Praxis Institute Science Shoulder Research Questions

After reading the provided article on the Shoulder (Post-Op Subacromial Impingement):

Note: The Shoulder SAIS Article & Home Training pamphlet has been provided as a PDF in Blackboard ‘Shoulder’ section.

Answer the following questions in your own word to reflect your own interpretation of the information to address the following questions.

1.  What is the purpose of the article? [2 points]

2.  How was the research conducted? [Summarize the methods and procedures- 4 points]

3.  What did the authors find (i.e. results and conclusions)?  [4 points]

4.  What are at least TWO strengths of the research? What are at least TWO weaknesses of the research?    [4 points]

5.     What are at least TWO clinical implication(s) from this research? [4 points]

Research Report
Effectiveness of Standardized Physical
Therapy Exercises for Patients With
Difficulty Returning to Usual Activities
After Decompression Surgery for
Subacromial Impingement Syndrome:
Randomized Controlled Trial
David Høyrup Christiansen, Poul Frost, Deborah Falla, Jens Peder Haahr,
Lars Henrik Frich, Linda Christie Andrea, Susanne Wulff Svendsen
Background. Little is known about the effectiveness of exercise programs after decompression surgery for subacromial impingement syndrome. For patients with difficulty returning
to usual activities, special efforts may be needed to improve shoulder function.
Objective. The purpose of this study was to evaluate the effectiveness at 3 and 12 months
of a standardized physical therapy exercise intervention compared with usual care in patients
with difficulty returning to usual activities after subacromial decompression surgery.
Design. A multicenter randomized controlled trial was conducted.
Setting. The study was conducted in 6 public departments of orthopedic surgery, 2
departments of occupational medicine, and 2 physical therapy training centers in Central
Denmark Region.
Patients. One hundred twenty-six patients reporting difficulty returning to usual activities
at the postoperative clinical follow-up 8 to 12 weeks after subacromial decompression surgery
participated.
Intervention. A standardized exercise program consisting of physical therapist–supervised individual training sessions and home training was used.
Outcome Measures. The primary outcome measure was the Oxford Shoulder Score.
Secondary outcome measures were the Constant Score and the Fear-Avoidance Beliefs
Questionnaire.
Results. At 3 and 12 months, follow-up data were obtained for 92% and 83% of the patients,
respectively. Intention-to-treat analyses suggested a between-group difference on the Oxford
Shoulder Score favoring the exercise group at 3 months, with an adjusted mean difference of
2.0 (95% confidence interval⫽⫺0.5, 4.6), and at 12 months, with an adjusted mean difference
of 5.8 (95% confidence interval⫽2.8, 8.9). Significantly larger improvements for the exercise
group were observed for most secondary and supplementary outcome measures.
Limitations. The nature of the exercise intervention did not allow blinding of patients and
D.H. Christiansen, PT, PhD,
Department of Occupational
Medicine, Danish Ramazzini Centre, Regional Hospital West
Jutland–University Research Clinic,
Gl Landevej 61, 7400 Herning,
Denmark. Address all correspondence to Dr Christiansen at:
David.Christiansen@vest.rm.dk.
P. Frost, MD, PhD, Department of
Occupational Medicine, Danish
Ramazzini Centre, Aarhus Hospital, Aarhus University Hospital,
Aarhus, Denmark.
D. Falla, PT, PhD, School of Sport,
Exercise and Rehabilitation Sciences, College of Life and Environmental Sciences, University of
Birmingham, Birmingham, United
Kingdom, and Pain Clinic, Center
for Anesthesiology, Emergency
and Intensive Care Medicine, University Hospital Göttingen, Göttingen, Germany.
J.P. Haahr, MD, MPH, Department
of Occupational Medicine, Danish
Ramazzini
Centre,
Regional
Hospital West Jutland–University
Research Clinic.
L.H. Frich, MD, PhD, Orthopedic
Department, Odense University
Hospital, Odense, Denmark.
L.C. Andrea, MD, Department of
Occupational Medicine, Danish
Ramazzini
Centre,
Regional
Hospital West Jutland–University
Research Clinic.
S.W. Svendsen, MD, PhD,
Department of Occupational
Medicine, Danish Ramazzini Centre, Regional Hospital West Jutland–University Research Clinic.
Author information continues on
next page.
care providers.
Conclusion. The standardized physical therapy exercise intervention resulted in statistically significant and clinically relevant improvement in shoulder pain and function at 12
months compared with usual care.
June 2016
Volume 96
Number 6
Post a Rapid Response to
this article at:
ptjournal.apta.org
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Standardized Physical Therapy Exercises and Subacromial Impingement Syndrome
[Christiansen DH, Frost P, Falla D, et al. Effectiveness of standardized physical therapy
exercises for patients with difficulty returning to usual activities after decompression
surgery for subacromial impingement syndrome: randomized controlled trial. Phys
Ther. 2016;96:787–796.]
© 2016 American Physical Therapy Association
Published Ahead of Print:
February 25, 2016
Accepted: February 15, 2016
Submitted: November 27, 2015
S
ubacromial impingement syndrome (SIS) is the most common
upper extremity musculoskeletal
disorder in the working population.1
Initial treatment of SIS is nonsurgical and
includes
rest,
nonsteroidal
antiinflammatory drugs, corticosteroid injections, and different modalities of physical
therapy. Surgical intervention, in the
form of arthroscopic subacromial
decompression, is usually reserved for
patients who do not respond sufficiently
to initial nonsurgical treatment.2 Data
suggest 2- to 8-fold increases in surgery
rates since the late 1990s,3– 6 with probabilities of success varying between 60%
and 84%.7–9
Physical therapist–supervised exercises
and instructions in self-training are often
used to restore shoulder function after
surgery for SIS.10 There is no consensus
about the most appropriate postoperative exercise strategy, and little is known
about the effectiveness of different exercise programs following subacromial
decompression.11–14 It is unknown
whether physical therapist–supervised
exercises should be offered to all
patients or reserved for those with more
persistent symptoms. Special efforts may
be needed to facilitate return to normal
function for patients who have failed to
return to usual activities 8 to 12 weeks
after surgery. The aim of this study was
to compare the effectiveness of a standardized physical therapy exercise intervention with usual care in patients with
difficulty returning to usual activities
after subacromial decompression surgery for SIS. We hypothesized that standardized physical therapy exercises
would yield superior results with respect
to improvement in shoulder pain and
function compared with usual care.
Method
Design Overview
The study was conducted within the
framework of the Shoulder Intervention
Project, which included a pragmatic
multicenter randomized controlled trial
to evaluate the effectiveness of physical
therapy exercises and occupational medical assistance in reducing shoulder pain
and improving function and in reducing
postoperative work disability after
arthroscopic subacromial decompres-
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sion surgery for SIS.15 The trial had 4
randomization arms: (1) physical therapy
exercises, (2) occupational medical assistance, (3) physical therapy exercises and
occupational medical assistance, and (4)
usual care. Patients were randomized to
1 of the 4 arms if they were employed in
paid work for at least 25 hours per week.
