O’Shea SD, Taylor NF, Paratz JD (2007) A predominantly home-based progressive resistance exercise
program increases knee extensor strength in people with
chronic obstructive pulmonary disease:
a randomised controlled trial
Australian Journal of Physiotherapy 53: 229–237
Appendix 1
Trial Method
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GUIDELINES FOR INTERVENTION
PROGRESSIVE RESISTANCE EXERCISE GROUP
FREQUENCY
3 times per week
1 group session
supervised by
physiotherapist
in an outpatient
department
2 sessions
performed
independently at
home
DURATION
12 weeks
Individual exercise
sessions = 45–75 mins
Rest between sets ≤ 3
minutes
Rest between exercises
≤ 5 minutes
INTENSITY
3 sets x 8–12 RM
WEEKS 1–2
– familiarisation phase with focus on exercise
technique & breathing*
– build up from 1 to 3 sets of exercise
– appropriate resistance level determined
WEEKS 3–12
– increase resistance level (band colour) for
an exercise when 3 × 12 RM performed with
correct technique through full ROM in two
exercise sessions
Band Colour Progressions
1. Body weight only (no band)
2. Yellow band
3. Red band
4. Green band
5. Blue band
6. Black band
7. Black & yellow band
8. Black & red band
9. Black & green band
10. Black & blue band
11. Black & black band
12. Gold band
13. Gold & yellow band
14. Gold & red band
15. Gold & green band
16. Gold & blue band
17. Gold & black band etc.
WEEKS 12–24
Own choice on
Ongoing exercise
Own choice on intensity
exercise frequency performance optional
*
Breathing: To avoid valsalva manoeuvre participants were instructed to breathe out during
concentric phase of exercise.
The training program included six exercises for the major upper and lower limb muscle
groups. Each exercise is shown and described below. The exercises were designed to be
simple to perform in the home setting and to reflect functional movement patterns. The
exercises were performed with Thera-band® and exercise handles (Thera-band
Academy, Hygenic Corporation, USA).
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PRE Program
Exercise
Description of Exercise
Equipment
Band placed underneath feet and
Kitchen chair
held with moderate tension by
Exercise band
1. Sit-to-stand
tucking elbows into side. Participant
stands up and sits down from chair
against resistance of band whilst
maintaining still upper limbs.
2. Lunges
Participant stands in wide stride
Exercise band
stance with band placed under the
front foot and held with the elbows
tucked into sides. Keeping hips level
and trunk upright, participant bends
both knees to lower back knee
towards the ground, then pushes up
again.
3. Hip Abduction
Participant stands at bench with
Exercise band
band around ankles. One leg is taken
Bench (balance)
out to the side against the resistance
of the band. Toes are pointed
forwards and trunk held still.
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4. Simulated Lifting
Participant stands with middle of
Exercise band
band underneath feet and holding
the ends in each hand. Knees are
slightly bent as if preparing to lift. In
one action, the participant
straightens knees and lifts both arms
up against resistance of band, as if
lifting something towards a high
shelf.
5. Chest press
When seated, participant places
Exercise band
middle of band around back of chair, Chair
holding an end in each hand. With
hands starting movement near the
axilla, participant pushes both arms
forward to straighten elbows against
the resistance of the band.
6. Seated row
In sitting, participant places band
Exercise band
around pole. With arms held straight
Chair
out in front the participant pulls both
Sturdy pole
elbows backwards against the
resistance of the band (as if rowing)
The resistance provided by elasticised resistance bands depends on the band colour
used, and the degree of band elongation during exercise (Page et al 2000). It is estimated
that resistance increases by approximately 20% with each change in band colour (Page
et al 2000). In order to standardise resistance received between training sessions, an
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effort was made to standardise starting position, and exercise range of movement so that
150% band elongation was achieved during each exercise repetition. Bands were also
measured and marked with permanent marker in order to ensure the correct starting
length was used for each exercise, thus minimising variability in the degree of band
elongation occurring between sessions. Minor adjustments to the standardised band
lengths were needed for some participants in order to achieve 150% band elongation
during exercise.
An example of the exercise log-book is provided below. Log-books were
checked weekly by the supervising physiotherapist in order to monitor the effectiveness
and progression of training. Participants were encouraged to use the comments section
to record queries for the supervisor to address at the next group session, any
problems/concerns, as well as any reasons for missing exercises or training sessions.
NO-INTERVENTION CONTROL GROUP

Advised to continue their normal daily activities and previous level of exercise.

