Rotator cuff related shoulder pain. Describing home exercise adherence and the use of behavior change interventions to promote home exercise adherence: a systematic review of randomized controlled trials

Figures & data

Figure 1. PRISMA Flow Diagram (from Moher et al. (34)).

(N = original search 31st October 2018, n = second search 7th January 2020)

Table 1. Study characteristics for home exercise participation and the measures of adherence.

Author	Diagnosis	HEP (N)	Comparator HEP (N)	Measure of home exercise adherence used	Completion of measure of adherence	Percentage adherent	Target adherence	Adherent to what?
Bennell et al. (35)	N = 120 Rotator cuff pathology	Active group n = 59 HEP was progressed over the 10-week period. Consisted of 5-7 exercises: Mobilization of the thoracic spine, stretching of the anterior shoulder girdle and multidirectional resistance training of the upper limb. Exercises performed 2x/day for weeks 1-2 and once a day from week 3 onwards.	Placebo group n = 61 Received no instruction in home exercise.	Exercise Diary	91%	82% Group average	N/R	Completed home exercise sessions
Brox et al. (36)	N = 125 Chronic rotator cuff pathology	Supervised exercise n = 50. Relaxed repeated movements (rotation, flexion, extension, abduction and adduction). ‘1-hour duration’ of daily home exercises performed for 3-6 months. Specific dose and exercise regime not clearly specified.	Arthroscopic surgery n = 45. Bursectomy with resection of acromium and CA ligament. Detuned soft laser N = 30. Twice weekly for 12 sessions	Exercise diary	N/R	N/R	N/R	N/R
Crawshaw et al. (37)	N = 232 Subacromial impingement syndrome	Exercise only n = 117 The treating physiotherapists chose exercises for each patient from 23 possible exercises. Unknown number of exercises and unknown number of sets, repetitions, pain response, sessions/week.	Exercise and injection n = 115 Lateral approach injection of triamcinolone acetonide and lidocaine. Received the same HEP.	N/R	N/R	N/R	N/R	N/R
Dickens et al. (38)	N = 85 Subacromial impingement	Treatment group n = 45 The exercise program involved strengthening of infraspinatus, subscapularis and teres minor. Exercises progressed through range and into functional positions. The resistance and speed were altered and progressed. Asked to complete the exercises at least twice a day. Specific dose and exercise regime not clearly specified.	Control group n = 40 The control group did not receive any intervention.	N/R	N/R	N/R	N/R	N/R
Elsodany et al. (39)	N = 60 Rotator cuff tendinopathy	Exercise group n = 30 Received an exercise program in addition to sham laser treatment of three sessions per week for 4 weeks. Exercises performed daily at home. ROM exercises in the form of pendulum exercise progressed to active assisted ROM exercises with canes and active exercises. Exercises included flexibility, postural, and strengthening exercises. Focused on the rotator cuff muscles and scapular stabilization exercises using resistance bands. Specific dose and exercise regime not clearly specified.	Laser group n = 30 Patients in the treatment group received high intensity laser therapy.	N/R A family member Confirmed that the patient performed the exercises at home	N/R	N/R	N/R	N/R
Guitierrez- Espinoza et al. (40)	N = 80 Subacromial pain syndrome	Intervention group n = 40 Participants from both groups received advice and an exercise program to perform at home, which consisted of six movement exercises for the neck and shoulder without any external load. Each exercise was repeated 10 times, twice daily. The intervention group also performed a program of stretching exercises using the ‘unilateral corner stretch’ protocol, which consisted of 10 repetitions of 1-min stretches with a 30-s interval between repetitions. Specific exercise regime not clearly specified.	Control group n = 40 Participants from the control group performed only the six movement exercises for the neck and shoulder without any external load	‘To monitor the adherence at home, the participants reviewed the exercise program with the physiotherapist once a week’.	N/R	N/R	N/R	N/R
Haahr et al. (41)	N = 90 Subacromial impingement	Exercise group n = 45 Active training of the periscapular muscles (rhomboid, serratus, trapezoid, levator scapulae, and pectoralis minor muscles) and strengthening of the rotator cuff, within the limits of pain. The patients were encouraged to continue to do active exercises at home on a daily basis. After carrying out the full program for at least 12 weeks, the patients were encouraged to continue two to three times a week. Specific dose and exercise regime not specified.	Surgical group n = 45 Bursectomy with partial resection of the anteroinferior part of the acromion and the coracoacromial ligament. Also prescribed increasingly active exercises, including exercises for strengthening the rotator cuff muscles.	N/R	N/R	N/R	N/R	N/R
Heron et al. (42)	N = 120 Rotator cuff tendinopathy/shoulder impingement syndrome	N = 40 Exercise group 1 = Open Chain exercises (OC). Lateral rotation, medial rotation and abduction to 30 degrees using resistance band. Progress through range of abduction to 90 degrees and strength of band. N = 40 Exercise group 2 = Closed Chain exercises (CC) - Double arm wall press, press-up in 4-point kneeling, seated tricep dip. Progress to single arm and lifting body clear of chair. N = 40 Exercise group 3 = Range of movement exercises (ROM). Abduction, lateral rotation and medial rotation (HBB) progressed from passive to active (MR and LR in 90 degrees abduction).	All 3 groups did 3 exercises, 3 sets of each, 10 reps / set. Performed x2/day. All groups also performed stretches for the anterior and posterior shoulder (5 sec holds 5 reps twice a day). Any provoked pain should resolve within 1 h.	Exercise Diary	35, 30, 32%	83, 83, 85% were > 75% adherent.	N/R	N/R
Holmgren et al. (43)	N = 102 Subacromial impingement syndrome	Specific exercise group n = 52 Performed strengthening eccentric exercises for the rotator cuff and scapular; 6 exercises (2 eccentric for the rotator cuff and 3 for the scapular and 1 posterior shoulder stretch). 15 reps 3 sets 2x/day for 8 weeks then once a day from week 8-12. Stretch performed 30-60 s 3 sets 2x/day. Pain monitoring model, < 5/10 pain, settled by next exercise session. Encouraged to feel some pain during exercise. Continue for 2/12 following discharge.	General exercise group = 50 Performed 6 movements of the neck and shoulder; shoulder abduction, retraction, elevation, neck retraction, (10 reps 3 sets 2x/day) stretch of upper fibres of trapezius and pectoralis major (3 times 2x/day). No progressions and same program for the whole duration.	Exercise Diary	88-89%	86 and 87% Group average	<18% days missed	Days missed
