The effect of brochure use versus therapist teaching on patients performing therapeutic exercise and on changes in impairment status.

In the treatment of neck and low back pain, exercise therapy is often indicated.[1-7] The success of these exercises is generally thought to be determined by several factors. Most practitioners contend that for positive results, exercises must be specific,[8-14] of the proper intensity,[15-17] and performed consistently with the correct technique. Techniques are often taught by a physical therapist or by use of various media, such as brochures, audiotapes, and videotapes. In various areas of medicine, brochures are used for patient education.[18-23] Brochures are relatively inexpensive, they can be made available to a great number of patients, and they enable patients to exercise when and where they want. Supervised exercise also has several advantages, such as the low rate of in injuries[24] and the better compliance due to the motivation[25] in addition to the prolonged supervision, the feedback,[26,27] and the clear instructions given by the therapist.[28]

The effectiveness of exercise is most likely related to the quality of exercise performance. To our knowledge, however, no studies have examined whether there is a difference in the quality of exercise performance between patients taught by physical therapists and patients learning their exercises only from a brochure.

The goal of this study was to investigate whether the mode of teaching therapeutic exercises affects whether patients correctly perform the exercises and whether it affects changes in muscle performance measurements. We compared two groups of patients; one group exercised under the supervision of a physical therapist, and the other group received their instructions from a brochure. Patient characteristics and variables that might have an impact on the results were evaluated.

Method

Subjects

Ninety-six patients who were referred to the Department of Orthopedic Physiotherapy, Orthopedic Hospital Speising (Vienna, Austria), for exercise treatment for neck and low back pain were included in this prospective study. In the opinion of the referring physicians (ie, orthopedic specialists or neurosurgeons), the patients, pain was essentially due to muscular factors (imbalance in force and problems with length), which were expected to be treated successfully with exercises. The patients, history and the clinical examination performed by a physician or a physical therapist at the start of the study were used to indicate the presence of muscular imbalance. The muscle status was registered using a manual examination procedure to determine whether the force and length of selected muscles deviate from normal in specific patterns.[29]

Subjects had to be between the ages of 20 and 70 years, with a duration of pain of more than 6 weeks, and with no record of participation in any physical exercise program prior to the training phase of this study. Patients with radiographic findings (eg, spinal stenosis, spondylolisthesis, neoplasms), patients with neurological signs, and patients recently having undergone an operation were excluded, as were those for whom exercise therapy would have been contraindicated for other reasons, such as cardiac disease, hypertension, or stroke. Patients who were unable to speak or understand German or use a visual analogue scale and patients who were thought to have difficulties adhering to therapeutic regimens, such as those with alcoholism or severe depression, were also excluded. Thus, the data from 87 patients were included in the analysis. Informed consent was obtained from all patients.

Procedure

At the beginning of the study, the age and gender of the patients were recorded, as were the deviation of the actual weight from the ideal weight according to Broca (ideal weight = height [in centimeters] = 100) (expressed as a percentage),[30] amount of physical work done by the patient (amount of physical work per workday more than 70%: yes/no), and educational level (college education: yes/no). These variables were recorded to resolve whether patients who are obese, patients who are not accustomed to doing physical work, or less educated patients have greater difficulty learning and carrying out their exercises correctly. The severity of pain was determined by means of a visual analogue scale[31] ranging from 0 (no pain) to 100 (maximum of pain assessable). Finally, the muscle status was measured using a procedure for determination of muscle force and length.

Assessment of muscle force was based on the principles reported by Janda,[32] taking into account gravity as a component of resistance. The muscle test procedure and possible pitfalls of the test have been illustrated and described in detail by Janda. Briefly, the force of the deep cervical flexor, rhomboideus, and abdominal muscles and the gluteus maximus and medius muscles was assessed by manual examination according to a six-tier rating scale ranging from 5 to 0, with 5 indicating normal strength. For evaluation purposes, the difference in the number of points between the pathological and the normal status was used.