Patients who did not meet the 25 hours’
employment criterion were randomly
assigned to only 1 of the 2 arms without
occupational medical assistance (ie,
physical therapy exercises or usual care).
Accordingly, we planned to use a parallel
group design to evaluate the effectiveness of the physical therapy intervention, treating occupational medical assistance as a cointervention; all patients
(with and without paid work) could be
included in these analyses. For patients
who were employed in paid work, the
effectiveness of the occupational intervention will be evaluated in a separate
publication, with primary outcomes
being sickness absence percentage at 3
months and transfer income percentage
at 12 months.15
Setting and Participants
Patients were recruited from the 6 public
departments of orthopedic surgery in
Central Denmark Region over a 3-year
period until December 31, 2013. At the
postoperative clinical follow-up 8 to 12
weeks after surgery, patients aged ⱖ18
to ⱕ63 years and living in the region
were assessed for eligibility if they had
undergone arthroscopic subacromial
decompression surgery (surgical code
KNBH51, KNBH91, KNBG09, KNBL39,
or KNBM79 according to the Danish version of the Nordic Medico-Statistical
Committee Classification of Surgical
Procedures16) under a main diagnosis of
SIS or acromioclavicular osteoarthritis
(International Classification of Diseases, 10th revision17: M75.1–M75.8 or
M19). Exclusion criteria were fullthickness rotator cuff tear, traumatic
lesion, rheumatoid arthritis, frozen
shoulder, severe fibromyalgia, glenohumeral osteoarthritis, and insufficient
Danish language skills. Until April 2012,
patients also were excluded if they had
previous shoulder surgery or diabetes, if
they were not employed in paid work for
at least 25 hours per week, and if they
were not full-time sick-listed; these
June 2016
Standardized Physical Therapy Exercises and Subacromial Impingement Syndrome
exclusion criteria were abandoned due
to slow recruitment.15 Eligible patients
were provided with information on the
Shoulder Intervention Project. Via a telephone interview, patients who consented to be contacted were invited to
participate if they reported at least slight
shoulder problems doing usual activities,
when assessed on a 5-level scale (no
problems, slight problems, moderate
problems, severe problems, and
unable).18 Written informed consent was
given by all patients who participated in
the trial. Within 1 week after the postoperative clinical follow-up, a baseline
assessment was performed in 1 of the 2
departments of occupational medicine in
Central Denmark Region (east or west
center).
Randomization and
Interventions
Randomization took place after baseline
data collection and was performed by a
research secretary, who assigned participants to interventions. Computergenerated randomization (1:1 ratio) was
used, with stratification by the surgical
department and blocking within strata
using randomly permuted block sizes of
12, 8, and 4.
Physical therapy exercise intervention.
The intervention consisted
of a standardized exercise program,
which was conducted in 1 of 2 municipal
training centers. The development of the
intervention and details of the program
have been presented elsewhere.19 Additionally, a detailed manual for physical
therapists and a patient pamphlet with
home training instructions and a training
diary are available.20 The intervention
was delivered as a combination of physical therapist–supervised individual training sessions and home training for 8
weeks followed by home training for an
additional 4 weeks. The supervised training sessions lasted up to 60 minutes
each. All training sessions started with
aerobic exercise on a stationary bicycle,
and additional manual treatment was
offered in case of restricted range of
motion or pain. The shoulder-specific
training consisted of a core set of 7 exercises, each with 3 performance levels:
(1) exercises focusing on activation of
the scapula and rotator cuff muscles, (2)
June 2016
progression in terms of starting position
and range of motion, and (3) exercises in
full range of motion and with higher
demands on coordination and core stability. Patients were scheduled to receive
a minimum of 8 and a maximum of 15
training sessions (including the initial
and final clinical evaluations) during the
first 8 weeks. During the first 4 of these
weeks, the training was typically distributed with supervised sessions 2 times a
week plus home training at least twice a
week. During the next 4 weeks, the frequency of supervised sessions could be
reduced and the frequency of home
training increased, depending on the
patient’s individual need for supervision
and ability to perform the exercises. This
was done to gradually make the patients
more confident in handling the training
themselves. Patients were informed that,
in general, shoulder activities are not
harmful and may lead to reduced symptoms and improved function. Patients
also were advised to be physically active
at moderate-to-high intensity for at least
30 minutes at least 3 times a week,21 as
physical activity is generally recommended in the management of musculoskeletal pain.22,23
Each patient kept a diary for home training and physical activity. The physical
therapists registered any adverse events,
their assessment of deviations from the
exercise program, and the patient’s overall adherence to the intervention in the
manual. The latter 2 assessments were
made using a 5-point scale ranging from
“to a very great extent” to “to a very little
extent” and from “very good” to “very
poor,” respectively. The 5 intervention
physical therapists had an average of 10
years (range⫽6 –14) of experience in the
management of patients with shoulder
disorders and treated an average of 12
(range⫽7–15) patients with shoulder
complaints per week. They had completed 2 to 5 postgraduate courses on
the treatment of shoulder disorders.
Throughout the project period, a uniform application of the intervention was
supported by center-specific team meetings, with the presence of an investigator
every second month.
Usual care. Patients in the usual care
group received no intervention as part of
the study, but they were advised to continue treatment as directed by the hospital. At 3 months, questionnaire data were
collected on the number of treatments, if
any, received by physical therapists since
baseline and the type of treatment
received (shoulder-specific exercise
instructions or supervised exercise
therapy, manual therapy, or other
modalities).
Cointerventions.
The subgroup of
patients who were employed in paid
work for at least 25 hours per week
could be randomized to occupational
medical assistance provided by an occupational physician. This intervention
included a standardized assessment of
work instability (ie, imbalance between
functional capabilities and job demands
to an extent where job retention is
threatened) and construction of a
3-month action plan to promote job
retention. At 6 weeks, progress was evaluated by telephone, and at the 3-month
follow-up, patients were seen for a final
consultation and workplace-oriented
advice. Details of the occupational medical assistance are provided elsewhere.15
Information on treatment received from
physicians, chiropractors, or other
health care providers was obtained by
questionnaire at the 3-month follow-up.