Advised not to start any new exercises or increase their level of exercise

Advised not to perform any exercises against resistance

Participants contacted at 6, 12, 18 and 24 weeks of the study to monitor exercise
& activity levels.
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EXAMPLE OF LOG-BOOK USE
Hip
Abduction
In the first session of
the week the
participant was able to
complete 2 x 12
repetitions with a red
band
Simulated
Lifting
For this exercise the
participant was able to
do 10 reps in the first
set, 8 in the second and
6 in the last set, using
the yellow band
SESSION 1
Date: 4/5/04
SESSION 2
Date: 6/5/04
SESSION 3
Date: 8/5/04
Colour: Red
Set 1: 12
Set 2: 12
Set 3: 0
Borg: 13
Colour: Red
Set 1: 12
Set 2: 12
Set 3: 12
Borg: 13
Colour: Green
Set 1: 10
Set 2: 10
Set 3: 8
Borg: 14
For this session they used
the next colour band (green)
because they did 3 x12 reps
at the previous level
In the second they
were able to
complete 3 x 12
reps
Colour: Yellow
Set 1: 10
Set 2: 8
Set 3: 6
Borg: 15
Colour: Yellow
Set 1: 12
Set 2: 9
Set 3: 8
Borg: 15
In session 2 they
completed one set of 12
reps, a set of 9 reps and
finally a set of 8 reps
Colour: Yellow
Set 1: 12
Set 2: 12
Set 3: 10
Borg: 15
In session 3, they did 2 x 12
and 1 x 10. For the next
session they would try to
reach 3 x 12 reps before
changing band colour
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WEEK 1
SESSION 1
Date:
SESSION 2
Date:
SESSION 3
Date:
Hip
Abduction
Colour:
Set 1:
Set 2:
Set 3:
Borg:
Colour:
Set 1:
Set 2:
Set 3:
Borg
Colour:
Set 1:
Set 2:
Set 3:
Borg
Simulated
Lifting
Colour:
Set 1:
Set 2:
Set 3:
Borg
Colour:
Set 1:
Set 2:
Set 3:
Borg
Colour:
Set 1:
Set 2:
Set 3:
Borg:
Sit-to-stand
Colour:
Set 1:
Set 2:
Set 3:
Borg
Colour:
Set 1:
Set 2:
Set 3:
Borg
Colour:
Set 1:
Set 2:
Set 3:
Borg
Seated Row
Colour:
Set 1:
Set 2:
Set 3:
Borg
Colour:
Set 1:
Set 2:
Set 3:
Borg
Colour:
Set 1:
Set 2:
Set 3:
Borg
Lunges
Colour:
Set 1:
Set 2:
Set 3:
Borg
Colour:
Set 1:
Set 2:
Set 3:
Borg
Colour:
Set 1:
Set 2:
Set 3:
Borg
Chest Press
Colour:
Set 1:
Set 2:
Set 3:
Borg
Colour:
Set 1:
Set 2:
Set 3:
Borg
Colour:
Set 1:
Set 2:
Set 3:
Borg
Comments: _________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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PROTOCOL FOR ASSESSMENT
Assessments conducted at baseline (0 weeks), 12 weeks & 24 weeks. The same protocol
was followed for all assessments.
SPIROMETRY
Lung function assessed to monitor disease stability throughout trial. Measures taken at
all three assessment periods using SuperSpiro (Micro Medical, Rochester, Kent, UK).
Spirometry assessed the following measures:

Forced vital capacity (FVC)

Forced expiratory volume in one second (FEV1)

The percentage FEV1 to the total FVC (FEV1/FVC)

