Manual Therapy xxx (2015) 1e9

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

Does training frequency and supervision affect compliance,

performance and muscular health? A cluster randomized
controlled trial
Tina Dalager a, *, Thomas G.V. Bredahl a, Mogens T. Pedersen b, Eleanor Boyle a,
Lars L. Andersen c, Gisela Sjøgaard a
a
Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
b
Department of Nutrition, Exercise and Sports, University of Copenhagen, Denmark
c
National Research Centre for the Working Environment, Copenhagen, Denmark

a r t i c l e i n f o a b s t r a c t

Article history: The aim was to determine the effect of one weekly hour of specific strength training within working
Received 3 September 2014 hours, performed with the same total training volume but with different training frequencies and du-
Received in revised form rations, or with different levels of supervision, on compliance, muscle health and performance, behavior
30 December 2014
and work performance.
Accepted 22 January 2015
In total, 573 office workers were cluster-randomized to: 1WS: one 60-min supervised session/week,
3WS: three 20-min supervised sessions/week, 9WS: nine 7-min supervised sessions/week, 3MS: three
Keywords:
20-min sessions/week with minimal supervision, or REF: a reference group without training. Outcomes
Workplace intervention
Strength training
were diary-based compliance, total training volume, muscle performance and questionnaire-based
Exercise self-efficacy health, behavior and work performance. Comparisons were made among the WS training groups and
Physical activity between 3WS and 3MS. If no difference, training groups were collapsed (TG) and compared with REF.
Results demonstrated similar degrees of compliance, mean(range) of 39(33e44)%, and total training
volume, 13.266(11.977e15.096)kg. Musculoskeletal pain in neck and shoulders were reduced with
approx. 50% in TG, which was significant compared with REF. Only the training groups improved
significantly their muscle strength 8(4e13)% and endurance 27(12e37)%, both being significant
compared with REF. No change in workability, productivity or self-rated health was demonstrated.
Secondary analysis showed exercise self-efficacy to be a significant predictor of compliance.
Regardless of training schedule and supervision, similar degrees of compliance were shown together
with reduced musculoskeletal pain and improved muscle performance. These findings provide evidence
that a great degree of flexibility is legitimate for companies in planning future implementation of
physical exercise programs at the workplace.
ClinicalTrials.gov, number NCT01027390.
© 2015 Elsevier Ltd. All rights reserved.

1. Introduction
The workplace is a potential arena for increasing health
enhancing physical exercise, as it provides an opportunity to reach
* Corresponding author. Department of Sports Science and Clinical Biomechanics,
Campusvej 55, 5230 Odense M, Denmark. Tel.: þ45 28 68 02 45.
E-mail addresses: tdalager@health.sdu.dk (T. Dalager), tbredahl@health.sdu.dk
(T.G.V. Bredahl), mtpedersen@nexs.ku.dk (M.T. Pedersen), eboyle@health.sdu.dk
(E. Boyle), lla@arbejdsmiljoforskning.dk (L.L. Andersen), gsjogaard@health.sdu.dk
(G. Sjøgaard).
a large and diverse population and engage individuals who might
not otherwise have time and/or who face other obstacles to
participate in physical exercise training (Proper et al., 2003;
Robroek et al., 2009). High prevalence of musculoskeletal pain in
the neck and shoulders has been reported among workers, and
physical exercise training has proven to reduce pain effectively
(Proper et al., 2003; Blangsted et al., 2008; Andersen et al., 2008b,
2011; Coury et al., 2009; Zebis et al., 2011). Besides individual
health benefits for the employee per se, physical exercise at the
workplace also generates organizational benefits such as improved
employee performance and reduced disability costs (Pronk et al.,
2004; Conn et al., 2009; Cancelliere et al., 2011).