Ingwerson et al. (44)	N = 100 Rotator cuff tendinopathy.	Progressive high-load exercise n = 49 Patients were instructed to perform exercises 3 times per week. The program consisted of six exercises; 2 exercises for the scapula-stabilizing muscles; 2 for the rotator cuff muscles; and 2 mobility exercises for the rotator cuff and scapulothoracic complex. Increasing resistance from a 15-repetition maximum in week 1 to a 6-repetition maximum in weeks 9 to 12. Patients performed isometric exercises if pain exceeded 50 mm on VAS.	Low load exercise n = 51 Both groups received the same exercises, attention, and basic information. The control group performed a 20- to 25-repetition maximum from weeks 1 to 12 with no increase in resistance.	Exercise Diary	N/R	57 and 61% Group average achieved target	80%	‘Number of sets and repetitions per set for every training session’
Ketola et al. (45)	N = 140 Shoulder impingement	Exercise group n = 70 An individual HEP was devised. Elasticated bands and light weights were used in training, which was based on long painless series and repetitions aiming at tendon strengthening. The sessions were performed at least four times a week using nine different exercises with 30 to 40 repetitions of each repeated over three sets. Resistance was increased and repetitions diminished as strength increased at follow-up sessions.	Arthroscopic acromioplasty and exercise n = 70 Patients received similar individually planned and progressive training programs to the exercise group.	N/R	N/R	N/R	N/R	N/R
Kukkonen et al. (46)	N = 160 Non-traumatic rotator cuff tears	Physiotherapy n = 60 First 6-weeks, exercise to improve glenohumeral motion and active scapular retraction. Then static and dynamic exercises to improve scapular and glenohumeral muscle function were gradually increased until twelve weeks. After 12-weeks the participants increased resistance and strength training up to six months. Specific dose and exercise regime not clearly specified.	The Acromioplasty and Physiotherapy Group n = 60. Arthroscopic subacromial debridement and acromioplasty with rehabilitation (same as for Group 1) The Repair, Acromioplasty, and Physiotherapy Group n = 60 The supraspinatus tendon was repaired with subacromial debridement, acromioplasty. Immobilized for three weeks after which rehabilitation was the same as for group 1 and 2.	N/R	N/R	N/R	N/R	N/R
Littlewood et al. (47)	N = 86 Rotator cuff tendinopathy	SELF group n = 42 Single exercise against resistive load (gravity, band or weight). 3 sets of 10-15 reps 2x/day. Direction of movement selected based on pain response in physical examination. Pain reproduced that is no worse upon cessation of the exercise. Exercise progressed through range, load and repetitions based on pain response.	Control group n = 44 Usual physiotherapy included a range of interventions including advice, exercise, stretching, manual therapy, massage, strapping, acupuncture, electrotherapy, corticosteroid injection. Specific dose and exercise regime not specified.	Exercise Diary (SELF arm only)	29% (SELF arm only)	20-100% Individual range (SELF arm only)	N/R	‘percent adherent’
Maenhout et al. (48)	N = 61 Subacromial impingement syndrome	Traditional and heavy training n = 31. Traditional rotator cuff training combined with heavy load eccentric training (TT + ET) at home. Same program as the (TT) group with one extra exercise twice a day at 3 sets of 15 reps for 12 weeks; full can abduction in scapular plane with dumbbell, eccentric phase at 5 sec/rep. Weight increased by 0.5 kg as pain allowed. Also same intervention as TT group. Exercise at increased pain level compared to rest but no more than 5/10. Pain to subside by next day.	Traditional training n = 30 Traditional rotator cuff training (TT) at home. Once a day for 3 sets of 10 repetitions for 12 weeks. Internal and external rotation with resistance band. at 6 s/per rep. No increase in pain during exercise. Increased load with pain reduced.	Logbook (exercise diary)	N/R	N/R	N/R	N/R
Nejati et al. (49)	N = 62 Subacromial impingement syndrome	Exercise therapy group n = 31 Supervised exercise once a week for three months and performed a HEP on the other days of the week. Continued HEP for six months. Each exercise session began with warm-up aerobic activities lasting for 10 to 15 min and ended with ice packs being applied on the affected areas for 20 min to relieve pain. Exercises included; 15-20 sets of GHJ ROM and postural correction exercises, 10 sets of isometric and PROM exercises, four sets / day of neck and posterior shoulder tightness stretches.	Platelet-Rich Plasma Group n = 31 PRP group received two injections one month apart.	N/R	N/R	N/R	N/R	N/R
Paavola et al. (50)	N = 210 Shoulder impingement syndrome	Exercise group n = 71 4 phases with different regimes. Phase 1; 13 exercises of passive movements and isometric rotator cuff activation. Phase 2; 11 exercises of active movement and maximal rotator cuff activation with mobility of thoracic spine. Phase 3; 7 exercises for resisted dynamic multidirectional upper limb strengthening (3 sets of 15-25 repetitions). Phase 4; 12 progression exercises for resisted dynamic multidirectional upper limb strengthening. Exercise was performed once a day (3 sets of 15-25 repetitions).	Diagnostic arthroscopy n = 63 One post-operative visit to a physiotherapist for guidance and instructions for home exercise Arthroscopic subacromial decompression n = 59 One post-operative visit to a physiotherapist for guidance and instructions for home exercise	N/R	N/R	N/R	N/R	N/R
Seven et al. (51)	N = 120 Rotator cuff injury	Exercise group n = 60 No details were provided on number of exercises, number of repetitions, or number of sets. Participants were advised to perform exercise 3x/day on the non-supervised days.	Prolotherapy group n = 60 Prolotherapy solution and dextrose solution was injected into the burse, muscle and muscle insertions under ultrasound guidance.	N/R	N/R	N/R	N/R	N/R