To improve interrater and intrarater reliability, it has been a practice at our clinic for many years to perform at least two muscle status tests per patient and to train the team of therapists and physicians in the test methods on a regular basis to foster agreement on the operational definitions used. A protocol with a detailed description of the test procedure is available to all team members. Data on reliability of these measurements, however, do not exist. The reliability of these measurements, therefore, could affect our results. The reliability of measurements of muscle force obtained with manual tests has been questioned in several studies.[33]

The lengths of the trapezius pars descendens, pectoralis major, iliopsoas, quadratus lumborum, and ischiocrurale muscles were assessed according to a four-level scale, with 0 indicating normal length and 3 indicating severe shortening. The tests assessing the extent of muscle shortening were done after determination of the full range of motion, using standard external fixation. Details have previously been described by Janda.[32] The reliability of these measurements has not been evaluated.

Total muscle status was defined as the sum of the deviations from normal with regard to muscle strength and length. Thus, a score of 0 indicated that the muscle status was normal, and the higher the score, the more compromised the muscle status. We treated our measurements as interval-level data by adding them, although we cannot document the interval nature of the force or length measurements.

All patients were randomly assigned to receive one of three different brochures (A, B, or C). The exercises in each of the three brochures were described somewhat differently and the illustrations were not identical, but the goal of treatment was essentially the same (ie, to strengthen weak muscles and stretch shortened muscles, thereby alleviating the muscular problems). All exercises were based on the principles reported by Janda et al,[29] Evjenth and Hamberg,[34] and Spring et al[35] and could be carried out without a physical therapist or other partner.

Depending on the muscle status of each patient, the prescribed regimen consisted of three to five different strengthening and stretching exercises. Zero to 4 days after giving out the brochure, the performance of the patients was assessed in terms of whether they were doing their exercises correctly. A three-grade scale was used. Grade I indicated that the exercise was done so well that the goal of treatment was reached; grade 2 indicated that the exercise was not carried out correctly and the goal was not reached, but that no negative impact was to be expected; and grade 3 indicated that the exercise was performed incorrectly and the goal was not reached and that there was reason to believe that the exercise might have had harmful effects. The final grade was calculated by dividing the sum total of the grades by the number of exercises, so that I was the best grade and 3 was the worst grade.

Examination was performed in a blinded manner by three different reviewers who did not have knowledge of the group to which the patients had been assigned. The examiners, two physical therapists and one physician, each had several years of experience in muscle status evaluation. A reliability study assessing the interobserver agreement among the three examiners for the grading of exercise performance yielded a kappa coefficient of .88. subsequently, the patients were randomly assigned to one of two treatment groups. The 47 patients in the first group were instructed individually by a physical therapist and participated in eight treatment sessions between the initial and follow-up examinations. On the days between treatment sessions, the patients were supposed to exercise on their own for 20 minutes once daily. Fifteen of the patients in this group had originally received brochure A, 17 patients had received brochure B, and 15 patients had received brochure C.

The 40 patients assigned to the second group were given a brochure by the physical therapist, who told them which exercises to carry out. Patients were not given any initial instructions, but they were free to ask questions whenever they felt something was unclear. Patients in this group continued exercising on their own without the guidance of a physical therapist. They also had been told to exercise for 20 minutes once daily. Fourteen of the patients were using brochure A, 13 patients were using brochure B, and 13 patients were using brochure C.

The follow-up examination included assessment of muscles status as previously described and grading of the quality of exercise performance in terms of whether patients were doing their exercises correctly. Moreover, the weekly training frequency in the period between the initial and follow-up examinations was recorded, as was any concomitant treatment, such as massage and hot packs. Pain intensity was again, registered on a visual analogue scale, and the difference between the pain intensity reported at baseline and at follow-up was taken as a measure of improvement or aggravation.

Data Analysis

Statistical evaluation with regard to the comparability of the supervised group and the brochure group was done using t tests (age, interval between initial and follow-up examinations), U tests (muscle status at baseline, deviation from ideal weight according to Broca, training frequency, and initial grading), and chi-square tests (gender, amount of physical work, educational level, and concomitant treatment).

The comparability of the three brochure groups was investigated using analysis of variance (age, interval between initial and follow-up examinations), the Kruskal-Wallis one-way analysis of variance (muscle status, deviation from ideal weight, training frequency, initial grading), and chi-square tests (gender, educational level, amount of physical work, concomitant treatment).

For calculating the differences between the supervised group and the brochure group regarding the dependent variables quality of exercise performance, muscle status, and pain relief at follow-up, U tests were used. To verify within-group changes in the dependent variables quality of exercise performance and muscle status between baseline and follow-up, the sign test was used.

