Background
Methods
Inclusion criteria
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Subacromial impingement syndrome, regardless of age, sex, employment status, activity level, cause (trauma or overuse), and the severity and duration of symptoms. In order to fulfil inclusion patients had to reveal 3 positive tests out of 5: Positive Neer’s test, positive Hawkins test, positive Jobe’s test, painful arc, and pain on resisted external rotation of the arm [24]. All participants were examined with an ultrasound scanner at inclusion.
Exclusion criteria
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Ongoing claim with the Labour market insurance, insurance company or comparable institution.
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Ongoing application for job revalidation or health related pension.
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Radiating neck pain.
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Ultrasound verified complete rotator cuff tendon lesion, as defined by hypoechoic or anechoic full thickness defect of the tendon, or absence of the tendon.
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Periarthritis humeroscapularis.
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Acute luxation or fracture of the shoulder.
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Ongoing steady analgetic treatment of other concomitant painful condition, unrelated to the patients shoulder problem.
Flow
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All patients that fulfilled inclusion criteria, and did not have any exclusion criteria were offered participation in the trial. Age, sex, and self-reported employment status were recorded.
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All patients that accepted participation, were randomised blindly to either a supervised training regimen (STR) or a home training regimen (HTR).
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Participants in the STR group were supervised in the clinic.
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Participants in the HTR group were instructed in a home-based exercise regimen.
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All participants were examined with an ultrasound scanner at inclusion.
Randomisation procedure
Training regimens
Supervised heavy training regimen (STR) [4, 9]
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Motion training consisted of 6 exercises including postural and glenohumeral training.
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Postural training consisted of shoulder shrugs and shoulder retraction exercises.
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Glenohumeral training consisted of pendulum exercises, and active assisted flexion, abduction and external rotation. Motion training ended when the full passive flexion, abduction and external rotation had been re-established.
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Strengthening of the rotator cuff included 3 exercises: side lying external rotation, internal rotation and scaption.
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Strengthening of the scapular muscles included 5 exercises: press-up, push-up with a plus, serratus anterior supine punch, standing rowing (low row), and seated rowing (high row).
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Training sessions ended with 4 stretches: anterior shoulder stretch, posterior shoulder stretch, inferior capsular stretch, sleepers stretch.
Choice of exercises
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Side lying external rotation
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Internal rotation
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Scaption
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Press-up
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Push-up with a plus
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Serratus anterior supine punch
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Standing rowing (low row)
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Sitted rowing (high row)
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Stretching exercises
Home based exercise (HTR) [5]
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1 motion exercise: upper trapezius relaxation
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3 strengthening exercises: serratus anterior strengthening exercise, humeral external rotation with the arm at the side of the body, and humeral external rotation with a rubber band and the arm at 90 degrees abduction.
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2 stretching exercises: posterior shoulder and pectoralis minor stretching,
Detailed training regimens
Supervised training regimen (STR)
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Motion training
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Postural training
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shoulder shrugs
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shoulder retraction
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Glenohumeral training
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Pendulum exercises
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Active assisted motion (with the help of the opposite arm, cane, or training cable)
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flexion
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abduction
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external rotation
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Strengthening of the rotatorcuff
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Side lying external rotation
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Internal rotation
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Scaption
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Strengthening of the scapular muscles
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Press-up
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Push-up with a plus
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Serratus anterior supine punch
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Standing rowing (low row)
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Sitted rowing (high row)
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Stretching
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Anterior shoulder stretch
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Posterior shoulder stretch
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Inferior capsular stretch
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Sleepers stretch
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1st. week: 15 repetitions with maximal weight (RM)
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Week 2–3: 12 RM
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Week 4–5: 10 RM
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Week 6–8: 8 RM
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Week 9–12: 6 RM
Home based exercise (HTR)
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Posterior shoulder stretch 30 s 5 times / day: the patients lifted their arm 90 degrees and pulled the elbow towards the opposite shoulder with their free hand.
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Pectoralis minor stretch 30 s 5 times / day: the patients placed each hand at shoulder height on adjacent walls of a corner and leant forward
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Upper trapezius relaxation exercise 5 times / day: the patients where instructed to abduct their arms without a shrugging the shoulders.
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Serratus anterior strengthening exercise: the patients lifted a weight vertically from a supine position and protraction of the scapulas.
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Humeral external rotation with a rubber band and the arm at the side of the body.
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Humeral external rotation with a rubber band and the arm at 90 degrees abduction.
Compliance
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Level 1: full compliance, defined as performance of all planned training sessions.
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Level 2: partial compliance, where only part of the planned exercises sessions were performed.
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Level 3: no compliance.
Evaluation
Effect-variables
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CS (max. 100 points).
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SRQ (max 100 points).