N = total number of participants in the trial participants.

n = number of participants in this arm of the study.

HEP = home exercise program.

N/R = not reported.

ROM = range of movement.

SELF = self managed home exercise program.

Table 2. Agreement between reviewers for inclusion and risk of bias evaluation.

	% Agreement	Kappa
Initial search title	96	0.93
Initial search abstracts	95	0.90
Initial search full text	76	0.52
2° search titles	89	0.78
2° search abstracts	86	0.72
2° search full text	100	1.0
RoB agreement	91	0.87

Table 3. Risk of Bias (RoB) 2.0 tabulated results for each included study and each domain.

	Randomization process	Deviations from intended interventions	Missing outcome data	Measurement of the outcome	Selection of reported result	Overall RoB
Bennell et al. (35)	Low	Low	Low	Low	Low	Low
Brox et al. (36)	Some Concerns	High	High	High	Some Concerns	High
Crawshaw et al. (37)	Low	High	Some Concerns	Some Concerns	Low	High
Dickens et al. (38)	Low	High	Low	High	Some Concerns	High
Elsodany et al. (39)	Some Concerns	High	Low	Low	Some Concerns	High
Guitierrez-Espinoza et al. (40)	Low	High	High	Some Concerns	Low	High
Haahr et al. (41)	Low	High	Low	High	Some Concerns	High
Heron et al. (42)	Low	High	Some Concerns	Low	Low	High
Holmgren et al. (43)	Low	Some Concerns	Low	Low	Low	Some Concerns
Ingwerson et al. (44)	Low	Low	Low	Low	Low	Low
Ketola et al. (45)	Low	High	Low	High	Some Concerns	High
Kukkonen et al. (46)	Low	High	Low	High	Low	High
Littlewood et al. (47)	Low	High	Some Concerns	Some Concerns	Low	High
Maenhout et al. (48)	Some Concerns	High	High	High	Low	High
Nejati et al. (49)	Some Concerns	High	High	High	Low	High
Paavola et al. (50)	High	High	Low	High	Low	High
Seven et al. (51)	Low	High	High	High	Some Concerns	High
Percentage Low RoB	71	12	53	29	65	12
Percentage High RoB	6	82	29	53	0	82
Percentage ‘some concerns’	23	6	18	18	35	6

RoB = Risk of Bias.