Outcome Measures and
Follow-up
The patients were assessed at baseline
(8 –12 weeks postsurgery) and at 3- and
12-month follow-ups. At baseline and 3
months, the patients completed a questionnaire prior to a standardized shoulder examination and physical testing. At
12 months, data were collected using a
mailed questionnaire. The primary outcome measure was the validated Oxford
Shoulder Score,24 –28 which contains 12
items related to pain and activities of
daily living summarized into a total score
of 0 to 48, with 48 being the best outcome. Secondary outcome measures
were the Constant Score (evaluated only
at baseline and at 3 months) and the
Fear-Avoidance Beliefs Questionnaire
physical activity scale. The Constant
Score is a 100-point system for functional
assessment of the shoulder, which combines subjective parameters (pain and
activities of daily living) and objective
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Standardized Physical Therapy Exercises and Subacromial Impingement Syndrome
parameters (range of motion and
strength), with a score of 100 points
being the best outcome.29,30 The assessment of Constant Score was performed
according to a standardized test protocol,31 which has demonstrated acceptable intrarater and interrater reliability.32
Shoulder strength was measured with an
IsoForceControl dynamometer (Medical
Device Solutions AG, Oberburg, Switzerland). The Fear-Avoidance Beliefs Questionnaire physical activity scale was used
in a version modified to the shoulder,
yielding a 0- to 24-point score, with
higher scores reflecting a higher tendency for fear-avoidance beliefs.33,34
According to the fear-avoidance model,
pain-related fear may cause patients to
avoid physical activities in order to
reduce pain, and if exaggerated, this
reaction pattern may increase pain and
lead to disability.35 Reduction of fear
avoidance might be part of the intervention’s mechanism of action on shoulder
pain and function.36,37
We included 5 supplementary outcome
measures. Health-related quality of life
was measured at 3 and 12 months with
the EQ-5D-3L questionnaire,38 and the
measurements combined with utility values derived from a general population
sample to calculate an index score ranging from ⫺0.6 to 1.0, with higher scores
representing a better health state.39 At 3
months, the following clinical outcome
measures were evaluated: maximum
oxygen uptake, positive pain provocation signs, and scapula dyskinesis. Maximum oxygen uptake (mL O2/min/kg)
was evaluated using the Astrand and
Rhyming Cycle Ergometer Test (Monark
928E Pro VO2 bike, Monark Exercise AB,
Vansbro, Sweden).40,41 This outcome
measure was included, in part, as an
incentive for the patients to follow the
advice on general physical activity and
because increased fitness might be part
of the intervention’s mechanism of
action on shoulder pain. Positive pain
provocation signs were evaluated and
defined as ⬎2 positive tests out of the
following: Hawkins test, modified Hawkins test, painful arc test, and Jobe test.42
Scapular dyskinesis was evaluated and
defined in terms of a positive Scapula
Dyskinesis Test with obvious signs of
altered scapular movement judged by
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visual inspection combined with a positive Scapula Assistance Test or a positive
Scapula Retraction Test showing an
effect of manual correction on dysfunction and symptoms.42,43 This outcome
measure was included because it was
thought that scapular dyskinesis might
be associated with postoperative pain
and disability and that reduction of
altered mobility patterns might be part of
the intervention’s mechanism of action.
Finally, at both 3 and 12 months, the
Patients’ Global Impression of Change
scale scores were evaluated to assess the
patients’ global impression of change in
their shoulder condition. This score was
assessed on a 7-point scale ranging from
“much better” to “much worse.” Clinical
examinations were performed by a
blinded assessor, but blinding of the
patients and those who provided the
interventions was not possible. At 3
months, the allocation of each patient
was estimated by the assessor so that the
success of blinding of the assessor could
be evaluated.
Data Analysis
With a power of 0.8, a significance level
of .05, and a total of 65 patients who
received the physical therapy intervention and 65 patients who did not receive
it, a minimal mean difference of 2.4
points in the Oxford Shoulder Score
could be detected at 12 months when
assuming a standard deviation of 9.0
points,25 a correlation between baseline
and follow-up scores of 0.5, and a 10%
dropout rate.
Main analyses were performed in accordance with the intention-to-treat principle. Supplementary per-protocol analyses (ie, analyses restricted to patients
who received the intervention as
intended) also were performed. The
effectiveness of the physical therapy
intervention was estimated as mean differences between groups using linear
regression models for continuous outcomes and as odds ratios using nominal
logistic regression for binary outcomes
and ordered logistic regression for the
categorical outcome measure Patients’
Global Impression of Change scale,
where the 7 original response categories
were collapsed to 4. Models included the
occupational
intervention
(yes/no/
Number 6
irrelevant), center (east/west), and
respective baseline values where applicable. The robustness of the results was
investigated by sensitivity analyses (ie,
assigning higher and lower scores in
patients without follow-up data). For
comparison with previous literature on
exercise management, standardized
effect size was calculated for the primary
outcome (ie, the unadjusted mean difference between the groups divided by the
pooled standard deviation at baseline).
The minimal clinically important change
(MCIC) for the Oxford Shoulder Score
has been estimated to be 6 points44,45;
the number of patients who clinically
improved and the number needed to
treat were calculated based on this previously reported threshold. Stata version
13 (StataCorp LP, College Station, Texas)
was used.
Role of the Funding Source
The study was a researcher-initiated
study, primarily funded by The Danish
Agency for Science, Technology and
Innovation (grant number 09-066985),
with co-funding from the Danish
Ramazzini Centre.
Results
Participants
The Figure shows the flow of participants from assessment of eligibility at the
postoperative clinical follow-up 8 to 12
weeks after surgery and throughout the
trial. Patients who declined to participate
in the study did not differ from those
who participated with respect to age,
sex, and employment status. A total of
126 patients were randomized. Patients
in the 2 comparison groups were balanced with respect to baseline characteristics, allocation to occupational medical
assistance (Tab. 1), and baseline outcome scores (Tab. 2), except for the
EQ-5D-3L index, maximum oxygen
uptake, and the prevalence of patients
with positive pain provocation signs.
Missing and Incomplete Data
At baseline, 1 patient left 2 questions
unanswered on the Oxford Shoulder
Score, and 2 patients left 1 and 2 questions unanswered, respectively, on the
Fear-Avoidance Beliefs Questionnaire
physical activity scale. This was remedied by replacing the missing question
June 2016
Standardized Physical Therapy Exercises and Subacromial Impingement Syndrome
Table 1.