http://dx.doi.org/10.1016/j.math.2015.01.016
1356-689X/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Dalager T, et al., Does training frequency and supervision affect compliance, performance and muscular
health? A cluster randomized controlled trial, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.01.016
2 T. Dalager et al. / Manual Therapy xxx (2015) 1e9
However, the effectiveness of workplace health interventions
depends on compliance by the target population complying with
the offered intervention (Robroek et al., 2009; Rongen et al., 2014).
A physical exercise program should be feasible to incorporate into
the workplace's normal routines as this has a marked effect on
compliance (Proper et al., 2003; Rongen et al., 2014). Several studies
have already highlighted the fact that compliance to physical ex-
ercise interventions (percentage of completed training sessions) is
challenging and report highly different levels: 35% (Blangsted et al.,
2008) and up to 85% (Andersen et al., 2008b). Poor compliance will
impair the efficacy of the training and thereby also the identified
health outcomes in terms of e.g. improved musculoskeletal health
(Andersen et al., 2013; Pedersen et al., 2013b). Thus, it is of great
importance to study factors influencing compliance. A recent sys-
tematic review has pointed towards 1) timewise planning of the
exercise as well as 2) supervision of the exercise training (Coury
et al., 2009).
Intervention studies often have a planned training frequency of
three times per week for a duration of 20 min per workout with a
total of 1 h per week (Proper et al., 2003; Blangsted et al., 2008;
Andersen et al., 2008b; Zebis et al., 2011). However, physiolog-
ical adaptations and reduced musculoskeletal pain have been
attained both in response to long exhausting bouts of strength
training with several days of rest in between, and in response to
shorter bouts performed several times a week (Candow and Burke,
2007; Coury et al., 2009; Andersen et al., 2011). Knowledge
regarding the significance of training frequency is important since
fewer constraints on specific numbers and durations of training
sessions per week will allow for more flexibility in the planning of
workplace physical exercise training, which per se may increase
compliance.
Strong indications of higher effectiveness of supervised
compared with unsupervised training has been reported (Coury
et al., 2009). However, a recent study demonstrated clinically
relevant effects of strength training on musculoskeletal pain in the
neck and shoulders without the use of supervision besides the first
training session (Andersen et al., 2011). Likewise, other studies
report no significant differences between supervised and unsu-
pervised training, in relation to improved cardiometabolic risk
factors as well as reduced low back pain (Hartvigsen et al., 2010;
Stefanov et al., 2013). Hence, existing evidence does not demon-
strate a clear consensus whether or not supervision is pertinent. In
practice, supervision of exercise training at the workplace may
impair the flexibility of individually scheduling the training in
relation to other obligations during a workday, and therefore per se
may impair compliance.
In addition to optimal planning and implementation of training
schedules, it is essential to identify characteristics of potential
participants with poor compliance (Jordan et al., 2010; Rongen
et al., 2014). Exercise self-efficacy has in a number of studies been
identified as an important factor regarding participation in physical
exercise training (Kaewthummanukul and Brown, 2006; Fletcher
et al., 2008; Andersen, 2011; Pedersen et al., 2013a; Rongen et al.,
2014). By identifying this, it allows us to specifically target such
individuals, for particular support in the enrollment and thus
improve compliance.
The primary aim of the present study was to determine a
possible effect of different scheduled training frequencies on
compliance when the same total training volume per week was
planned by adjusting the duration per training session. Likewise,
the effect of different levels of supervision on compliance was
studied, when offering the same training schedule and total
training volume per week. In addition, baseline levels of variables
such as exercise self-efficacy and self-rated health were analyzed
Please cite this article in press as: Dalager T, et al., Does training frequency and supervision affect compliance, performance and muscular
health? A cluster randomized controlled trial, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.01.016
for predictive values of compliance to the strength training
intervention.
The second aim was to analyze the effect of different patterns in
training frequency, as well as supervision, on: 1) health outcome
variables such as musculoskeletal pain symptoms and general
health behavior and work performance outcomes; 2) muscle per-
formance outcome variables such as maximal muscle strength and
strength-endurance.
2. Methods
2.1. Study design
The present paper represents secondary analyses of a cluster
randomized controlled trial that was conducted in Denmark from
January to June 2010 (Andersen et al., 2010). Primary analyses e
change in neck and shoulder pain - have been published previously
(Andersen et al., 2012; Gram et al., 2014). Office workers were
recruited from 12 geographically different units located in all major
cities throughout Denmark, balanced according to the population
density with around half in the Copenhagen area and half in other
parts of Denmark. Details regarding recruitment procedure have
been described previously (Andersen et al., 2010). The study com-
plies with the CONSORT statements.
2.2. Subjects and recruitment
In short, workers who worked 17 h per week within the office
environment were invited by e-mail containing a link to an
internet-based questionnaire regarding working conditions, health
behavior, musculoskeletal pain, and physical activity level. A total of
2114 employees were invited, 47% replied to the questionnaire, and
a total of 27% of the invited employees (351 females/222 males)
were cluster randomized (Fig. 1). All study participants gave their
written informed consent to participate in the study. The local
ethics committee approved the study protocol (H-C-2008-103), and
the trial was registered at ClinicalTrials.gov, number NCT01027390.
Exclusion criteria were a) hypertension (systolic blood pressure
>160 mmHg or diastolic blood pressure >100 mmHg), b) cardio-
vascular diseases, c) symptomatic herniated disc or severe disor-
ders of the cervical spine, d) postoperative conditions in the neck
and shoulder region, e) history of severe trauma or other serious
disease, and f) pregnancy. Exclusion was based on the question-
naire replies.
2.3. Cluster-randomization and blinding
Randomization was performed on a cluster level, for details see
(Andersen et al., 2010). All examiners performing the muscle per-
formance tests were blinded to group allocation as well as to the
baseline values at follow-up. The trainers managing the supervision
were blinded to outcome measures. A blinded statistician per-
formed all data analysis.
2.4. Intervention
The four training groups were scheduled to perform the same
total amount of exercises and repetitions per week - i.e. an equal
training volume - for a total of 1 h per week for 20 weeks during
working-hours. Each week, nine exercises were to be conducted.
Each exercise was estimated to last a maximum of 7 min. The
training groups differed on the frequency and the duration of
each single training session, as well as, the level of supervision:
1WS had one 60-min training session per week with supervision
 T. Dalager et al. / Manual Therapy xxx (2015) 1e9 3