Table 4. Behavior change techniques used in each study.

Publication	BCTTv1 code
Bennell et al. (35, 53)	1.1, 1.4, 2.1, 2.3, 3.1, 4.1, 6.1, 8.1, 12.5(9 BCTs)
Brox et al. (36, 54) and Bohmer et al. (55)	1.1, 1.4, 2.3, 4.1, 6.1, 8.1, 12.5(7 BCTs)
Crawshaw et al. (37) (and online appendix)	4.1, 6.1, 8.1(3 BCTs)
Dickens et al. (38)	1.1, 4.1, 6.1, 8.1, 12.5(5 BCTs)
Elsodany et al. (39)	1.1, 4.1, 6.1, 8.1, 12.5(5 BCTs)
Guitierrez-Espinoza et al. (40)	1.1, 1.4, 2.1(3 BCTs)
Haahr et al. (41) and Haahr and Anderson (56)	4.1, 6.1, 8.1(3 BCTs)
Heron et al. (42) and appendix	1.1, 1.4, 2.3, 4.1, 6.1, 8.1, 12.5. (7 BCTs)
Holmgren et al. (43) and appendix and Hallgren et al. (57)	1.1, 1.4, 2.3, 4.1, 6.1, 8.1, 12.5(7 BCTs)
Ingwerson et al. (44) and Appendix A and B and Ingwerson et al. (58) (protocol)	1.1, 1.4, 2.3, 4.1, 5.1, 6.1, 8.1. (7 BCTs)
Ketola et al. (45)	1.1, 1.4, 4.1, 6.1, 8.1, 12.5(6 BCT’s)
Kukkonen et al. (46, 59)	4.1, 6.1, 8.1. (3 BCTs)
Littlewood et al. (47) and Littlewood et al. (60) (protocol) and Littlewood et al. (61) (protocol)	1.1, 1.2, 1.3, 1.4, 1.7, 2.3, 3.1, 3.3, 4.1, 5.1, 6.1, 8.1, 9.1, 12.5, 13.2 (15 BCTs)
Maenhout et al. (48)	1.1, 1.4, 2.3, 4.1, 6.1, 8.1, 12.5(7 BCTs)
Nejati et al. (49)	1.1, 1.4, 4.1, 6.1, 8.1.(5 BCTs)
Paavola et al. (50) and Paavola et al. (62) and appendix I and II	1.1, 1.4, 4.1(3 BCTs)
Severn et al. (51)	1.1, 4.1, 6.1, 8.1(4 BCTs)

Table 5. Frequency of use of behavior change techniques.

Behavior Change technique	BCTTv1 Code	Frequency (in 17 studies)
Goal Setting (behavior)	1.1	14
Problem solving	1.2	1
Goal Setting (outcome)	1.3	1
Action planning	1.4	11
Review outcome goal(s)	1.7	1
Monitoring of behavior by others without feedback	2.1	2
Self-monitoring of the behavior	2.3	7
Self-monitoring of outcome of outcome(s) of behavior	2.4	1
Social support (Unspecified)	3.1	2
Social support emotional	3.3	1
Instruction on how to perform the behavior	4.1	16
Information about Health Consequences	5.1	2
Demonstration of the behavior	6.1	15
Behavioral practice and rehearsal	8.1	15
Credible source	9.1	1
Adding objects to the environment	12.5	9
Framing / reframing	13.2	1

Table 6. Recommendations for Clinicians and researchers.

Group	Recommendations
Researchers and clinicians	Use a combination of objective, patient self-reported and clinician assessed measures of adherence when prescribing HEPs. Careful consideration of the role of educational interventions, with clarity regarding the purpose of the educational intervention and how it might influence the target behavior. Consideration of the use of a wider variety of BC techniques to promote adherence with HEP. Consideration of the parameters of HEP adherence (for example completed sets, days exercised, days fatigue reached).
Researchers	Define the target adherence for HEP in the study protocol. Define the parameters of exercise adherence in the study protocol (for example completed sets, days exercised, days fatigue reached). Use sensitivity analysis of adherence rates to provide an understanding of the impact of adherence on outcome. Explicit reporting of BC interventions It is strongly recommended that when HEP is compared with an intervention that is more invasive, more costly and less safe, the level of adherence in both arms of the study is recorded and reported with equal rigor.