The percentage of the predicted FEV1 (determined from reference values for
healthy adults of similar gender, age, height and weight) (FEV1%pred).
Participants performed a maximal inspiration, followed by a forced expiratory
manoeuvre, where they emptied their lungs as fully as possible into the mouthpiece of
the electronic flow meter. Three trials, varying by less than 200 ml, were performed and
recorded for each participant (ATS, 1995). The best result at each assessment session
was used for data analysis.
Standardised Instructions
‘This test looks at your lung function. In standing, you will take in the biggest breath that
you can. Then when you cannot inhale any more put the mouthpiece in your mouth and
blast the air out of your lungs, as hard and as fast as you can. It is important to make
sure that your lips seal firmly around the mouthpiece, and to keep blowing until there is
no air left. I will now demonstrate the technique for you.’ [Assessor demonstrates
technique]
‘You will perform the test at least three times. It is important that you give your best
effort for each test. You will have time to sit and rest between trials. Do you have any
questions about the test?’
Standardised Encouragement/Coaching during Test
‘Take in the biggest breath you can’
‘Seal your lips around the mouthpiece and blast the air out as quickly as you can’
‘Now keep blowing, keep blowing…all the way until there is no air left’
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PRIMARY OUTCOME MEASURES
MUSCLE STRENGTH
Assessed using a hand-held dynamometer (Nicholas Manual Muscle Tester, Lafayette).
Muscle groups and techniques outlined in Table 2. Muscle strength was measured by
conducting three 4-second isometric contractions for the specified muscle groups on
each limb. Trial 1 was considered a practice trial, with the results of the second and third
trials averaged to provide an estimate of isometric muscle strength (Taylor, Dodd, &
Graham 2004, Whitley & Smith 1963). As the exercises included in the training
program were performed bilaterally, strength scores for each limb (right and left) were
combined to provide a total strength score for each muscle group.
Muscle Strength Testing Procedure
Muscle Group
Position
Limb Starting Position
Hip Abductors
Standing Hip abducted 20. Resistance applied to the lateral
aspect of the distal thigh (12 cm above the knee joint
line). Tester stabilises the pelvis contralateral to that
being tested. The participant is positioned in front of a
raised plinth or bench to assist with balance.
Knee Extensors
Sitting
Participant seated on a raised plinth. Knee flexed 70.
Resistance applied to the anterior tibia, 5 cm above the
lateral malleolus. For comfort a towel is placed
between dynamometer and tibia.
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Sh Horizontal Flexors
Sitting
Shoulder abducted 30 and flexed 75, and the elbow
flexed 45 (‘stop’ sign position). Resistance applied
through the palm of the hand; therefore a force strut
needs to be placed over the curved force plate to
ensure an even distribution of force during testing.
Shoulder Flexors
Sitting
Shoulder flexed 90 and elbow flexed approximately
15. Resistance applied to the anterior arm over the
biceps, 4 cm above the elbow crease. A towel can be
used for comfort as required.
SIX MINUTE WALK TEST
Participants were required to walk as many laps of a measured walkway as possible in
six-minutes. Lap length varied between 20–30 m across sites, with three sites having
straight corridor walking courses, and the remaining site having a continuous circuit.
The 6MWT was performed twice at each assessment session, with a minimum of 45
minutes between tests. The first test at each session was deemed a practice trial with the
results of the second trial used for data analysis. Participants were provided with a
standardised set of instructions prior to each test, and standardised encouragement at
minute intervals during test performance
Standardised Instructions for 6MWT
‘The aim of this test is to walk as far as possible in six minutes by completing as many
laps of the corridor as you can. You are permitted to slow down, to stop, and to rest as
necessary, but resume walking as soon as you are able. Remember you are aiming to
walk as far as you possibly can in the six minutes’
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Standardised Encouragement
Two standardised encouragement statements were provided for use during the six
minute walk test. The assessor alternated which statement was used each minute, and
added in the appropriate time where x is written in the statement.
‘Keep up the good work. You have completed x minutes’
‘You are doing well. You only have x minutes left’
SECONDARY OUTCOME MEASURES
CHRONIC RESPIRATORY DISEASE QUESTIONNAIRE
The questionnaire examines four domains: dyspnoea, fatigue, emotion, and mastery. The
questionnaire was interviewer-administered and took approximately 15–20 minutes to
complete. Participants answered each question using a seven-point Likert scale, where
higher scores were indicative of higher levels of functioning. The dyspnoea component
differed from the other three domains in that participants nominated important daily
tasks causing breathlessness. From the individually generated list of tasks, participants
then chose the five most important activities causing dyspnoea, before rating their level
of breathlessness for each activity on the seven-point scale.
TIMED UP & GO TEST
To perform the Timed Up and Go test, a standard chair with arms was placed 3 m from
a marker or wall. On the command ‘Go’, participants were instructed to stand up from
the chair and walk at their preferred pace to the marker/wall, before turning around, and
walking back to the chair to sit down (Hill, Denisenko, Miller, Clements & Batchelor
2005). Participants were timed as they completed the test, with faster times indicating
higher levels of physical mobility (Podsiadlo & Richardson 1991). The test was
performed three times, and the results of Trials 2 and 3 averaged.
Standardised Instructions
‘When I say ‘Go’, I’d like you to stand up from the chair and walk at a safe and
comfortable pace to the marker on the floor or wall three metres away. When you reach
the marker/wall I would like you to turn around and walk back to the chair and sit down
again.’
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GROCERY SHELVING TASK
The Grocery Shelving Task required participants to stand up from a chair and carry two
grocery bags, each filled with 10 items (410g each) two metres to a bench, before
stacking the items onto a shelf 15 cm above shoulder height. The test was timed and
participants were instructed to perform the task as quickly as possible. Participants were
given one practice trial at each assessment session, before completing two further trials
from which the times were averaged to provide the Grocery Shelving Task score.
Standardised Instructions
‘The aim of this test is to perform a grocery shelving task as quickly as you can. When I
say ‘Go’ I’d like you to stand up from the chair and carry the two shopping bags on the
ground beside you, to the bench in front of you. I then want you to place each of the
items from the shopping bags onto the shelf in front of you as quickly as you can. I will
be timing how long it takes you to finish the task. You may slow down or rest if you
need to. It is best to pace yourself so that you can finish the task in the quickest
possible time.’
PATIENT-SPECIFIC FUNCTIONAL SCALE
Participants were asked to nominate up to five activities they had difficulty with because
of their breathing problem. Participants then rated each nominated activity on an 11point scale, where zero represented ‘Unable to perform activity because of breathing
problem’, and 10 corresponded with ‘Able to perform activity at same level as before
breathing problem’. At retest, participants were asked to rate their ability for the
previously nominated tasks using the same 11-point scale. Activity limitation was
assessed by adding the ratings for each nominated activity and dividing by the total
number of activities in order to provide a Total Activity Score (Stratford et al 1995).
LONDON HANDICAP SCALE
The six London Handicap Scale domains (mobility, physical independence, orientation,
occupation, social integration and economic self-sufficiency) relate to the areas of
handicap defined by the World Health Organisation (WHO 1980). Participants rated
themselves out of six (higher scores indicating greater handicap) for each scale item, and
then individual scores were weighted and combined to provide a total handicap score
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(Harwood & Ebrahim 1995). Handicap level was indicated by scores out of 100 points,
with higher scores indicative of higher levels of participation.
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PARTICIPANT INFORMATION FORM