Baseline Characteristics of Participants According to Random Allocation to Usual Care or
Physical Therapy Exercise Groupsa
Usual Care
Group (nⴝ66)
Physical Therapy
Exercise Group (nⴝ60)
42 (63.6)
40 (66.7)
Age (y), X (SD)
49.0 (7.1)
48.1 (7.9)
Body mass index (kg/m2), X (SD)
29.8 (7.5)
28.2 (5.0)
Characteristic
Female
b
30 (46.2)
22 (36.7)
45 (68.2)
37 (61.7)
Employed in paid work ⱖ25 h/wk
37 (56.1)
34 (56.3)
Self-employed
3 (4.6)
3 (5.0)
Unemployed
16 (24.2)
15 (25.0)
Early retirement/flexible job/disability pension
8 (12.1)
7 (11.7)
Student/on leave
2 (3.0)
1 (1.7)
42 (63.6)
38 (63.3)
Paracetamol/NSAIDs
52 (78.8)
43 (71.7)
Opioids
19 (28.8)
9 (15.0)
No instruction or handouts
10 (15.2)
10 (16.7)
Instruction by physical therapist in self-training
26 (39.4)
18 (30.0)
Physical therapist–supervised exercises
30 (45.5)
32 (53.3)
Number of sessions with a physical therapist,
median (IQR)
1 (1–9)
3 (1–7)
51 (77.3)
46 (76.7)
Bilateral shoulder pain
Dominant shoulder affected
Employment status
Sick leave because of shoulder symptoms
c
Treatment Effect
Use of analgesics within last 4 wk
Postoperative exercises in first 8–12 wk
Additional treatment
None
Steroid injection
6 (9.1)
4 (6.7)
Spinal manipulation/mobilization
5 (7.6)
8 (13.3)
Massage/acupuncture
4 (6.1)
2 (3.3)
Occupational medical assistance
20 (30.3)
22 (36.7)
Usual care
17 (25.8)
12 (20.0)
Irrelevant
29 (43.9)
26 (43.3)
Allocation to occupational medical assistanced
a
Values are numbers (percentages) unless otherwise stated. IQR⫽interquartile range,
NSAIDs⫽nonsteroidal anti-inflammatory drugs.
b
Data missing for one patient.
c
Patients sick-listed from paid work, self-employment, or unemployment.
d
Patients employed in paid work for at least 25 h/wk were randomly allocated to occupational
medical assistance (with or without physical therapy exercises) or usual care (with or without physical
therapy exercises); this was irrelevant for remaining patients.
by the mean value of their other
responses on the scale (single mean
imputation). Two patients, one who left
all items on the Fear-Avoidance Beliefs
Questionnaire physical activity scale
unanswered at baseline and one who
failed to answer the EQ-5D-3L questionnaire at 3 months, were left out of the
June 2016
patients at baseline (Tab. 2) and in 2
patients at 3 months (one in each group),
as they were not able to perform active
abduction or flexion ⬎90 degrees
because of pain. Missing clinical test values were not replaced. At 12 months,
scores were calculated by the use of single mean imputation in one patient who
left one question unanswered on the
Oxford Shoulder Score and in one
patient who left one question unanswered in the Fear-Avoidance Beliefs
Questionnaire physical activity scale.
analysis of these outcomes. For 9
patients (6 at baseline and 3 at 3-month
follow-up), the maximum oxygen uptake
could not be estimated due to medication use, inability to perform the cycle
ergometer test with enough resistance,
or other health problems. Scapular dyskinesis could not be assessed in 11
At 3 and 12 months, 92% and 83% of the
patients, respectively, were followed up.
At 3 months, intention-to-treat analysis
showed a nonsignificant difference in
favor of the physical therapy exercise
intervention with regard to the Oxford
Shoulder Score (Tab. 2). Analyses of secondary and supplementary outcome
measures significantly favored the exercise group with respect to the Constant
Score, scapular dyskinesis, maximum
oxygen uptake, and Patients’ Global
Impression of Change scale score. At 12
months, significantly larger improvements were found in the physical therapy exercise group with respect to the
Oxford Shoulder Score, the FearAvoidance Beliefs Questionnaire physical activity scale, the EQ-5D-3L index,
and the Patients’ Global Impression of
Change scale (Tab. 2). The standardized
effect size for the Oxford Shoulder Score
was 0.74 (95% confidence interval
[CI]⫽0.30, 1.17). More patients in the
exercise group (69%) than in the usual
care group (51%) improved ⱖ6 points in
their Oxford Shoulder Score; the
adjusted odds ratio was 2.4 (95% CI⫽1.0,
5.6), with a number needed to treat of
5.0 (95% CI⫽2.6, 48.6). When perprotocol analyses were performed, the
differences in favor of the physical therapy exercise intervention at 3 months
also reached statistical significance for
the Oxford Shoulder Score, with an
adjusted mean difference of 2.8 (95%
CI⫽0.2, 5.4), and for the Fear-Avoidance
Beliefs Questionnaire physical activity
scale, with an adjusted mean difference
of ⫺2.4 (95% CI⫽⫺4.5, ⫺0.4).
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Standardized Physical Therapy Exercises and Subacromial Impingement Syndrome
Table 2.
Effectiveness of Physical Therapy Exercises Compared With Usual Care With Respect to Primary, Secondary, and Supplementary Outcome
Measuresa
Usual Care
Group
Variables
Physical Therapy
Exercise Group
Continuous outcomes, n, X, (SD)
Intention-to-Treat
Treatment Effectb
Mean difference (95% CI)
Oxford Shoulder Scorec
Baseline
66
29.1 (8.0)
60
31.0 (6.4)
3 mo
61
35.0 (9.5)
55
37.7 (7.9)
2.0 (⫺0.5, 4.6)
12 mo
53
34.2 (11.3)
51
41.2 (7.1)
5.8 (2.8, 8.9)
Baseline
66
52.7 (13.5)
60
54.1 (15.0)
3 mo
59
63.9 (19.1)
54
70.4 (17.5)
Constant Scored
6.7 (1.2, 12.2)
Fear-Avoidance Beliefs Questionnaire physical activity scale scoree
Baseline
65
12.6 (6.0)
60
11.3 (6.4)
3 mo
61
10.1 (7.0)
55
7.8 (6.5)
⫺1.8 (⫺3.8, 0.3)
12 mo
53
10.2 (7.4)
51
6.0 (5.9)
⫺3.3 (⫺5.6, ⫺0.9)
Baseline
66
0.67 (0.16)
60
0.72 (0.11)
3 mo
60
0.72 (0.21)
55
0.77 (0.14)
0.04 (⫺0.02, 0.10)
12 mo
53
0.71 (0.24)
51
0.83 (0.14)
0.09 (0.02, 0.17)
EQ-5D-3L index scoref
Maximum oxygen uptake (mL O2/min/kg)
Baseline
61
26.3 (8.3)
59
29.3 (8.3)
3 mo
55
27.1 (7.6)
51
32.3 (9.6)
Binary outcomes, n, X, (%)
Positive pain provocation signs
2.1 (0.1, 4.1)
OR (95% CI)
g
Baseline
66
53 (80.3)
60
38 (63.3)
3 mo
55
36 (61.0)
54
23 (42.6)
Baseline
59
18 (30.5)
56
16 (28.6)
3 mo
52
13 (25.0)
50
4 (8.0)
0.6 (0.3, 1.3)
Scapular dyskinesish
0.2 (0.1, 0.8)i
Categorical outcome, n (%)
Patients’ Global Impression of Change scale score
3 mo
Worse
7 (11.5)
3 (5.5)
No change
21 (34.4)
19 (34.6)
Better
20 (32.8)
9 (16.4)
Much better
13 (21.3)
24 (43.6)
2.1 (1.0, 4.1)j
12 mo
Worse
10 (19.9)
3 (5.9)
No change
17 (32.1)
15 (29.4)
Better
12 (22.6)
10 (19.6)
Much better
14 (26.4)
23 (45.1)
2.2 (1.1, 4.6)j
a
CI⫽confidence interval, OR⫽odds ratio.