Table

1	Database	Search term	Results
1	EMBASE	"SHOULDER MUSCLE"/ OR "ROTATOR CUFF"/ OR "INFRASPINATUS MUSCLE"/ OR "SUBSCAPULARIS MUSCLE"/ OR "SUPRASPINATUS MUSCLE"/ OR "TERES MINOR MUSCLE"/ OR "ROTATOR CUFF DISORDERS"/ OR "ROTATOR CUFF DISORDER"/ OR "ROTATOR CUFF IMPINGEMENT"/ OR "ROTATOR CUFF INJURIES"/ OR "ROTATOR CUFF INJURY"/ OR "ROTATOR CUFF LESION"/ OR "ROTATOR CUFF PATHOLOGY"/ OR "SHOULDER IMPINGEMENT SYNDROME"/ OR "SHOULDER INJURIES"/ OR "SHOULDER INSTABILITY"/ OR "SHOULDER JOINT"/ OR "SHOULDER JOINT DISLOCATION"/ OR "SHOULDER LESION"/ OR "SHOULDER LESIONS"/ OR "SHOULDER LUXATION"/ OR "SUBSCAPULARIS MUSCLE"/ OR "TENDON RUPTURE"/ OR "ROTATOR CUFF RUPTURE"/ OR "ROTATOR CUFF RUPTURES"/ OR "ROTATOR CUFF SYNDROME"/ OR "ROTATOR CUFF TEAR"/ OR "ROTATOR CUFF TEAR ARTHROPATHY"/ OR "ROTATOR CUFF TEARS"/ OR "ROTATOR CUFF TENDINOPATHIES"/ OR "ROTATOR CUFF TENDINOPATHY"/ OR "ROTATOR CUFF TENDONITIS"/ OR "SHOULDER INJURY"/ OR "TENDON DISEASE"/	55562
2	EMBASE	"EXERCISE"/ OR "MUSCLE EXERCISE"/ OR "EXERCISE MOVEMENT TECHNIQUES"/ OR "ENDURANCE TRAINING"/ OR "EXERCISE INTENSITY"/ OR "MUSCLE STRENGTH"/ OR "MUSCLE STRENGTHENING"/ OR "MUSCLE STRETCH"/ OR "MUSCLE STRETCHING"/ OR "PHYSIOTHERAPY"/ OR "JOINT MOBILZATION"/ OR "JOINT MOTILITY"/ OR "ENDURANCE"/ OR "PHYSICAL ACTIVITY, CAPACITY AND PERFORMANCE"/ OR "ENDURANCE EXERCISE"/ OR "ENDURANCE EXERCISE TRAINING"/ OR "ISOMETRIC EXERCISE"/ OR "MUSCLE EXERCISE"/ OR "ISOMETRIC TRAINING"/ OR "ISOMETRICS"/ OR "REHABILITATION"/ OR "MUSCLE TRAINING"/ OR "PROPRIOCEPTIVE FEEDBACK"/ OR "SENSORY FEEDBACK"/ OR "ALEXANDER TECHNIQUE"/ OR "MUSCLE ISOMETRIC CONTRACTION"/ OR "MUSCLE ISOMETRIC TENSION"/ OR "MUSCLE ISOTONIC CONTRACTION"/	500512
85	EMBASE	1 AND 2 [DT FROM 1990] [English language] [Languages English] [Humans] [Clinical trials Randomized Controlled Trial]	616