Fig. 1. Flow-chart of study participants. The flow-chart displays the flow of study participants from baseline to follow-up. Study participants who replied to baseline questionnaire
(BQ) were randomized to one of the four training groups (1WS, 3WS, 9WS, 3MS) or the reference group (REF). Hereafter, study participants were categorized as: Drop-outs e study
participants from whom we do not have training diary or follow-up questionnaire. Training diary (TD) e study participants from whom we do have minimum one registered load in
the training diary. Lost-to-follow-up e study participants in the training groups from whom we have minimum one registered load in the training diary but no follow-up
questionnaire. Compliant participants (C) e study participants in the training groups from whom we have minimum one registered load in the training diary and follow-up
questionnaire (n ¼ 65 þ 76 þ 52 þ 60 ¼ 253). For study participants in REF, all who replied to the follow-up questionnaire were defined as complaint study participants (n ¼ 83).
Non-compliant participants e study participants in the training groups with no registered load in the training diary but whom we have follow-up questionnaire on.

where all nine exercises were conducted; 3WS had three 20-min
training sessions per week with supervision where three exer-
cises were conducted at each training session; 9WS had nine 7-
min training sessions per week with supervision where one ex-
ercise was conducted at each training session, and 3MS had three
20-min training sessions per week with minimal supervision and
where three exercises were conducted at each training session.
The three WS training groups received supervision by experi-
enced trainees for half of their training sessions. Minimal su-
pervision consisted of careful instructions given only during the
initial two weeks.
The specific strength training exercises were performed with
dumbbells and consisted of five dynamic exercises: 1) front raise, 2)
lateral raise, 3) reverse flies, 4) shrugs, and 5) wrist extension. Each
training session started by warming up for 10 repetitions with
loadings of 50% of one repetition maximum (RM) for each respec-
tive exercise of that session. Training intensity was progressively
increased over the weeks according to the principle of progressive
overload and periodization (American College of Sports, 2009), and
dumbbell weight increased from 20RM at the beginning of the
intervention period to 8RM during the later phase (Andersen et al.,
2010).
Throughout the training period, study participants filled out a
group-specific training diary, which also held information on how
to progress in weight during the 20-week intervention. The refer-
ence group did not receive any training throughout the interven-
tion period, but was informed that they would be offered
instruction to the training exercises after the 20-week period
(Andersen et al., 2010).
2.5. Data collection
2.5.1. Training diary
The study participants recorded for each training session the
load and number of training sets completed for each exercise. At
the end of the intervention, the hard copies of the training diaries
were scanned and data electronically entered into an Excel
spreadsheet. Quality control of the scanning was performed
continuously. Additionally the training diaries were systematically
checked for outliers and corrected with reference to the hard copy.
Compliance according to training diary, CD, was calculated as the
proportion of training sets completed out of the total possible
number of 420 training sets.
Taking a break of three weeks or more from the training inter-
vention was regarded to result in stagnation or even decrease in
muscle strength or strength-endurance (Mujika and Padilla, 2001).
First quitting time was accordingly defined as the first time a study
participant missed three continuous weeks of training.
Total training volume was calculated as the total accumulated
weight lifted (load  repetitions) summed for all sets performed
per week as well as for the whole training period.
Load progression was calculated as the weekly average load
summed for all five exercises throughout the 20-weeks for each
study participant.