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Passive motion (flexion, abduction, internal and external rotation) was assessed with a goniometer.
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Active motion (flexion, abduction, internal and external rotation) was assessed with a goniometer.
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VAS (Visual Analogue Scale) on a 10 cm scale for each muscle test (full can test, empty can test, lift off test, resisted external rotation, palm-up test, Yergason’s test). 0 indicates no pain, and 10 worst pain.
Full can test
Empty can test
Lift off test
Resisted external rotation test
Palm-up test
Yergason’s test
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Neer’s test (rated positive = 1 and negative = 0).
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Hawkins test (rated positive = 1 and negative = 0).
Ultrasound
Analysing strategy/statistics
Results
STR Group | HTR Group | p | |
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n = 63 | n = 63 | ||
Age (mean ± SD) | 61.7 ± 13.4 | 60.3 ± 13.0 | 0.56 |
Male/female (n) | 33/30 | 32/31 | – |
Employment status: | |||
Employed/unemployed/full time sick leave/partial sick leave/retired (n) | 33/2/2/0/26 | 33/3/2/0/25 | – |
Shoulder scores (mean ± SD) | |||
Constant Score (0–100) | 37.7 ± 11.6 | 36.3 ± 9.7 | 0.47 |
Shoulder Rating Questionnaire (0–100) | 54.1 ± 14.5 | 50.2 ± 14.9 | 0.14 |
Motion (degrees) | |||
Passive flexion | 148.8 ± 37.8 | 141.6 ± 42.0 | 0.32 |
Passive abduction | 119.7 ± 42.4 | 109.0 ± 40.1 | 0.15 |
Passive outer rotation | 42.4 ± 11.6 | 43.1 ± 9.5 | 0.74 |
Passive inner rotation | 3.0 ± 1.5 | 3.1 ± 1.6 | 0.61 |
Active flexion | 145.1 ± 39.4 | 140.6 ± 42.4 | 0.54 |
Active abduction | 115.0 ± 42.8 | 107.6 ± 40.3 | 0.32 |
Active outer rotation | 42.4 ± 11.6 | 43.0 ± 9.5 | 0.77 |
Active inner rotation | 3.0 ± 1.5 | 3.2 ± 1.6 | 0.50 |
Muscle tests (VAS scale 0–10) | |||
Full can test | 4.4±2.7 | 5.4±2.9 | 0.04 |
Empty can test | 4.7 ± 2.7 | 5.3 ± 2.9 | 0.19 |
Lift off test | 3.4±3.3 | 4.4±3.3 | 0.12 |
Resisted external rotation test | 3.1 ± 2.9 | 3.4 ± 2.9 | 0.61 |
Palm up test | 5.1±3.3 | 5.0±3.1 | 0.95 |
Yergasons test | 2.3 ± 2.4 | 2.0 ± 2.4 | 0.53 |
Ultrasonography (n) | |||
Joint effusion, yes/no | 3/60 | 1/62 | – |
Sulcus effusion, yes/no | 17/46 | 16/47 | – |
Normal/oedema/partial lesion/ | |||
total lesion/degeneration (n) | |||
Caput longum bicipitis | 56/7/0/0/0 | 53/8/1/1/0 | – |
Subscapularis | 51/3/0/0/9 | 55/3/0/0/5 | – |
Supraspinatus | 15/28/16/0/4 | 15/31/14/0/3 | – |
Infraspinatus | 60/1/1/0/1 | 60/1/2/0/0 | – |
Intra group results (Tables 2 and 4)
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Within each group all parameters improved significantly between the 1st
Variable | Visit | p | Visit | p | Visit | p | Visit | p | Visit | p | Visit | p |
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4 vs. 1 | 4 vs. 1 | 5 vs. 1 | 5 vs. 1 | 5 vs. 4 | 5 vs. 4 | |||||||
