
line and at several follow-up points 40,43,45) , whereas in the of employees of today’s organizations. Accordingly, in-
remaining three studies burnout was measured at two time terventions are needed that may reduce burnout. We hy-
points only, i.e., pre- and post-intervention 41,42,44) . As to pothesized that regular physical activity may constitute an
criterion 3 (intervention content), the initial problem re- instrument that may be used for the reduction of burnout.
garding burnout was well-explained, and the intervention Therefore, this study systematically reviewed longitudinal
fitted the initial problem in five studies40,42-45). Only Freitas and intervention studies that investigated the strength of
et al. (2014) 41) presented the problem insufficiently, with the relationship between physical activity and burnout.
very little research evidence to argue for their intervention Ten studies, four longitudinal and six intervention studies,
content. Five studies provided information on the imple- were identified. The consistency of the evidence for a
mentation process (criterion 4), but Freitas et al. (2014)41) negative relationship between physical activity and the
did not mention in detail how the intervention was imple- key component of burnout (i.e., exhaustion) in longitudi-
mented. As regards the measurement of burnout (criterion nal studies was moderate, while the consistency of this
5), in all studies burnout was measured with a validated evidence in intervention studies was strong.
instrument40-45). A non-response analysis (criterion 6) was Moreover, for intervention studies, we found limited
applied in two studies but only at baseline and not at evidence for a positive relationship between physical ac-
follow-up 43,45) . Furthermore, none of the six studies per- tivity and professional efficacy, and inconsistent evidence
formed an intention-to-treat analysis to examine external for a negative relationship between physical activity and
validity of the intervention (criterion 7). cynicism.
All in all, no intervention study scored “sufficient” (or
higher) for all of the seven criteria. This means that none Methodological quality of the studies
of these six studies can be classified as a high quality The SIC values that we calculated for longitudinal and
study. The Van Rhenen et al. ( 2005 ) 45) study scored intervention studies suggest that physical activity is re-
“good” for most criteria but also has one shortcoming, lated to a reduction of exhaustion at a later point in time.
whereas the study by Freitas et al. (2014)41) was of poorer It should also be acknowledged, though, that research into
quality with three methodological shortcomings. The the causal relation between physical activity and burnout
most frequent insufficiencies constitute the absence of is still in its infancy. This conclusion follows from the as-
non-response analysis ( four out of six studies ) and sessment of the methodological quality of the included
intention-to-treat analysis (all six studies). studies, as investigated by means of well-established cri-
Synthesis of evidence teria regarding design, measurement quality, and appro-
Five out of six studies demonstrated a significant influ- priateness of analyses. More trust can be put in those pub-
ence of the physical activity intervention on the key com- lished studies with design, measurements, and statistical
ponent of burnout, i.e., exhaustion 40,42-45) . We note that in analyses of sufficient or good quality, as these are less
the Freitas-study (2014) 41) , in which no reduction in ex- likely to suffer from biases that may reduce the validity of
haustion was found, the internal consistency of the MBI the findings46,31). However, in our systematic review, only
 Lea M. Naczenski, et al.: Physical Activity and Burnout 491

one of the longitudinal studies, and none of the interven- More research concerning the intensity, frequency, du-
tion studies, was qualified as a high quality study. This ration, and type of physical activity should be conducted
sheer absence of high quality studies prevented us from in order to specify which physical activity “dose” is best
conducting a second set of separate analyses of “ high to reduce burnout. With respect to the measurement of
quality studies only,” as advocated by De Lange et al. physical activity, future longitudinal studies could apply
(2003)46). validated scales, such as the Global Physical Activity
In the longitudinal studies, poorer report marks (“insuf- Questionnaire (GPAQ) 52) and the International Physical
ficient”) related to the measurement of physical exercise, Activity Questionnaire (IPAQ) 53) , or use objective meas-
the absence of non-response analysis, and the applied de- ures, such as accelerometers and pedometers, to validly
sign. Several methodological flaws can also be noted in measure different physical activity characteristics. In in-
the aforementioned intervention studies, such as lack of tervention studies, one may consider the comparison of
control conditions, no (described) randomization proce- different physical activity doses.
dure, a combination of exercise and other intervention in-
gredients, and lack of intention-to-treat analyses. Control Conceptualization of burnout
conditions are important for internal validity 47) . Sound All four longitudinal studies examined only exhaustion
randomization procedures minimize systematic differ- as the key burnout component, whereas most intervention
ences between conditions of known and unknown factors studies (four out of six) examined burnout conceptualized
that may affect intervention effects 47) . When intervention from a three dimensional perspective. Nine out of ten
ingredients are combined, such as in the study of Van studies found a significant result in reference to “exhaus-
Rhenen and colleagues (2005) 45) , it is unknown to what tion.”
extent beneficial effects were due to physical activity or Results concerning “professional efficacy” and “cyni-
to other intervention components 48) . As none of the inter- cism” were less frequent and consistent; they were only
vention studies analyzed the results according to the looked into in four intervention studies. Some of these
intention-to-treat principle 49) , it is possible that some of studies found positive effects of physical activity on these
the estimates of intervention efficacy were overoptimistic. dimensions (cynicism 42) ; professional efficacy 40,45) ), while
others did not find such an association (cynicism40,45); pro-
Dose and type of physical activity fessional efficacy42)).