Please cite this article in press as: Dalager T, et al., Does training frequency and supervision affect compliance, performance and muscular
health? A cluster randomized controlled trial, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.01.016
4 T. Dalager et al. / Manual Therapy xxx (2015) 1e9
2.5.2. Questionnaire
The questionnaire contained the following health variables:
self-rated health and musculoskeletal pain symptoms; behavior
variables: exercise self-efficacy and readiness to change; and work
performance variables: workability and productivity. At follow-up
the study participants in the training groups additionally replied
to a question about compliance to the training protocol.
Self-rated health was rated on a 5-step ordinal scale: How do you
perceive your overall health? The rating was: 1) excellent, 2) very
well, 3) well, 4) less well, and 5) poor and was dichotomized into
low (option 4e5) and high (option 1e3) for analysis (Ware and
Gandek, 1998).
Musculoskeletal pain symptoms were assessed by the Nordic
questionnaire on pain symptoms in the neck and shoulders during
the last three months. The intensity of pain was rated on a 10-point
numerical rating scale ranging from 0 (no pain) to 9 (worst possible
pain). The following question was answered: On average, how
intense was your pain in [name of body part] during the last three
months? (Kuorinka et al., 1987).
Exercise self-efficacy was summed of six sub-questions: I feel
convinced that I am able to exercise three times or more a week
with duration of at least 20 min at a time even though … (1) I am
under a lot of stress, (2) I feel I don't have the time, (3) I have to
exercise alone, (4) I don't have access to exercise equipment, (5) I
am spending time with friends or family who do not exercise, and
(6) Its raining or snowing. Questions were rated on a 5-step
ordinal scale (score): 1) not at all confident, 2) a little confident,
3) more or less confident, 4) very confident, 5) and completely
confident (Marcus et al., 1992; Benisovich et al., 1998). In the
analysis, exercise self-efficacy was dichotomized into low (score
6e22) and high (score 23e30).
Readiness to change in relation to physical activity was rated on
a 5-step ordinal scale: Do you exercise regularly, three to five times
per week for 20e60 min per training session? The scores were: (1)
yes, I have been for more than six months, (2) yes I have been for
less than six months, (3) no, but I intend to within the next 30 days,
(4) no, but I intend to within the next six months, and (5) no, and I
do not intend to within the next six months (Marcus et al., 1992;
Sarkin et al., 2001). In the analysis, readiness to change was
dichotomized into low (score 3e5) and high (score 1e2).
Workability was rated on an 11-step numerical rating scale as
one item in the work ability index: Imagine that your workability is
worth 10 points when it is the best. How many points would you
give your current workability? The rating went from 0 (unable to
work) to 10 (best workability) (Ilmarinen et al., 1997).
Productivity was rated on an 11-step numerical rating scale:
How do you perceive your overall productivity the last four weeks?
The rating went from 0 (the worst a worker could do) to 10 (the best
a worker in the same job could do) (Pronk et al., 2004).
Self-reported compliance, CQ, was rated on a 6-step nominal
scale: The offer to you as study participant was that you were
allowed to exercise 1 h weekly within your working hours. To what
extent have you used this offer? The rating was as followed: (1)
regularly 40e60 min a week; (2) regularly 20e40 min a week; (3)
irregularly, but minimum 80 min a month; (4) irregularly, but
minimum 40e60 min a month; (5) I stopped participating [write
date], and (6) I have not used the offer regarding training 60 min a
week (Blangsted et al., 2008).
2.5.3. Muscle performance test
A representative and equally distributed subsample across the
five intervention groups of approximately one third of the ran-
domized study participants was tested for: 1) Maximal muscle
strength (1RM) assessed as 1RM for bilateral lateral raise (i.e. from
neutral position to 90 abduction in the scapula plane), 2) Strength-
Please cite this article in press as: Dalager T, et al., Does training frequency and supervision affect compliance, performance and muscular
health? A cluster randomized controlled trial, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.01.016
endurance assessed with a submaximal load of one kg less than
1RM at baseline. The study participant performed as many repeti-
tions as possible with proper technique, and without rest or breaks
in between repetitions (Andersen et al., 2010).
2.6. Statistics
Comparison between training groups was performed among
those with supervision but different training schedules (1WS vs.
3WS vs. 9WS), and between those with the same training schedule
but different levels of supervision (3WS vs. 3MS). In case of no
differences between training groups, these were collapsed, TG, and
tested against the REF group.
Differences in the baseline characteristics were examined by
either chi-square test or one-way analysis of variances with Bon-
ferroni post hoc test based on all baseline questionnaire replies
(BQ). Sub-group analysis was performed for study participants also
filling in a training diary (TD), and filling in a training diary as well
as responding to the follow-up questionnaire (C). Analyses of
intervention effects, within and between groups were based on
compliant study participants (C) only. Analyses of CD, total training
volume, and load progression were based on the total number of
training diaries (TD).
To analyze for changes from baseline to follow-up we used
paired sample T-test or McNemar test, and a one-way analysis of
variances was performed to identify differences in the changes
across groups (interval scale data). The KruskaleWallis test was
performed instead, when Levene's test of homogeneity of variance
showed significance, and multiple ManneWhitney tests were
performed to locate the differences.
A multilevel linear regression analysis was conducted to deter-
mine differences in load progression over the 20-week period
across training groups. Furthermore, multivariable linear regres-
sion analysis with backward elimination procedure was performed
to test baseline variables' association with CD. A KaplaneMeier
curve was constructed to determine if there was any difference
across training groups in first quitting time. In addition, to test the
reliability of CQ, total amount of completed training sets according
to training diary was correlated (Spearman's rho) to average weekly
compliance according to the follow-up questionnaire (CD).
SPSS version 21 and Stata version 12SE were used. For all ana-
lyses, a two-tailed significance level of 0.05 was considered statis-
tically significant. However, when performing multiple
comparisons the level of significance was adjusted according to the
number of comparisons.
3. Results
3.1. Study population
At baseline there were no differences in the demographics, self-
rated health, musculoskeletal pain symptoms, workability or pro-
ductivity across the five groups or the subgroups C and TD (Table 1).
However, in BQ 1WS, 37.9% of the study participants reported high
exercise self-efficacy, which was significantly smaller than the
proportion in BQ 9WS (67.0%). Further, both BQ 1WS and BQ REF
had a significantly smaller proportion of study participants
reporting high readiness to change compared with BQ 9WS (48.3%
and 52.5% vs. 73.6%).
Study participants randomized to 9WS were more likely to
drop-out compared with 1WS (28.3% vs. 11.2%) but not compared
with 3WS (15.7%). No difference was shown between 3WS and 3MS
(15.7% vs. 20.2%). A significantly higher proportion of male study
participants dropped out compared with female study participants
(23.4% vs. 15.7%).
 T. Dalager et al. / Manual Therapy xxx (2015) 1e9 5