Results of linear and logistic regression analyses adjusted for occupational medical assistance, center, and the respective baseline values.
c
Oxford Shoulder Score: 0 – 48.
d
Constant Score: 0 –100.
e
Fear-Avoidance Beliefs Questionnaire physical activity score: 0 –24.
f
EQ-5D-3L index score: ⫺0.6 to 1.0.
g
Positive pain provocation signs defined as ⬎2 positive of Hawkins test, modified Hawkins test, painful arc test, and Jobe test.
h
Scapular dyskinesis defined as a positive Scapula Dyskinesis Test (obvious signs) and a positive Scapula Assistance Test or Scapula Retraction Test.
i
Adjustment for occupational medical assistance and center not applicable because of few cases.
j
Results of ordered logistic regression analyses adjusted for occupational medical assistance and center.
b
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June 2016
Standardized Physical Therapy Exercises and Subacromial Impingement Syndrome
Intervention and Adherence
In the east center, the number of patients
treated in each municipal center and by
each physical therapist was as follows:
first physical therapist (n⫽6), second
physical therapist (n⫽14), and third
physical therapist (n⫽10). In the west
center, one physical therapist treated all
patients (n⫽22) (the second physical
therapist substituted in only 1 or 2 sessions). Patients allocated to physical therapy exercises received a median of 12
(interquartile range⫽9 –13) supervised
training sessions. Ten patients did not
receive physical therapy exercises as
intended (Figure). The main reasons
given by these patients were long traveling distance, lack of time, or a new job.
Seven and 6 of the 10 patients who did
not adhere provided data at 3 and 12
months, respectively.
At the final training session, 37 out of 50
patients (74%) performed at least 5 of the
7 exercises at the highest level (level C),
and, on average, resistance in loaded
exercises had increased by 74% (95%
CI⫽53%, 95%). The physical therapists
rated the overall patient adherence to
the physical therapy exercise intervention as very high or high in 44 (88%) of
the 50 patients who received the intervention. The exercise manual could only
be followed to some extent for 8 patients
and to a very limited extent for 1 patient.
Of the 60 patients allocated to physical
therapy exercises, 44 (73%) adhered.
Additional manual treatment as part of
the intervention was received by 34
(68%) of 50 patients who received the
intervention, and the median number of
sessions that included manual treatment
was 2 (interquartile range⫽0 –7). A total
of 46 patients filled in their home training diary; they completed their home
training program an average of 2.1
(SD⫽0.8) times a week and performed
physical activity at moderate-to-high
intensity for at least 30 minutes an average of 3.1 (SD⫽1.7) days a week over the
12-week period.
At 3 months, 48 (79%) of the 61 patients
in the usual care group reported that
they had received shoulder-specific exercise instructions or exercise therapy during the intervention period. Twentyseven patients (44%) had received
June 2016
Figure.
Flowchart of participants in the study. *In April 2012, when 9 patients were included in the
trial, the following exclusion criteria were abandoned due to slow recruitment: previous
shoulder surgery or diabetes, not employed in paid work for at least 25 hours per week, and
not full-time sick-listed.
massage/manual treatment, 7 (11%) had
received acupuncture, 22 (36%) had
received electrotherapy or thermotherapy, and 34 (56%) had seen a physical
therapist for their shoulder problem,
with a median of 8 (interquartile
range⫽4 –16) treatments received.
Cointerventions
The number of patients who had consulted a physician for their shoulder
problem during the intervention period
was significantly lower in the physical
therapy exercise group than in the usual
care group (5 [9%] versus 18 [30%],
P⬍.001). No significant differences were
observed between groups for the number of patients who received one or
more subacromial injections (6 [11%] in
the physical therapy exercise group versus 11 [18%] in the usual care group).
Chiropractor treatment was received by
1 patient (2%) in the exercise group and
6 patients (10%) in the usual care group,
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Standardized Physical Therapy Exercises and Subacromial Impingement Syndrome
and alternative treatment was received
by 3 patients (6%) versus 7 patients
(12%), with no significant differences
between groups.
Adverse Events
Except for muscle tenderness after training and 2 cases of temporary headache in
relation to training, no adverse events
were noted. Two patients were reoperated on (one in each group) within the
first 3 months (Figure).
Sensitivity Analysis and Success
of Blinding
Sensitivity analysis demonstrated that for
the results to no longer significantly
favor the intervention at 12 months, a
14-point higher mean Oxford Shoulder
Score would be needed in patients who
were lost to follow-up in the usual care
group than in those who were lost to
follow-up in the physical therapy exercise group. In total, 96 (85%) of 113
patients were examined by the same
assessor at baseline and follow-up. The
assessors correctly classified 32 patients
(54%) in the usual care group and 23
patients (43%) in the physical therapy
exercise group.
Discussion
A standardized physical therapy exercise
intervention was compared with usual
care for patients with difficulty returning
to usual activities after subacromial
decompression surgery for SIS. At 3
months,
intention-to-treat
analyses
showed a statistically nonsignificant difference in favor of the intervention with
respect to the primary outcome measure, the Oxford Shoulder Score, and in
per-protocol analyses, this difference
was significant. At 12 months, intentionto-treat analyses demonstrated significantly larger improvement in the physical therapy exercise group with respect
to the Oxford Shoulder Score, fearavoidance beliefs, health-related quality
of life, and the patients’ perception of
overall improvement.
The study benefited from a randomized
design, high treatment adherence, validated primary and secondary outcome
measures, limited loss to follow-up,
blinding of clinical assessors, and evaluation of treatment application and co-
794
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Volume 96
interventions. The study had some limitations. The total number of 613 patients
assessed for eligibility over a 3-year
period was lower than expected. This
lower number most likely reflected general difficulty of recruiting patients from
clinical practice, rather than systematic
selection, and, therefore, should not
affect the generalizability of the results to
patients with orthopedic conditions evaluated for SIS. Patients could be included
only if they reported at least slight problems doing usual activities, and it may be
questioned whether this could be
defined as difficulty returning to usual
activities. However, we find it unlikely
that patients would agree to participate
in the trial if they did not experience
significant shoulder problems. The blinding of the outcome assessors at 3 months
was successful, but the nature of exercise interventions did not allow blinding
of patients and care providers. Information on physical therapy received by
patients in the usual care group was collected at the 3-month follow-up. This
approach might imply underestimation
of the use of physical therapy, as visits to
a physical therapist might have been forgotten, but such underestimation would
not explain the results in favor of the
intervention. Within the first year of the
trial, we widened the inclusion criteria to
increase recruitment. Before that, only 9
patients had been included; therefore,
the change probably only affected our
results in terms of larger generalizability
because the population was more representative of postoperative SIS patients of
working age.