Ranking correlations were used to establish the links between the dependent variables quality of exercise performance, muscle status improvement, and pain relief at follow-up.

To assess the possible influence of the variables deviation from ideal weight, educational level, amount of physical work, and training frequency on the dependent variables, chi-square tests were used. The null hypothesis was dismissed if P<.01. All analyses were performed on a personal computer(*) using the SPSS statistical package.[dagger]

(*) Escom DX4 100 MHz, A-6020, Intel, Adechstr.65, Innsbruck, Austria. [dagger] SPSS/PC+ 4.0 for PC/DOS, SPSS Inc, 444 N Michigan Ave, Chicago, IL 60611.

Results

No differences were observed between the two groups with respect to their baseline characteristics, the interval between the initial and the follow-up examinations, and the concomitant treatment. Only the training frequency reported by the patients in the supervised group tended to be higher than that reported by the brochure group (Tabs. 1, 2). The randomized distribution of brochures A, B, and C did not yield any differences with regard to any of the variables tested.

Table 1.
Patient Characteristics and Clinical Results at Baseline

                        Supervised         Brochure
                        Group              Group
Characteristic          (n = 47)           (n = 40)        P

Gender
 Male                   29 (62%)           25 (62.5%)
 Female                 18 (38%)           15 (37.5%)

Age (y)
 X                      49                 47              .5
 SD                     13.6               11.6
 95%  CI(a)             44.87-52.67        43.13-50.76

Predominantly
    physical work (n)   15 (32%)           14 (35%)        .8

Higher educational
    level (n)           9 (19%)            13 (33%)        .2

Deviation from ideal
    weight  (%)(b)      +2.7 (-9.4-17.9)   +1.3 (-6.0-14.1).8

Muscle [status.sup.b]    2.0 (2-4)          3.0 (2-4)      .6

Quality of exercise
    [performance.sup.b]  1.75 (1.5-2)       1.75 (1.6-2)   .6

(a) CI = confidance interval
(b) Median with 25th to 75th percentiles in parentheses.

Table 2.
Concomitant Treatment, Interval Between Initial Assessment and
Follow-up, and Weekly Training Frequency

                                Supervised  Brochure
                                Group       Group
                                (n = 47)    (n = 40)       P

Concomitant treatment (n)       19 (40%)    29 (73%)       .2

Interval between initial and
  follow-up examinations (d)
  X                             34          33             .4
  SD                             7.9         5.4
  95% CI(a)                     31-36       31-34

Weekly training frequency(b)     7 (3.5-7)   4.5 (3-6.25)  .013

At follow-up, the groups, differed with regard to the quality of exercise performance, muscle status, and pain relief (Tab. 3). Thus, we found that 45 of the 47 patients in the supervised group had improved in the way they were doing their exercises between the initial and follow-up examinations, whereas the remaining 2 patients had not made any progress or were performing worse (P<.01). By contrast, 19 of the 40 patients in the brochure group performed better at the follow-up examination; the remaining 21 patients had either not improved or were doing worse (P=.9). In terms of muscle status, 40 of the 47 patients in the supervised group showed an improvement, whereas for the remaining 7 patients, no change or a deterioration was noted (P<.01). By comparison, 21 of the 40 patients in the brochure group showed an improvement, whereas the muscle status of the remaining 19 patients had remained unchanged or had even deteriorated (P=.9).

Table 3.
Results of follow-up Examination in the Supervised Group in the
Brochure Group(a)

                      Supervised    Brochure
                      Group         Group
                      (n = 47)      (n = 40)        P

Quality of exercise
 performance          1.0 (1-1.3)    1.6 (1.4-1.9)  <.01

Muscle status         1.0 (1-2)      2.0 (2-3)      <.01

Pain relief          50 (25-71.25)  25 (10-40)      <.01

(a) Median with 25th to 75the percentiles in parentheses.

The quality of exercise performance at follow-up was correlated both with muscle status improvement (r=-.38,P<.01) and with pain relief (r=-.47, P<.01). In addition, muscle status improvement was related to pain relief (r=.30, P<.01).