STR Group | HTR Group | STR Group | HTR Group | STR Group | HTR Group | |||||||
n = 63 | n = 63 | n = 63 | n = 63 | n = 63 | n = 63 | |||||||
Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | Mean ± SD | |||||||
Shoulder scores
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CS | 16.0 ± 15.8 | 0.0001 | 19.7 ± 16.7 | 0.0001 | 22.7 ± 20.5 | 0.0001 | 23.7 ± 18.2 | 0.0001 | 6.7 ± 11.9 | 0.0001 | 4.0 ± 11.6 | 0.008 |
SRQ | 11.7 ± 4.2 | 0.0001 | 16.4 ± 18.1 | 0.0001 | 17.7 ± 19.5 | 0.0001 | 18.1 ± 18.1 | 0.0001 | 6.0 ± 12.0 | 0.0001 | 1.6 ± 10.3 | 0.21 |
Passive Motion (degrees)
| ||||||||||||
Flexion | 12.8 ± 35.7 | 0.0001 | 16.9 ± 38.3 | 0.0001 | 15.1 ± 38.6 | 0.038 | 21.4 ± 41.6 | 0.0001 | 2.26 ± 24.6 | 0.72 | 4.5 ± 22.0 | 0.09 |
Abduction | 21.2 ± 38.1 | 0.0001 | 33.4 ± 44.4 | 0.0001 | 26.9 ± 39.4 | 0.003 | 39.3 ± 46.6 | 0.0001 | 5.9 ± 32.0 | 0.15 | 5.9 ± 31.7 | 0.14 |
Ext. rotation | 4.6 ± 9.2 | 0.0001 | 3.2 ± 9.36 | 0.0001 | 5.2 ± 9.0 | 0.0001 | 3.8 ± 9.7 | 0.0020 | 0.65 ± 4.5 | 0.26 | 0.63 ± 2.9 | 0.10 |
Int. rotation | 1.1 ± 1.5 | 0.0001 | 1.0 ± 1.5 | 0.0001 | 1.5 ± 1.6 | 0.0001 | 1.3 ± 1.8 | 0.0001 | 0.37 ± 1.1 | 0.01 | 0.30 ± 1.0 | 0.02 |
Active Motion (degrees)
| ||||||||||||
Flexion | 13.9 ± 33.7 | 0.0001 | 17.7 ± 39.1 | 0.0001 | 16.5 ± 39.3 | 0.002 | 21.8 ± 42.7 | 0.0001 | 2.7 ± 26.9 | 0.44 | 4.06 ± 20.7 | 0.12 |
Abduction | 24.1 ± 36.4 | 0.0001 | 34.0 ± 44.8 | 0.0001 | 30.0 ± 41.6 | 0.0001 | 39.2 ± 47.7 | 0.0001 | 5.9 ± 31.9 | 0.15 | 5.2 ± 31.5 | 0.19 |
Ext. rotation | 4.6 ± 9.2 | 0.0001 | 3.3 ± 9.4 | 0.007 | 5.2 ± 9.0 | 0.0001 | 3.9 ± 9.7 | 0.002 | 0.65 ± 4.5 | 0.26 | 0.63 ± 2.9 | 0.09 |
Int. rotation | 1.0 ± 1.5 | 0.0001 | 0.97 ± 1.6 | 0.0001 | 1.4 ± 1.6 | 0.0001 | 1.3 ± 1.9 | 0.0001 | 0.37 ± 1.1 | 0.01 | 0.30 ± 1.0 | 0.02 |
Muscle tests (VAS scale)
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Full can | −1.7 ± 2.7 | 0.0001 | −1.9 ± 3.4 | 0.0001 | −2.2 ± 3.0 | 0.0001 | −1.9 ± 3.8 | 0.0001 | −0.49 ± 2.0 | 0.06 | −0.04 ± 2.5 | 0.90 |
Empty can | −1.9 ± 2.5 | 0.0001 | −1.5 ± 2.8 | 0.0001 | −1.9 ± 2.9 | 0.0001 | −1.5 ± 3.2 | 0.0001 | −0.02 ± 1.6 | 0.93 | −0.04 ± 1.8 | 0.87 |
Lift off | −0.81 ± 2.7 | 0.02 | −1.5 ± 3.4 | 0.0001 | −1.0 ± 3.6 | 0.028 | −1.7 ± 3.5 | 0.0001 | −0.22 ± 2.4 | 0.46 | −0.02 ± 1.5 | 0.30 |
Ext. rotation | −1.4 ± 2.4 | 0.0001 | −1.40 ± 2.0 | 0.0001 | −1.3 ± 2.7 | 0.0001 | −1.6 ± 2.2 | 0.0001 | 0.07 ± 1.5 | 0.72 | −0.20 ± 1.2 | 0.19 |
Palm up | −2.8 ± 3.0 | 0.0001 | −2.3 ± 3.1 | 0.0001 | −3.0 ± 3.1 | 0.0001 | −2.5 ± 3.3 | 0.0001 | −0.15 ± 1.9 | 0.51 | −0.21 ± 1.9 | 0.39 |
Yergason | −0.92 ± 2,3 | 0.003 | −0.72 ± 2.0 | 0.007 | −0.90 ± 2.8 | 0.02 | −0.81 ± 2 | 0.002 | −0.09 ± 1,4 | 0.62 | 0.02 ± 1.3 | 0.90 |
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Between the 1st. and 5th. visit, CS improved by 22.7 points for the STR group an
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Between the 4th and the 5th visit, there was significant improvement in CS,