The number of missing responses to
items in the questionnaires was limited,
which supports the internal validity of
the study findings. For the evaluation of
scapular dyskinesis at 3 months, missing
information was more common because
the assessment could not always be performed due to pain provocation. Consequently, these results may not apply to
patients with higher pain intensities and
more severe limitations in shoulder function. Furthermore, the validity and reliability of combining visual inspection
and manual correction to identify scapular dyskinesis have not been established.
We chose to omit patients without outcome data at 3 and 12 months from the
Number 6
analyses (complete case analysis).46,47
More advanced statistical approaches to
handle loss to follow-up are available (ie,
multiple imputation),48 but sensitivity
analyses suggested that our findings
were robust.
To our knowledge, this is the largest
study that has evaluated physical therapy
exercises after decompression surgery
for SIS. Previous studies that have compared exercises and home training have
reached
contradictory
results.11–14
Holmgren et al13 and Park et al14 found
superior short-term effectiveness of exercises aiming to strengthen rotator cuff
and scapular muscles compared with
instructions in mobility-focused home
exercises or passive modalities only (ie,
electrotherapy and thermotherapy). In
contrast, no short-term or long-term
effects of physical therapist–supervised
exercises were found compared with
home training with rotator cuff strengthening exercises11 or when more progressive exercise programs were compared
with traditional exercise programs.12
Compared with the exercise intervention in previous studies, our program
was initiated later because we wanted to
focus our intervention efforts on patients
who did not respond sufficiently to surgery and initial postoperative care.
We included fear-avoidance beliefs, maximum oxygen uptake, and scapular dyskinesis as secondary and supplementary
outcome measures because they might
be part of the intervention’s mechanism
of action. This possibility was not contradicted by the reported results. Maximum
oxygen uptake could further be interpreted as a marker of adherence. Patients
in the physical therapy exercise group
continued to improve after the intervention period, whereas no further improvement was observed in the usual care
group. Supported by a detailed patient
pamphlet with home training instructions, patients in the physical therapy
exercise group were gradually encouraged to handle training themselves and
taught how to progress home training,
maintain or improve general physical
activity, and handle flare-ups, which may
have contributed to this result. The
observed treatment effect size for the
Oxford Shoulder Score was moderate to
June 2016
Standardized Physical Therapy Exercises and Subacromial Impingement Syndrome
large, with patients in the exercise group
having 2.4 times higher odds of clinically
important improvement (ie, ⱖ6 points)
at 12 months, and this was found for a
health condition where exercise
interventions typically show small-tomoderate effects.49 At 3 months, more
than half of the patients in the usual care
group had received physical therapy for
their shoulder problem. Nevertheless,
we observed significantly greater
improvement in the physical therapy
exercise group across outcome measures
at both 3- and 12-month follow-ups. In
our opinion, this finding suggests that
the standardized physical therapy exercise intervention could be of substantial
benefit for patients with SIS who have
difficulty returning to usual activities
after decompression surgery.
We conducted a pragmatic trial, with the
intervention delivered by general physical therapists in the existing framework
of public rehabilitation, and the intervention was compared with usual care,
which often included physical therapy
and shoulder-specific exercises. Consequently, we would expect that comparable results could be achieved in other
physical therapy outpatient settings.
In conclusion, the results supported the
effectiveness of a standardized physical
therapy exercise intervention compared
with usual care in patients with difficulty
returning to usual activities 8 to 12
weeks after subacromial decompression
surgery for SIS. Thus, the present study
suggests a potential for optimizing the
quality of care for patients with SIS who
are surgically treated. A detailed exercise
manual and a patient pamphlet allow
researchers to replicate the trial and clinicians to apply the exercise program.
Dr Frost and Dr Svendsen conceived the
project. All authors were involved in the
design of the study. Assisted by Dr Frost and
Dr Svendsen, Dr Christiansen developed the
physical therapy intervention, performed the
statistical analyses, and drafted the manuscript. All authors contributed to interpretation of data and critical revision of the manuscript. All authors read and approved the
final manuscript and stand by the integrity of
the entire work.
June 2016
The authors thank Janne Nielsen, PT, Mette
Balle Olsen, PT, Bjarne Leif Sørensen, PT,
Anja Ellegaard Kjeldsen, PT, and Jesper Eliasen, PT, who delivered the trial intervention;
Anders Damgaard Møller, PT, and Klaus
Dahlerup Djernes, PT, for assistance with
clinical outcome assessment; and research
secretaries Inge-Lis Laursen and Ann Christie
Poulsen.
The study was approved by the Central Denmark Region Committees on Biomedical
Research Ethics (identification number:
M-20100131) and by the Danish Data
Protection
Agency
(journal
number:
2010-41-4316).
This was a researcher-initiated study, primarily funded by the Danish Agency for Science,
Technology and Innovation (grant number
09-066985) with co-funding from the Danish Ramazzini Centre.
Trial registration: Current Controlled Trials
(ISRCTN55768749).
DOI: 10.2522/ptj.20150652
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June 2016
–
]
]
]
]
]
]
]
]
]
]
Patient’s ID. no.:
Patient’s name:
Making good progress following
shoulder surgery
home training
Department of
Occupational Medicine
Regional Hospital West Jutland
University Research Clinic
Department of
Occupational Medicine
Aarhus Hospital
Aarhus University Hospital
PRACTICAL INFORMATION
This folder contains instructions for the exercises that your physiotherapist has given you to
do at home.
Exercise training
Each exercise is divided into levels of low intensity, medium intensity and high intensity.
Mobility and strength training have to be built up gradually. The exercises and elastic band
resistance which you will use in your training will be adjusted by your physiotherapist. All
exercises must be performed on both sides in order to ensure good muscular symmetry,
and to give your shoulder a rest between the sets.
You must be able to do 3 sets of 10 repetitions of the exercise with a high level of control,
and without your pain getting worse, prior to going on to the next level. Once you have
reached the highest intensity level for the exercise, the elastic band resistance may gradually
be increased.
If your pain becomes worse when doing the exercise, this is a sign that you are training
at too high intensity level, and you have to go back a level.You will also be able to use the
programme’s gradual build-up when training is resumed after a break.