For lost to follow-up, no difference across training groups was

Data presented as mean values (SD). BQ ¼ Baseline questionnaire; C ¼ Compliant study participants; TD ¼ study participants who filled in a training diary. Self-rated health, exercise self-efficacy and readiness to change are
46.9 (10.0)
81.3 (15.6)
175.5 (9.8)
found (1WS ¼ 26.7%; 3WS ¼ 19.0%; 9WS ¼ 19.8%; 3MS ¼ 27.4%).

26.3 (4.6)

3.3 (2.3)
1.9 (2.4)
1.6 (2.0)

9.9 (1.0)
9.2 (1.3)
Female study participants were more likely to be lost to follow-up

89.2

48.2
51.8
compared with male study participants (22.5% vs. 14.0%), and the
55
C
study participants lost to follow-up were significantly younger
45.6 (10.0)
80.4 (15.6)
175.3 (9.4)
26.1 (4.5)
(approx. 2 years).

3.2 (2.3)
2.0 (2.4)
1.5 (1.9)

9.9 (1.1)
9.1 (1.4)
91.1

47.5
52.5
REF

BQ

58

3.2. Training diary

76.9 (16.0)
172.7 (9.7)
44.7 (10.8)

25.7 (4.1)

3.4 (2.4)
2.0 (2.4)
1.7 (2.2)

9.8 (1.2)
9.1 (1.4)
The total training volume of weights lifted per person for the
91.5

45.7
59.6
whole training period was for all four training groups as a mean
TD

65

13.266 kg (SD 11.843 kg) and ranged from 11.977 kg (SD 12.144 kg) to
46.6 (10.0)
78.4 (14.5)
174.3 (9.6)
25.7 (3.9)

15.096 kg (SD 12.810 kg), and with no difference among 1WS, 3WS
3.5 (2.5)
2.2 (2.5)
1.7 (2.2)

9.8 (1.4)
9.1 (1.4)
and 9WS or between 3WS and 3MS (Fig. 2). Fig. 3A depicts the weekly
91.7

48.3
63.3
58

total training volume of weights lifted, which did not show any dif-
C

ferences across training groups. Also, the average of the weekly load
174.6 (10.2)
45.1 (10.7)
78.6 (15.9)

25.6 (3.8)

lifted for all exercises, throughout the 20-weeks, was similar across
3.2 (2.4)
2.0 (2.4)
1.6 (2.3)

9.8 (1.2)
9.1 (1.4)

training groups (Fig. 3B), hence load progression was similar. This
3MS

91.9

47.6
58.1
BQ

58

was also present when examined for each type of exercise.

CD showed no difference among 1WS (40%), 3WS (39%) and 9WS
74.9 (13.2)
173.4 (9.1)
45.4 (9.5)

24.8 (3.3)

10.1 (1.0)
3.1 (2.3)
1.9 (1.9)
1.9 (2.2)

9.5 (1.1)

(44%) or between 3WS and 3MS (39% versus 33%). A multivariable

93.2

65.8
69.9

linear regression analysis determined that being female or rating

TD

64

exercise self-efficacy high at baseline was positively associated with

73.5 (13.9)
172.3 (9.1)

compliance.
45.6 (9.4)

24.6 (3.4)

10.1 (1.0)
3.1 (2.4)
1.9 (1.9)
2.1 (2.4)

9.5 (1.1)

The median first quitting time ranged from five weeks for the
94.2

63.5
67.3

3MS group to eight weeks for the 3WS (Fig. 4). The 95% confidence
69
C

interval for each group was: 1WS (6e8 weeks), 3WS (6e13 weeks),
77.7 (14.7)
174.8 (9.1)
45.4 (9.7)

25.3 (3.7)

9WS (4e11 weeks), and 3MS (4e7 weeks).