Table

Author	Description from the text for coding		BCTTv1 description	BCTTv1 code
Bennell et al. (35, 53)	Bennell et al. (53) 1. ‘These exercises will be taught and performed during each treatment session’		‘Instruction on how to perform the behavior’ and ‘Behavioral practice and rehearsal’ ‘Demonstration of the behavior’	4.1 8.1 6.1
	2. ‘Resistance for specific [home] exercises will be provided by hand weights or elastic theraband’		‘Adding objects to the environment’	12.5
	3. ‘Compliance will be monitored via a weekly log book completed by the participant’		‘Self-monitoring of the behavior’	2.3
	4. Twice daily in first two weeks and Once a day thereafter (10 reps × 2 using theraband)		‘Goal Setting (behavior)’ and ‘Action planning’	1.1 1.4
	Bennell et al.(35)
	1. ‘We incorporated behavioural strategies, including education….’		Not sufficient to code BCT.	–
	2. ‘Goal setting’		‘Goal Setting’ (behavior)	1.1
	3. ‘Motivation and positive reinforcement’		‘Social support (unspecified)’	3.1
	Posted back to the assessor on a monthly basis and checked for completion		Monitoring of behavior by others without feedback	2.1
Brox et al. (36, 54) and Bohmer et al. (55)	From Brox et al. (54)
	‘Patients were supervised twice weekly’		‘Instruction on how to perform the behavior’ and	4.1
			‘Demonstration of the behavior’ and	6.1
			‘Behavioral practice and rehearsal’	8.1
	‘In addition, three lessons were given on the anatomy and function of the shoulder, pain management, and ergonometrics’.		Not sufficient to code BCT.	–
	Perform one hour daily		Action planning and goal setting	1.1, 1.4
	Brox et al. (36)
	‘A training diary was used to motivate the patients and to guide the progression of the load and the variety of exercises’		‘Self-monitoring of the behavior’	2.3
	Bohmer et al. (55) (published after the initial trial results)		Not sufficient to code BCT	–
	‘three lessons on functional anatomy, active coping, simple ergonomics and the injury mechanism are provided’
	Using a long, light elastic cord		Adding objects to the environment	12.5
Crawshaw et al. (37) (and online appendix)	‘given standard advice to avoid activities that caused or provoked pain; stop all sporting activity and training; avoid using the arm for overhead activities; and avoid repetitive movements or activities that could have contributed to the shoulder symptoms for one week’		Not sufficient to code BCT	–
	‘the therapy log sheet completed by the treating physiotherapist’		Not sufficient to code BCT	–
	Both groups received a programme delivered by a physiotherapist …. … the treating physiotherapists chose …. exercises for each patient from … 23 exercises. Exercises were progressive as deemed appropriate by the treating physiotherapist.		‘Instruction on how to perform the behavior’ and ‘Behavioral practice and rehearsal’	4.1 6.1
			‘Demonstration of the behavior’	8.1
Dickens et al. (38)	‘asked to complete the exercises at least twice a day’		‘Goal Setting (behavior)’	1.1
	‘Exercises were taught to all subjects’		‘Instruction on how to perform the behavior’ and ‘Behavioral practice and rehearsal’	4.1 8.1
			‘Demonstration of the behavior’	6.1
	‘progressed to involve strengthening of infraspinatus, subscapularis and teres minor’		Not sufficient to code BCT	–
	‘progressed to inner range, through range, outer range and into functional positions’		Not sufficient to code BCT	–
	‘patients were given Theraband’		‘Adding objects to the environment’	12.5
Elsodany et al. (39)	‘using a Thera-Band’		‘Adding objects to the environment’	12.5
	‘Exercises were taught by a physiotherapist’		‘Instruction on how to perform the behavior’ and ‘Behavioral practice and rehearsal’	4.1 8.1
			‘Demonstration of the behavior’	6.1
	‘Asked to perform the exercises daily at home’		‘Goal Setting (behavior)’	1.1
Guitierrez-Espinoza et al. (40)	‘Received advice and an exercise program to perform at home’		Not sufficient to code BCT	–
	‘Each movement exercise was repeated 10 times, and each stretching exercise 3 times, twice daily at home’		Goal setting	1.1
	‘To monitor the adherence at home, the participants reviewed the exercise program with the physiotherapist once a week,….’		Action Planning	1.4
	‘Addressing questions regarding the exercises’		Monitoring of behavior by others without feedback	2.1
			Not sufficient to code BCT	–
Haahr and Anderson (56) and Haahr et al. (41)	‘The patients were encouraged to continue to do active exercises at home on a daily basis’ [for 12 weeks then 2-3 times per week]		Not sufficient to code BCT (goal setting or action planning)	–
	The physiotherapeutic treatment consisted of 19 sessions, each lasting up to 60 min … active training of the periscapular muscles (rhomboid, serratus, trapezoid, levator scapulae, and pectoralis minor muscles) and strengthening of the stabilizing muscles of the shoulder joint (the rotator cuff).		‘Instruction on how to perform the behavior’ and ‘Behavioral practice and rehearsal’	4.1 8.1
			‘Demonstration of the behavior’	6.1
Heron et al. (42) and appendix	‘Participants completed three sets of 10 repetitions, twice per day’		‘Goal Setting (behavior)’ and ‘Action planning’	1.1 1.4
	‘Participants attended three appointments over 6 weeks, with the exercises progressed in difficulty at each appointment’, ‘all participants were taught stretching exercises for the anterior and posterior shoulder capsule’		‘Behavioral practice and rehearsal’	4.1 6.1