Inter group results (Tables 3 and 4)
Variable | Inter-group | SE | p | Inter-group | SE | p | Inter-group | SE | p |
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difference | difference | difference | |||||||
Mean | Mean | Mean | |||||||
Visit 4 vs. 1 | Visit 5 vs. 1 | Visit 5 vs. 4 | |||||||
Shoulder Scores | |||||||||
Constant score | −3.7 | 2.9 | 0.20 | −1.0 | 3.5 | 0.77 | 2.7 | 2.1 | 0.20 |
SRQ | −4.8 | 2.9 | 0.10 | −0.42 | 3.4 | 0.90 | 4.4 | 2.0 | 0.03 |
Passive motion (degrees) | |||||||||
Flexion | −4.1 | 6.6 | 0.54 | −6.3 | 7.16 | 0.38 | −2.3 | 4.1 | 0.58 |
Abduction | −12.3 | 7.4 | 0.10 | −12.4 | 7.7 | 0.11 | −0.05 | 5.7 | 0.99 |
Ext. rotation | 1.39 | 1.65 | 0.400 | 1.41 | 1.7 | 0.40 | 0.02 | 0.70 | 0.98 |
Int. rotation | 0.03 | 0.27 | 0.90 | 0.11 | 0.31 | 0.73 | 0.07 | 0.19 | 0.70 |
Active motion (degrees) | |||||||||
Flexion | −3.9 | 6.5 | 0.55 | −5.3 | 7.3 | 0.47 | −1.4 | 4.2 | 0.74 |
Abduction | −9.9 | 67.3 | 0.18 | −9.2 | 8.0 | 0.25 | 0.65 | 5.6 | 0.91 |
Ext. rotation | 1.32 | 1.6 | 0.43 | 1.34 | 1.7 | 0.42 | 0.02 | 1.7 | 0.98 |
Int. rotation | 0.05 | 0.27 | 0.86 | 0.12 | 0.31 | 0.70 | 0.07 | 0.19 | 0.70 |
Muscle tests (VAS scale) | |||||||||
Full can | 0.23 | 0.55 | 0.67 | −0.21 | 0.60 | 0.73 | −0.45 | 0.41 | 0.28 |
Empty can | −0.36 | 0.48 | 0.45 | −0.34 | 0.54 | 0.53 | .02 | 0.30 | 0.95 |
Lift off | 0.65 | 0.55 | 0.24 | 0.62 | 0.63 | 0.33 | −0.03 | 0.35 | 0.93 |
Ext. rotation | 0.00 | 0.39 | 0.99 | 0.27 | 0.43 | 0.54 | 0.27 | 0.24 | 0.26 |
Palm up | 0.05 | 0.55 | .878 | −0.43 | 0.57 | 0.46 | − 0.48 | 0.33 | 0.38 |
Yergason | −0.21 | 0.39 | 0.60 | −0.09 | 0.43 | 0.83 | 0.11 | 0.24 | 0.65 |
STR Group (n = 63) | HTR Group (n = 63) | STR vs. HTR group | |||||||||||||
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Visit | Visit | Visit | |||||||||||||
1 | 4 | 5 | 4 vs. 1 | 5 vs. 1 | 5 vs. 4 | 1 | 4 | 5 | 4 vs. 1 | 5 vs. 1 | 5 vs. 4 | 1 vs. 1 | 4 vs. 4 | 5 vs.5 | |
Positive:Negative | p | Positive:Negative | p | p | |||||||||||
n:n | n:n | ||||||||||||||
Neer’s | 51:11 | 17:45 | 14:48 | < 0.0001 | < 0.0001 | 0.55 | 56:8 | 21:43 | 18:46 | < 0.0001 | < 0.0001 | 0.45 | 0.41 | 0.51 | 0.48 |
Hawkins | 41:21 | 37:25 | 30:32 | 0.34 | 0.11 | 0.10 | 45:19 | 33:31 | 31:33 | < 0.03 | < 0.008 | 0.88 | 0.10 | 0.34 | 1.00 |
Drop out rate (Table 5)
STR Group | HTR Group | p | |
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n = 63 | n = 63 | ||
Dropout rate at | |||
Visit 2 | 5 | 8 | 0.418 |
Visit 3 | 8 | 12 | 0.335 |
Visit 4 | 13 | 19 | 0.218 |
Visit 5 | 21 | 27 | 0.274 |
Training group | STR | HTR |
---|---|---|
Non-compliant to training | 2 | |
Steroid injection | 2 | |
New job | 1 | |
Pain | 1 | 3 |
Did not show up | 12 | 17 |
Did not have the time | 1 | 2 |
Preferred other kind of training | 1 | |
Hand surgery | 1 | |
Moved | 1 | |
Parkinsonism | 1 | |
Treatment with prednisolone | 1 | |
Frozen shoulder | 1 | 1 |
Total | 21 | 27 |