3.0 (2.3)
1.9 (2.2)
1.7 (2.2)

9.9 (1.1)
9.4 (1.1)
9WS

92.5

67.0
73.6
BQ

58

3.3. Change in health, behavior and work performance outcomes

46.4 (10.3)
73.4 (16.3)
173.0 (9.8)
24.3 (3.7)

3.3 (2.4)
2.1 (2.3)
1.7 (2.3)

9.9 (1.1)
9.2 (1.1)

For compliant study participants (C), no change from baseline to

97.0

48.0
58.0

follow-up was present for self-rated health, exercise self-efficacy,

TD

69

workability or productivity for any of the five groups. However,

presented only as % of high score. Pain is presented as pain intensity (body region) previous three months.
173.8 (10.0)
46.7 (10.3)
73.6 (15.2)

TG significantly increased the percentage of low exercise self-

24.2 (3.2)

3.0 (2.4)
1.8 (2.1)
1.4 (2.0)

9.9 (1.0)
9.3 (1.1)

efficacy: 47.7% at baseline to 56.4% at follow-up. Regarding readi-

98.7

55.3
60.5

ness to change, only the REF group significantly increased the

65
C

percentage of high readiness to change: 52.0% at baseline to 67.5%

46.5 (10.5)
74.7 (17.5)
173.1 (9.7)
24.7 (4.3)

at follow-up.
3.1 (2.4)
2.3 (2.4)
1.8 (2.3)

9.9 (1.1)
9.3 (1.1)

Musculoskeletal pain decreased significantly with delta values

3WS

97.6

50.0
59.5
BQ

(post minus pre values) and 95% CI in all five groups for the neck:
69

1WS ¼ 1.51 (0.97 to 2.05), 3WS ¼ 1.51 (0.92 to 2.10),

46.2 (10.2)
76.7 (15.6)
173.8 (9.3)
25.2 (4.1)

9WS ¼ 1.54 (0.95 to 2.13), 3MS ¼ 1.70 (1.25 to 2.15), and

3.3 (2.1)
2.2 (2.3)
1.5 (2.0)

9.7 (1.1)
9.2 (1.1)
91.7

39.6
47.9
TD

62
46.7 (10.5)
77.3 (15.8)
173.7 (9.5)
25.5 (4.4)

3.4 (2.1)
2.3 (2.4)
1.6 (2.0)

9.8 (1.0)
9.2 (1.2)
95.4

43.1
49.2
57
C

46.5 (10.2)
76.8 (15.5)
174.0 (8.9)
25.2 (4.0)

3.3 (2.2)
2.2 (2.3)
1.5 (2.1)

9.7 (1.3)
9.2 (1.3)
1WS

89.7

37.9
48.3

BQ 9WS differs from BQ 1WS and BQ REF.

BQ
Baseline characteristics of study participants.

62

Pain in the right shoulder (scale 0e9)c

Pain in the left shoulder (scale 0e9)

BQ 1WS differs from BQ 9WS.

Readiness to change (high) % b

BQ 3WS differs from C 3WS.

Exercise self-efficacy (high) %a
Pain in the neck (scale 0e9)
Self-rated health (high) %

Productivity (scale 0e10)

Workability (scale 0e10)
Body height in cm
Body weight in kg
Females %
Age years
Table 1

BMI

Fig. 2. Total training volume for the whole training period, for each training group
a
b
c

separated by sex. Dark bars ¼ males; Light bars ¼ females.

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health? A cluster randomized controlled trial, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.01.016
6 T. Dalager et al. / Manual Therapy xxx (2015) 1e9

Fig. 3. Figure 3A: Average of the weekly accumulated weight lifted for all exercises for each individual by training group. SE þ/. Solid ¼ 1WS; Dashdot ¼ 3WS; Dot ¼ 9WS;
Dash ¼ 3MS. Figure 3B: Average of the weekly load lifted for all exercises for each individual by training group. SE þ/. Solid ¼ 1WS; Dashdot ¼ 3WS; Dot ¼ 9WS; Dash ¼ 3MS.