Initially, you will be training twice a week with your physiotherapist and once or twice at
home. When you get more familiar with the exercises, you will do more training at home.
The exercise training must be performed at least 3-4 times a week for it to be effective.
Training at home may be split into several periods throughout the day – the important thing
is that you complete all the exercises within one day.
Physical activity/cardio training
Besides these exercises, it is important that your training also involves some other kind of
physical activity/exercise. Physical activity may provide some pain relief and help you to do
your exercises better.
The recommendation is that you are physically active for at least 30 minutes at a moderate
to high intensity, 3-4 times per week. This physical activity may be divided into shorter
periods, e.g. 15 minutes in the morning and 15 minutes in the evening, or 3 x 10 minute
sessions over the course of the day. See under PHYSICAL ACTIVITY for examples of
moderate to high intensity activities.
Record keeping of home training
To follow your exercise training as closely as possible, we will ask you to fill in the training
diary at the end of this folder.
Your physiotherapist’s name and tel. no.:
2
DAILY EXERCISE
Posture
This exercise will make you more aware of your posture and improve mobility in your
shoulders. Ideally, this exercise should be performed repeatedly throughout the day,
both standing and sitting.
Relax your lower back and allow your shoulders to
fall forwards. Now sit upright by tilting your lower
back and lifting your chest forward and up so that
your posture is more upright. Hold the position for 5
seconds.
This posture should also be maintained while
performing the other exercises.
Sitting
Standing
3
TRAINING 2-4 TIMES PER WEEK
mobility
These exercises are intended to help you regain mobility in your shoulder. Continue the
exercises frequently until you have full mobility in your shoulder.
ARM RAISE
Exercise 1a: Assisted arm raise
Attach the pulley system to the top of a door. Stand
facing the door and hold the handles with both hands.
Low intensity level
Pull with one arm so that your other arm is lifted up as
far as possible. Hold the end position for a short time.
Lower your arms again and repeat with the other arm.
Exercise 1b: Active arm raise
Raise both arms in front of you as high as possible.
Hold the end position for a short time. Lower your
arms again and repeat.
Medium intensity level
4
INTERNAL AND EXTERNAL ARM ROTATION
Exercise 2a: Assisted internal and external rotation
Attach the pulley system to the top of a door. Stand
with your back to the door. Reach one hand behind
your lower back and hold one of the handles.
Low intensity level
Pull with your other arm so that your hand is raised
up your back – as far as possible. Hold the end
position for a short time. Lower your arms again and
repeat.
Perform the exercise on both sides.
Exercise 2b: Active internal and external rotation
Try to get your fingertips to touch behind your back.
Hold the end position for a short time. Lower your
arms again and repeat on the other side.
Medium intensity level
5
TRAINING THE MUSCLES OF THE SHOULDER BLADE
These exercises train the musculature that controls the shoulder blade when you move
your arm.
Exercise 3a – 1: Wallslide
Stand with one foot in front of the other facing a
door/wall. Rest your elbows and forearms against the
door/wall.
Now allow your arms to slowly slide up and slightly
out to the side until your arms are fully extended or
stretched out as far as you can manage.
Low intensity level
Hold the end position for a short time before going
back to the start position.
Exercise 3a – 2: Knee push up plus
In a four point kneeling position, push your upper
back upwards.
Exercise 3b: Knee push up plus with leg extension
Medium intensity level
In a four point kneeling position push your upper
back upwards.
Extend one leg straight out while keeping your
shoulders and hips stable. Hold the end position for a
short time. Return to the start position and repeat on
the opposite side.
Exercise 3c: Knee push up plus with diagonal arm/leg raise
High intensity level
In a four point kneeling position, push your upper
back upwards.
Extend one leg and the opposite arm at the same
time (diagonally) while keeping your shoulders and
hips stable. Hold the end position for a short time.
Return to the start position and repeat on the
opposite side.
6
Exercise 4a: Low row (Isometric)
Low intensity level
Place the palm of one hand against the edge of a
table or a door frame. With your arm straight, press
against the table edge/door frame, while pushing your
shoulder backwards and down. Hold the position for
about 5 seconds. Release.
Pause briefly before repeating the exercise.
Perform the exercise on both sides.
Exercise 4b: Low row
Medium intensity level
Attach an elastic band to a door at about waist height.
Hold the elastic band with one hand. Move away from
the door until the elastic band is taut and your arm is
stretched out in front of you.
Pull the elastic band down to your hip, while at
the same time pushing your shoulder back and
downward. Hold the end position for a short time.
Return to the start position and repeat.
Perform the exercise on both sides.
Exercise 4c: High row
Attach the elastic band to a door at about head
height. Hold the elastic band with one hand. Move
away from the door until the elastic band is taut and
your arm is raised to just above shoulder height.
High intensity level
Pull the elastic band down to your hip, while at
the same time pushing your shoulder back and
downwards. Hold the end position for a short time.
Return to the start position and repeat.
Perform the exercise on both sides.
7
TRAINING THE MUSCLES OF THE SHOULDER JOINT
These exercises train the musculature that controls and stabilises the shoulder joint when
you raise your arm.
Exercise 5a: Low arm raise
Low intensity level
Attach the elastic band to a door close to floor level.
Stand with your back to the door and hold the elastic
band in one hand. Move away from the door until the
elastic band is taut.
Lift your arm forward and slightly to the side to just
above waist height. Hold the end position for a short
time before going back to the start position.
Perform the exercise on both sides.
Exercise 5b: Medium arm raise
Attach the elastic band to a door close to floor level.
Stand with your back to the door and hold the elastic
band in one hand. Move away from the door until the
elastic band is taut.
Medium intensity level
Lift your arm forward and slightly to the side to just
below shoulder height. Hold the end position for a
short time before going back to the start position.
Perform the exercise on both sides.
Exercise 5c: High arm raise
Attach the elastic band to a door close to floor level.
Stand with your back to the door and hold the elastic
band in one hand. Move away from the door until the
elastic band is taut.
High intensity level
Lift your arm forward and slightly to the side to just
above shoulder height. Hold the end position for a
short time before going back to the start position.
Perform the exercise on both sides.
8
Low intensity level
Exercise 6a: Internal arm rotation
Attach the elastic band to a door at waist height.
Place a rolled-up towel under your arm. Stand
sideways-on to the door. Hold the elastic band with
the hand closest to the door and bend your elbow.
Move away from the door until the elastic band is
taut.
Pull the elastic band in towards your abdomen Hold
the end position for a short time. Return to the start
position and repeat the exercise.
Exercise 6b: Internal rotation with inward arm-pull
Medium intensity level
Attach the elastic band to a door at shoulder height.
Stand sideways-on to the door. Hold the elastic band
with the hand closest to the door and bend your
elbow. Move away from the door until the elastic
band is taut and your arm is lifted a bit away from
your body.