Neither the performance quality nor the muscle status at follow-up, however, was correlated with the deviation from the ideal weight according to Broca, the level of education, the amount of physical work, or the weekly training frequency, both when calculated for the total sample and when the two groups were considered separately. In the supervised group, there was a trend among patients who were obese to have greater difficulty doing their exercises.

Discussion

The optimal success of exercises may be expected if the exercises are performed correctly (eg, in accordance with the instructions based on the patient's diagnosis or condition). This study was not designed to permit us to draw a conclusion about the effectiveness of different exercise programs for patients with neck and low back pain or about whether any treatment would be better than no treatment.

Even though we had expected that the patients directed by a physical therapist would do better than those exercising on their own, we were surprised to find such a pronounced difference between the groups. Our findings are in marked contrast to the practice of prescribing exercises by merely providing the patient with some instructive booklet in the hope that he or she will be able to cope and that the method will yield at least reasonable results.

The more favorable outcome in terms of muscle status and pain relief in the supervised group may be due to several factors resulting from a good relationship between patient and health care provider. Numerous investigations[36-40] have shown that the therapist plays an essential role, particularly with regard to compliance. Patients may be more motivated to carry out their exercises correctly when a physical therapist is present. Prolonged supervision is a strong factor in compliance, and this factor may explain why patients in the supervised group exercised more frequently than those in the brochure group. The increased frequency of exercise may, in turn, improve the quality of exercise performance.

The support and counseling given by therapists often appear to be appreciated by the patients.[41] We believe that patients who receive clear instructions and constant feedback comply better than patients without supervision. Likewise, compliance is more likely when the regimen is tailored to the patient's situation or daily routine.[28,24] Finally, complex and inconvenient regimens cause more noncompliance than simple and convenient regimens.[43,44]

For methodological reasons, only relatively simple and easily assessable stretching and strengthening exercises were used in this study, whereas more complex coordinating types of exercise were avoided; we believe that these more difficult exercises would be even more difficult to learn from a book. Another possible explanation why the success rate was lower in the patients who were exercising individually may be that the brochure did not exactly serve its purpose because of the way it was written. For example, it has been shown that brochures with Illustrations and narrative text are superior to those without illustrations or with lists of instructions presented in outline format.[45] Therefore, to reduce the possible influence of the type and quality of the brochure on outcome, we used three different brochures but did not observe any difference in the results.

Furthermore, we sought to determine whether educational level, amount of physical work, or body weight had an influence on the patients, ability to carry out their exercises correctly. Some patients may be unable to understand a written text and to translate the written word into practical exercises. Our results, however, do not support this assumption. We found that even persons with a higher educational level did not achieve better grades than those who were less well educated. Yet, the educational level may have an influence on compliance. In one study,[40] the patients' level of education was found to be related to compliance, with highly educated patients being less compliant with home exercises than less educated patients.

Some patients may understand what a brochure states but may not have adequate somatesthesia and sense of space to be able to carry out the exercises correctly without the guidance of a physical therapist. This hypothesis, however, was not supported by our results, because patients who were accustomed to doing physical work showed no better skills in doing their exercises than did other patients.

Although the patients in the supervised group who were obese had greater problems learning the exercises, these findings may not be generalizable because the difference we found was not significant and because it may well be that obesity presents a greater problem with certain types of exercises.

Generally, it is for administrative, personnel, and cost-saving reasons that patients are advised to use only brochures. Our study demonstrates, however, that this may not be the most appropriate way of reducing costs, because patients learning their exercises from brochures often do not carry them out correctly. The expected success of treatment, therefore, may not be fully achieved.

To balance treatment effectiveness with cost effectiveness, we can ask whether equally good results could be achieved if the number of supervised treatment sessions is reduced, if some treatment sessions are undertaken in small groups instead of on an individual basis, or if brochures are used as additional aids and not as the only instrument of education, with the therapist and the patient working with the booklet together while reducing the number of supervised sessions. These modalities could help reduce health care costs without completely foregoing the motivational benefits of the therapist@ patient relationship.

Conclusions

The results of our study confirm that exercises that are based only on written instructions often are not performed properly and therefore lead to poorer outcomes compared with exercises learned under the supervision of a physical therapist. Additional studies emphasizing the economic element would be of interest in clarifying whether supervised therapy really has to be performed on an individual basis or whether therapy undertaken in groups would yield the same results.

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