A large variety in the “dose” and type of physical ac- These findings seem theoretically plausible. Several
tivity was applied in the selected studies. It was found psychological and physiological mechanisms underlying
that engagement in physical activity once or twice a week the relationship between physical activity and exhaustion
for 4 weeks40) to 18 weeks43) has promising effects on pre- have been proposed (e.g., psychological detachment 17,18) ;
venting 33) and reducing 45) burnout symptoms. This effect the cardiovascular fitness hypothesis 24) ), while the theo-
might be especially visible in initially inactive employ- retical foundation for the association between physical ac-
ees 33) and in clinical populations who show considerable tivity and professional efficacy, and, in particular, cyni-
compliance to the physical activity intervention 43) . On the cism, is weaker. As regards professional efficacy, it is
other hand, more exhausted employees may also have possible that mastery experiences obtained through physi-
greater difficulties and less motivation to initiate and con- cal activity spill over to the work domain 21,22) . While it
tinue exercise 34) , as has also been suggested in previous thus may be theoretically plausible that physical activity
cross-sectional research50,36). improves one’s sense of personal accomplishment, a plau-
Although physical activity seems effective to reduce sible theoretical mechanism that relates physical activity
exhaustion, it is still unclear which type, intensity, dura- to cynicism seems more difficult to construe.
tion, or frequency of physical activity might be most ef-
fective. In one study, it was concluded that higher- Strengths and limitations of this systematic review
intensity physical activity (not more than twice a week) is We believe that one strength of this systematic review
effective to prevent burnout33) , whereas others found that is that the literature search and synthesis of evidence were
low-intensity physical activity yields positive results35) . In extensive and well-structured. The application of two sets
Bretland and Thorsteinsson’s (2015)40) study, 4 weeks of of quality criteria to assess the quality of longitudinal and
exercise three times a week for 30 min already reduced intervention research on this topic may be considered an
symptoms of burnout. asset as well.
In most studies, physical activity was defined as aero- This study also has limitations. As studies with signifi-
bic exercise. It also became clear, though, that flexibility cant results are more often accepted and published, we
and strength exercise (e.g., yoga, pilates, resistance train- cannot exclude the possibility of publication bias. An-
ing) was able to reduce burnout symptoms40,44), which is in other limitation follows from the “moderate,” not high,
accordance with prior work that found non-aerobic exer- quality of the studies that we identified. Such poorer
cise to be beneficial for depression51). study designs increase the chances of biased findings and
 492 J Occup Health, Vol. 59, 2017

force researchers to be cautious in making firm claims 3) Kristensen MB, Borritz M, Villadsen E, Christensen KB. The
about both internal and external validity. copenhagen burnout inventory: a new tool for the assessment
of burnout. Work & Stress 2005; 19: 192-207. (doi: 10.1080/
Future research 02678370500297720).
First, we recommend future research on the relation- 4) Schaufeli WB, Leiter MP, Maslach C. Burnout: 35 years of re-
ship between physical activity and burnout to aim to be of search and practice. Career Development International 2009;
a high methodological quality, which can be achieved, for 14: 204-220. (doi: 10.1108/13620430910966406).
example, by relying on the quality criteria used in this 5) Alarcon G, Eschleman KJ, Bowling NA. Relationships be-
study. tween personality variables and burnout : a meta-analysis.
Second, we believe that this area can also be moved Work & Stress 2009 ; 23 : 244-263. ( doi : 10.1080 /
forward by paying more attention to the process evalu- 02678370903282600).
ation of intervention studies. Process evaluation opens the 6) Ekstedt M, Söderström M, Åkerstedt T, Nilsson J, Sønder-
“black box” to see what happened during the intervention gaard H-P, Aleksander P. Disturbed sleep and fatigue in occu-
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views of participants), and setting (i.e., the general inter- 7) Deligkaris P, Panagopoulou E, Montgomery AJ, Masoura E.
vention and implementation context) and thus helps in in- Job burnout and cognitive functioning: a systematic review.
terpreting intervention outcomes, designing future effec- Work & Stress 2014 ; 28 : 107-123. ( doi : 10.1080 /
tive exercise interventions for burnout, and successfully 02678373.2014.909545).
implementing the intervention(s) in practice54-57). 8) Oosterholt BG, Van der Linden D, Maes JH, Verbraak MJ,
Third, we recommend that future research pays more Kompier MA. Burned out cognition: cognitive functioning of
attention to bi-directional relationships between physical burnout patients before and after a period with psychological
activity and burnout. The “ reverse ” relationship, with treatment. Scand J Work Environ Health 2012; 38: 358-369.
burnout having an impact on physical activity, may also (doi: 10.5271/sjweh.3256).
be theoretically plausible. Generally, fatigue is seen as a 9) Arvidson E, Börjesson M, Ahlborg G, Lindegård A, Jonsdottir
stop emotion to protect against an excessive depletion of IH. The level of leisure time physical activity is associated
energy stocks 58,59) . When fatigued, people have a lower with work ability - a cross sectional and prospective study of
tendency to start or complete a task, especially when this health care workers. BMC Public Health 2013; 13: 855. (doi:
task requires large effort 23) . As physical activity requires 10.1186/1471-2458-13-855).
(high) effort, one may assume that high fatigue levels 10) Melamed S, Shirom A, Toker S, Berliner S, Shapira I. Burn-
negatively affect employees’ physical activity levels. out and risk of cardiovascular disease : evidence, possible
Fourth, the results of this systematic review seem to in- causal paths, and promising research directions. Psychol Bull
dicate that physical activity may be effective for the pri- 2006; 132: 327-353. (doi: 10.1037/0033-2909.132.3.327).
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Our systematic review suggests that physical activity is 10.1097/01.jom.0000249782.60321.2a).
effective to reduce burnout. However, more high quality 13) Toppinen-Tanner S, Ojajärvi A, Väänänen A, Kalimo R, Jäp-
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Conflicts of interest: The authors declare that there are 14) Eurofound. Fifth European working conditions survey
no conflicts of interest. [EWCS]. Luxembourg: Publications Office of the European
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