Pull the elastic band down and in toward your
abdomen. Hold the end position for a short time
before going back to the start position.
Perform the exercise on both sides.
High intensity level
Exercise 6c: Internal rotation with inward arm-pull
Attach the elastic band to a door above head height.
Stand sideways-on to the door. Hold the elastic band
with the hand closest to the door and bend your
elbow. Move away from the door until the elastic
band is taut and your arm is lifted up to shoulder
height.
Pull the elastic band down and
in toward your abdomen. Hold
the end position for a short
time before going back to the
start position.
Perform the exercise on both
sides.
9
TRAINING THE MUSCLES OF THE SHOULDER JOINT
Exercise 7a: External arm rotation
Low intensity level
Attach the elastic band to a door at waist height.
Place a rolled-up towel under your arm and stand
sideways on to the door. Hold the elastic band with
the hand furthest from the door and bend the elbow.
Move away from the door until the elastic band is
taut.
Pull the elastic band away from your body. Hold the
end position for a short time before going back to
the start position.
Perform the exercise on both sides.
Exercise 7b: External rotation with outward arm-pull
Medium intensity level
Attach the elastic band to a door at knee height.
Stand sideways-on to the door. Hold the elastic band
with the hand furthest from the door and bend the
elbow. Move away from the door until the elastic
band is taut.
Pull the elastic band away from your body and lift
your arm up slightly. Hold the end position for a
short time before going back to the start position.
Perform the exercise on both sides.
Exercise 7c: External rotation with outward arm-pull
High intensity level
Attach the elastic band to a door close to floor level.
Stand sideways-on to the door. Hold the elastic band
with the hand furthest from the door and bend the
elbow. Move away from the door until the elastic
band is taut.
Pull the elastic band away from your body until your
arm is straightened outward at shoulder level, Hold
the end position for a short time. Return to the start
position and repeat the exercise.
Perform the exercise on both sides.
10
Progressions of the EXERCISE PROGRAMME
Mobility
1. Arm raise
No exercise
Assisted
Active
2. Internal and
external rotation
No exercise
Assisted
Active
Wallslide/Knee push
up plus
Knee push up plus with
leg extension
Knee push up plus
with diagonal
arm/leg raise
Isometric
Low
High
Low
Medium
High
Neutral
With your arm out
from your side
From shoulder height
Neutral
With a slight arm
raise
To shoulder height
SHOULDER BLADE
muscles
3. Wallslide/
Knee push up plus
4. Row
SHOULDER JOINT
MUSCLES
5. Arm raise
6. Internal rotation
7. External rotation
11
PHYSICAL ACTIVITY
It is not that important what type of physical activity/exercise you do. The most important
thing is to get your heart rate up, so that you get out of breath. Find a type of physical
activity/exercise that you can fit into your daily routine and which you like doing.
It is also advised that you warm up with some form of physical activity/exercise before
doing your home training exercises. This ensures that the body is warm and ready to do the
exercises.
Physical activity/exercise should be done at a moderate to high intensity in order to be
effective.
See the table below for instructions and examples.
Intensity
Percentage
of the heart
rate reserve
Own experience of being out of breath
Examples of activity
Very light
< 20 Not out of breath Slow walk with stops/pauses Light 20-39 Slightly out of breath, able to talk without difficulty Ordinary walking (4 km/h) Moderate 40-59 Fairly out of breath, able to talk Cycling (4 km/h) and vigorous gardening High 60-84 Out of breath, short sentences Cycling (>15 km/h),
using the stairs,
swimming and running
Very high
>85
Very out of breath, words,
but no sentences
Short intervals of high
intensity of e.g. cycling,
running and swimming
Maximum
100
Breathing rapidly and in
gasps ­
Activity has to be
stopped after a few
minutes or seconds
12
YOUR TRAINING DIARY
We will ask you each week to put a tick to show how often you did the full exercise
programme and were physically active at home.
Week no.
Mon.
Tue. Wed. Thur.
Fri.
Sat.
Sun.
Exercise training
c
c
c
c
c
c
c
Physical activity/exercise ≥ 30 min.
c
c
c
c
c
c
c
Comments
Week no.
Mon.
Tue. Wed. Thur.
Fri.
Sat.
Sun.
Exercise training
c
c
c
c
c
c
c
Physical activity/exercise ≥ 30 min.
c
c
c
c
c
c
c
Week no.
Mon.
Tue. Wed. Thur.
Fri.
Sat.
Sun.
Exercise training
c
c
c
c
c
c
c
Physical activity/exercise ≥ 30 min.
c
c
c
c
c
c
c
Mon.
Tue. Wed. Thur.
Fri.
Sat.
Sun.
Comments
Comments
Week no.
Exercise training
c
c
c
c
c
c
c
Physical activity/exercise ≥ 30 min.
c
c
c
c
c
c
c
Comments
13
Week no.
Mon.
Tue. Wed. Thur.
Fri.
Sat.
Sun.
Exercise training
c
c
c
c
c
c
c
Physical activity/exercise ≥ 30 min.
c
c
c
c
c
c
c
Week no.
Mon.
Tue. Wed. Thur.
Fri.
Sat.
Sun.
Exercise training
c
c
c
c
c
c
c
Physical activity/exercise ≥ 30 min.
c
c
c
c
c
c
c
Week no.
Mon.
Tue. Wed. Thur.
Fri.
Sat.
Sun.
Exercise training
c
c
c
c
c
c
c
Physical activity/exercise ≥ 30 min.
c
c
c
c
c
c
c
Week no.
Mon.
Tue. Wed. Thur.
Fri.
Sat.
Sun.
Exercise training
c
c
c
c
c
c
c
Physical activity/exercise ≥ 30 min.
c
c
c
c
c
c
c
Comments
Comments
Comments
Comments
14
Week no.
Mon.
Tue. Wed. Thur.
Fri.
Sat.
Sun.
Exercise training
c
c
c
c
c
c
c
Physical activity/exercise ≥ 30 min.
c
c
c
c
c
c
c
Week no.
Mon.
Tue. Wed. Thur.
Fri.
Sat.
Sun.
Exercise training
c
c
c
c
c
c
c
Physical activity/exercise ≥ 30 min.
c
c
c
c
c
c
c
Week no.
Mon.
Tue. Wed. Thur.
Fri.
Sat.
Sun.
Exercise training
c
c
c
c
c
c
c
Physical activity/exercise ≥ 30 min.
c
c
c
c
c
c
c
Week no.
Mon.
Tue. Wed. Thur.
Fri.
Sat.
Sun.
Exercise training
c
c
c
c
c
c
c
Physical activity/exercise ≥ 30 min.
c
c
c
c
c
c
c
Comments
Comments
Comments
Comments
15