			‘Demonstration of the behavior’	8.1
	‘Diagrams were provided to all patients demonstrating the exercise techniques’		‘Instruction on how to perform the behavior’	8.1
	‘using rubber resistance bands. The length of each band was adjusted for each patient’		‘Adding objects to the environment’	12.5
	‘Participants also completed an exercise diary reporting how frequently they performed the exercises’		‘Self-monitoring of the behavior’	2.3
Holmgren et al. (43) and appendix and Hallgren et al. (57)	‘Both groups received thorough information about their shoulder condition, ergonomical advice, and correction of their posture’		Not sufficient to code BCT	–
	‘An exercise diary was used in both groups to monitor adherence’		‘Self-monitoring of the behavior’	2.3
	‘Each strengthening exercise was repeated 15 times in three sets twice daily for eight weeks’, (x1/day from 8 weeks).		‘Goal Setting (behavior)’ and ‘Action planning’	1.1 1.4
	‘The exercises were individually adjusted and progressed with increased external load by using weights and elastic rubber band at the physiotherapist visits once every other week during the whole rehabilitation period’.		‘Behavioral practice and rehearsal’	4.1
			‘Demonstration of the behavior’	6.1
			‘Instruction on how to perform the behavior’	8.1
	‘progressed with increased external load by using weights and elastic rubber band’		‘Adding objects to the environment’	12.5
Ingwerson et al. (44) and Appendix A and B and Ingwerson et al. (58) (protocol)	Ingwerson et al. (44)
	‘seen by a physical therapist for initial exercise instruction (60 min) in week 1 and for supervised exercise sessions (30 min) in weeks 2-4, 6, and 9′		‘Behavioral practice and rehearsal’	4.1
			‘Demonstration of the behavior’	6.1
			‘Instruction on how to perform the behavior’	8.1
	Provided with instructions/manual (see Appendix A and B)		‘Instruction on how to perform the behavior’	8.1
	“instructed to perform home-based exercises 3 times per week’, ‘[4 exercises] repeat the exercise 20 to 25 times. The exercise is carried out for 3 sets’		‘Goal Setting (behavior)’ and ‘Action planning’	1.1 1.4
	‘Patients were instructed to complete an exercise diary’		‘Self-monitoring of the behavior’	2.3
	Appendix A and B ‘Why We Believe This Training Works. The training is believed to have a positive effect on the muscles called the rotator cuff…..’		‘Information about Health Consequences’	5.1
	‘When you exercise, you may experience slight increased pain in the shoulder. This is normal and OK’		Insufficient to code BCT 13.2 ‘Framing / reframing’	–
	Ingwerson et al. (58) ‘The patients will be given a copy of the DVD and an exercise brochure to enable them to follow the instructions and exercises at home’		‘Instruction on how to perform the behavior’	8.1
Ketola et al. (45)	‘Information was first given by a trained physiotherapist’		Insufficient to cade a BCT	–
	‘Supervised exercise treatment’		‘Behavioral practice and rehearsal’	4.1,
			‘Demonstration of the behavior’	6.1
			‘Instruction on how to perform the behavior’	8.1
	‘at least four times a week using nine different exercises with 30 to 40 repetitions three times’		‘Goal Setting (behavior)’ and ‘Action planning’	1.1 1.4
	‘Elasticated stretch bands and light weights were used in training’		‘Adding objects to the environment’	12.5
	‘[Physiotherapy session were] continued until the patient and the therapist considered that the patient was able to maintain the established level independently’		Insufficient to cade a BTC	–
Kukkonen et al. (46, 59)	Kukkonen et al. (46)
	No information regarding which exercises were prescribed, the frequency or dose.		Insufficient to cade a BCT	–
	‘gave the patient written information and guidance for exercises to be conducted at home’		‘Instruction on how to perform the behavior’	4.1
	‘referred for ten sessions of physiotherapy in an outpatient health care facility where their progress was monitored’		Insufficient to cade a BCT	–
	Kukkonen et al. (59)
	‘gave the patient written information and guided the patient in how to perform a standardized training exercise protocol at home’		‘Instruction on how to perform the behavior’	8.1
			‘Behavioral practice and rehearsal’	6.1
			‘Demonstration of the behavior’	4.1
Littlewood et al. (47) and Littlewood et al. (60) (protocol) and Littlewood et al. (61) (protocol)	Littlewood et al. (47)
	‘exercise adherence data in the form of an exercise diary were completed during the intervention period’		‘Self-monitoring of the behavior’	2.3
	[single exercise] ‘against gravity, a resistive therapeutic band or hand weight over three sets of 10 to 15 repetitions twice per day’		‘Goal Setting (behavior)’ and ‘Action planning’	1.1 1.4
			Adding objects to the environment	12.5
	Littlewood et al. (61) (protocol)
	‘The patient is encouraged to communicate their understanding of the problem and the therapist is encouraged to frame the discussion from the perspective that the muscles and tendons are deconditioned (or weakened or lacking fitness) and need a progressive programme of exercise to restore condition and function. Description of tissue based pathology, e.g. rotator cuff tear, is avoided, or challenged’		‘Framing / reframing’	13.2