REF ¼ 0.73 (0.25 to 1.21). For the right and left shoulder, pain
decreased only significantly in the training groups: 1WS (R: 1.21
(0.56 to 1.86) and L: 1.21 (0.71 to 1.70)), 3WS (R: 0.82
(0.25 to 1.38) and L: 0.65 (0.19 to 1.10)), 9WS (R: 1.13
(0.52 to 2.75) and L: 1.00 (0.34 to 1.70)), and 3MS (R: 1.03
(0.31 to 1.76) and L: 0.83 (0.33 to 1.33)) but not in REF (R:
0.25 (0.2 to 0.70) and L: 0.35 (0.08 to 0.80)). No difference
was present among 1WS, 3WS and 9WS or between 3WS and 3MS
for any of the three pain variables. TG improved musculoskeletal
pain symptoms in the neck (1.56 (1.29 to 1.83)) and shoulders

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health? A cluster randomized controlled trial, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.01.016
 T. Dalager et al. / Manual Therapy xxx (2015) 1e9 7

and 3MS, calculated from both training diaries and follow-up

questionnaires. In concordance with these findings, the strength
training intervention showed similar effects on the health, behavior
and performance outcomes across training groups, and TG
demonstrated several improvements compared with REF. Impor-
tantly, higher exercise self-efficacy at baseline was associated with
a higher degree of compliance. Likewise interesting was that REF
increased readiness to change from baseline to follow-up.

4.1. Exercise training duration and frequency

Interestingly, 9WS - in spite of having a higher self-efficacy than

Fig. 4. Kaplan Meier curve of time until first quitting by training group. Solid ¼ 1WS;
Dashdot ¼ 3WS; Dot ¼ 9WS; Dash ¼ 3MS.
1WS - showed a higher initial drop-out rate compared with 1WS
resulting in similar compliance. A training frequency of nine times a
week may have been perceived insurmountable, but the short
bouts of training seemed manageable when first engaged to the
training regimen. Short bouts of training have also been found to be
effective and feasible where an average compliance (percentage of
completed training sessions) of 66% (approx. 3 days per week) was
attained (Andersen et al., 2011).

(R: 1.04 (0.72 to 1.35) and L: 0.91 (0.66 to 1.17)), which
was significant compared with the REF group.
3.4. Muscle performance test
Measurements of maximal muscle strength (1RM) and strength-
endurance at baseline (R1) and follow-up (R2) are shown in Table 2.
There were no baseline differences across groups. At week 20, all
four training groups significantly increased 1RM and strength-
endurance whereas no significant change was present for the REF
group. No differences across training groups were present, and the
improvement in muscle strength and strength-endurance attained
by TG was significantly different from the REF group.
3.5. Self-reported compliance
CQ showed no difference among 1WS, 3WS and 9WS or between
3WS and 3MS. In total, 37% of the study participants reported to
have trained regularly 40e60 min per week, 19% reported to have
trained regularly 20e40 min per week, 11% reported to have trained
minimum 40 min per month, and 33% of study participants re-
ported to have stopped or never used the offer of 1 h of weekly
training. In addition, a significant correlation was found for TG,
between CQ and CD (spearman's r ¼ 0.72).
4. Discussion
The major findings of this study were the similar levels of
compliance among 1WS, 3WS and 9WS as well as between 3WS
4.2. Supervision
Supervision was not found to be a significant predictor of
compliance or for any of the health, behavior and performance
outcomes in this study. This finding is highly relevant, as supervi-
sion of training can be a considerable cost for companies. In the
present study, five simple exercises were chosen and each study
participant was given careful instruction on how to perform the
exercises, as well as a training diary with detailed description of the
exercise, RM and number of training sets to be performed. Thus,
study participants were not left on their own and the flexibility of
when to perform the exercises was maintained. A similar approach
was used in a study with one single exercise, resulting in good
compliance and clinical relevant effects (Andersen et al., 2011).
Nevertheless, should the value of supervision not be under-
estimated as it was shown that 3MS's median quitting time was
three weeks before 3WS's (though not significant), suggesting that
supervision might play an important role in maintaining study
participants in a training intervention. Similar findings were
emphasized by (Hartvigsen et al., 2010) and (Stefanov et al., 2013)
who did not find supervision to be a significant predictor of
compliance, though the investigated effects were more pronounced
in the supervised group compared with the unsupervised group.
The median quitting time for TG occurred within the first half of
the training intervention period, which may be due to the expec-
tation of quick results when participating in a training intervention
at the workplace (Jones et al., 2005; Fletcher et al., 2008). Focused
feedback by trainees e or the use of setting specific goals for the
study participants in RCTs - may enhance compliance in future

Table 2
Baseline and follow-up values for maximal strength (1RM) and strength-endurance (reps. max.).