Age (yr)

Height (cm)

Weight (kg)

BMI

FEV1 %predicted

Smoking History
a. Current smoker
… YES / NO
b. Ex-smoker
… YES / NO
c. Non-smoker
… YES / NO
d. Pack/years
… ____________
e. No. of years quit
… ____________

Long term oxygen therapy

Co-morbidities

Medications

Living Arrangements
… YES / NO
… Alone… Partner… Carer…
… Other _____________________


Previous exercise
experience
… YES / NO
Current exercise levels
…Nil…… (performs no form of exercise)
…Low…… (performs exercise < 3 times/week)
…Moderate (performs exercise 3 – 5 times/week)
…High……(performs exercise > 5 times/week)

Current exercise activities
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SPIROMETRY
MEASURE
BASELINE
POST
FOLLOW UP
Date:
FVC
FEV1
FEV1% predicted
FEV1/FVC (%)
ISOMETRIC MUSCLE STRENGTH
MUSCLE GROUP
Date:
BASELINE
R
L
POST
R
FOLLOW UP
L
R
L
Hip Abductors
Trial 1
Trial 2
Trial 3
Average (2&3)
Knee Extensors
Trial 1
Trial 2
Trial 3
Average (2&3)
Chest press
Trial 1
Trial 2
Trial 3
Average (2&3)
Shoulder flexors
Trial 1
Trial 2
Trial 3
Average (2&3)
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6MWT
BASELINE
POST
FOLLOW UP
Date:
1st
2nd
1st
2nd
1st
2nd
FiO2
ie. R/A, 2lpm, 3lpm
Resting HR (bpm)
Resting SpO2 (%)
Resting Borg
Laps
Lap length (m) = _____
Distance (m)
No. Rests
End HR
End SpO2
End Borg
Symptoms eg:
Chest pain
Dizziness
Syncope
Calf pain
Fatigue
TIMED UP & GO
BASELINE
POST
FOLLOW UP
Trial 1
Trial 2
Trial 3
Average
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LONDON HANDICAP SCALE
DOMAIN
BASELINE
POST
FOLLOW UP
Date:
‘Getting around’
(Mobility)
‘Looking after yourself’
(Physical Independence)
‘Work & Leisure’
(Occupation)
‘Getting on with people’
(Social Integration)
‘Awareness of your
surroundings’
(Orientation)
‘Affording things you need’
(Economic Self-sufficiency)
TOTAL
GROCERY SHELVING TASK
BASELINE
POST
FOLLOW UP
Date:
Trial 1
Trial 2
Trial 3
Avg time (sec)
Legend:
6MWT = six-minute walk test
R = right side
L = left side
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