			‘Information about Health Consequences’	5.1
			‘Credible source’	9.1
	‘reliance is placed upon the development of a therapeutic alliance where doubts and concerns can be expressed by the patient and reassurance offered by the physiotherapist’		‘Social support’ (Unspecified)	3.1
			Social support emotional	3.3
	‘Observe the therapist undertaking the exercise’		‘Demonstration of the behavior’	6.1
	‘subsequently model their behavior on that of the therapist whilst repeating the exercise themselves’		‘Behavioral practice and rehearsal’	8.1
	‘re-enforced by a diagram, drawn by the patient, on an exercise diary which will serve as a visual memory stimulus’		‘Instruction on how to perform the behavior’	4.1
	‘goals are set using the patient specific functional scale’		Goal Setting (outcome)	1.3
	[Outcome goal (based on PSFS)] ‘is monitored, discussed at follow-up appointments and new goals set as appropriate’		‘Review outcome goal(s)’	1.7
	‘Following this the patients are encouraged to consider any barriers to implementation. Some pragmatic solutions to common problems, particularly time limitations, are factored in to the intervention’		‘Problem solving’	1.2
	‘Barriers to implementations are also raised and discussed with reference to the exercise diary at subsequent follow-up appointments’		Insufficient to code ‘discrepancy between current behavior and goal’ BCT 1.6	–
	Littlewood et al. (60) (protocol)
	3 sets of 10 to 15 repetitions completed twice per day.		‘Goal Setting (behavior)’ and ‘Action planning’	1.1 1.4
Maenhout et al. (48)	(TT) Each exercise was performed once a day for 3 sets of 10 repetitions.		Goal setting (behavior) and Action Planning	1.1 1.4
	(ET & TT) Three sets of 15 repetitions were performed twice a day		Goal setting (behavior) and Action Planning	1.1 1.4
	‘All patients completed a daily log-book to record pain during the exercises and adverse events’		Self-monitoring of the behavior	2.3
	‘These sessions were aimed at correcting performance of the exercises’		‘Instruction on how to perform the behavior’ and ‘Behavioral practice and rehearsal’	4.1 8.1
			‘Demonstration of the behavior’	6.1
	‘Emphasizing the importance of adherence to the home exercises’		Insufficient to code BCT
	[Provided patients with] ‘Information on basic anatomy of the shoulder (humerus, glenoid and scapula and position of the rotator cuff tendons) and pathology of subacromial impingement’		Insufficient to code BCT	–
	‘With a theraband’		Adding objects to the environment	12.5
Nejati et al. (49)	‘performed using an elastic band or a 1- to 1.5-kg weight in 3 sets of 10 repetitions each’		Goal setting (behavior) and Action Planning	1.1 1.4
	‘Received supervised exercise therapy in the hospital once a week for 3 months’		‘Instruction on how to perform the behavior’ and ‘Behavioral practice and rehearsal’	4.1 6.1 8.1
	‘A number of images showing how each exercise should be performed were also provided’		‘Instruction on how to perform the behavior’	4.1
	‘exhibited good compliance with treatment throughout the study period: 68.96% of the patients in the exercise group attended the 3-month course of exercise therapy (at home and in the hospital)’		Insufficient to code BCT	–
Paavola et al. (62) and Paavola et al. (50) and appendix I and II	Paavola et al. (62)
	‘Using a standardised protocol that relied primarily on daily home exercises as well as 15 visits to an independent physiotherapist’		Insufficient to code BCT	–
	‘Supervised, progressive, individually designed physiotherapy was started within two weeks of randomisation,’		Insufficient to code BCT	–
	Repeat 3 × 15-25 times.		Goal setting (behavior) and Action Planning	1.1 1.4
	Included 15 visits to an independent physiotherapist for guidance and monitoring of the progress		Not sufficient to code BCT	–
	‘the detailed exercise therapy protocol is available in appendix 1′ [formatting suggests this was provided as a patient handout]		‘Instruction on how to perform the behavior’	4.1
	Paavola et al. (50)
	The regimen was based on daily home exercises, and included 15 visits to an independent physiotherapist for guidance and monitoring of the progress,		Not sufficient to code BCT	–
Severn et al. (51)	‘advised to perform a home exercise program with same exercises on their own 3 times /day for the other days’		Goal setting (behavior)	1.1
	received [an exercise protocol] 3 sessions (an average of 30 min per session) per week for 12 weeks.		‘Instruction on how to perform the behavior’ and ‘Behavioral practice and rehearsal’	4.1 6.1
			‘Demonstration of the behavior’	8.1
In the description of interventions use of the phrases; ‘Supervised exercise session’, ‘Attended exercise sessions’, ‘Supervised’, ‘Taught’ were deemed sufficient to code for ‘Instruction on how to perform the behavior’ (1.1) and ‘Behavioral practice and rehearsal’ (6.1) and ‘demonstration of the behavior’ (8.1). Use of the terms; ‘physiotherapy sessions’, ‘physiotherapy’ and ‘individual sessions’ were deemed insufficient to code for BCT’s.
Abbreviations used; BCTTv1 = behavior change technique taxonomy (version 1) BCT = behavior change technique		Kg = kilo TT = traditional training ET = heavy load eccentric training PSFS = patient specific functional scale

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