1WSa 3WSa 9WSa 3MSa REF TGa

1RM N (%) of BQ 35 (30%) 45 (36%) 37 (35%) 29 (23%) 33 (33%) 146 (31%)

Baseline mean load (kg) 6.8 (2.6) 7.5 (2.8) 6.7 (3.0) 7.9 (2.6) 7.8 (2.7) 7.2 (2.8)
Follow-up mean load (kg) 7.6 (2.8) 8.0 (3.1) 7.0 (3.0) 8.6 (2.8) 8.0 (2.8) 7.8 (3.0)
Mean change in percentage (%)b 12.7% 6.0% 4.4% 8.8% 3.1% 7.7%
Reps. max. N (%) of BQ 35 (30%) 44 (35%) 37 (35%) 28 (22%) 32 (32%) 144 (31%)
Baseline mean number of reps. 11.1 (4.4) 10.3 (3.4) 11.4 (4.0) 11.0 (4.4) 10.3 (3.6) 10.9 (4.0)
Follow-up mean number of reps. 15.2 (6.3) 13.1 (4.5) 14.4 (6.2) 12.3 (4.4) 11.1 (3.6) 13.8 (5.45)
Mean change in percentage (%)b 37.1% 27.9% 27.1% 11.6% 7.6% 26.7%

Data presented as mean values (SD).

a
Significant change from baseline to follow-up for 1RM and strength-endurance.
b
TG differs from REF.

Please cite this article in press as: Dalager T, et al., Does training frequency and supervision affect compliance, performance and muscular
health? A cluster randomized controlled trial, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.01.016
8 T. Dalager et al. / Manual Therapy xxx (2015) 1e9
studies in which records of self-reported compliance will suffice
since measured and self-reported compliance correlated signifi-
cantly in line with the correlations found in other studies
(Andersen et al., 2008a, 2013).
4.3. Exercise self-efficacy
Exercise self-efficacy has previously been shown to be a good
predictor of compliance to physical exercise training, both among
the general population and the working population (Trost et al.,
2002; Kaewthummanukul and Brown, 2006; Fletcher et al., 2008;
Andersen, 2011; Rongen et al., 2014), and resemble the results
demonstrated in our multivariable linear regression analysis.
However, (Pedersen et al., 2013a) did not find exercise self-efficacy
to be a general significant predictor of compliance and points out
the possible diversity across workplaces. Thus, implementation of
physical exercise interventions at the workplace should emphasize
the different characteristics of the concerned workplace as well as
the possible barriers among potential study participants (Fletcher
et al., 2008; Bredahl et al., 2014; Rongen et al., 2014).
A surprising finding of this study was the decline in exercise
self-efficacy post intervention in TG. This finding is contrasting the
literature, but may be an indicator of the difficulties encountered by
the study participants in becoming regular exercisers, especially
when it takes place during working hours. Likewise, the complexity
of changing work culture and organizational barriers may also be
an explaining factor (Marshall, 2004; Rongen et al., 2014).
4.4. Musculoskeletal outcomes
Musculoskeletal pain symptoms improved to a similar extend
across the training groups and demonstrated a significant
improvement compared with the reference group, which is in
agreement with intention-to-treat analyses on the WS training
groups from this study, published previously (Andersen et al.,
2012). The overall reduction in pain of approximately 50% in the
neck, right and left shoulder is in accordance with other previous
studies using similar training regimens, and confirms that specific
strength training for neck and shoulder muscles has a great po-
tential to reduce musculoskeletal pain symptoms (Andersen et al.,
2008a, 2011, 2013; Blangsted et al. 2008).
Likewise, this study supports earlier findings that muscular
adaptations can be attained despite different training frequencies
of the strength training program, and that total training volume is
more important than training frequency in developing muscle mass
and strength in healthy males and females beginning a strength
training program (Candow and Burke, 2007).
4.5. Strength and limitations
This study included both males and females from 12
geographically different units located throughout Denmark, thus
the external validity of the study was high and generalizable to
office workers in general. The cluster randomization minimized
contamination between groups and provided a real-world setting
where colleagues had the opportunity to perform the same training
program together. A limitation of this study was the large propor-
tion that did not reply to our invitation or declined to participate. A
comparison of those who accepted to participate and those who
declined participation showed that they were broadly similar with
regard to gender, age, height, and body mass. However, employees
accepting participation had higher pain intensity in the neck and
shoulders during the previous 3 months, which could indicate se-
lection bias (Andersen et al., 2010). Furthermore the rather high
drop-out and low compliance together with the quite small
Please cite this article in press as: Dalager T, et al., Does training frequency and supervision affect compliance, performance and muscular
health? A cluster randomized controlled trial, Manual Therapy (2015), http://dx.doi.org/10.1016/j.math.2015.01.016
subgroup for measures of muscle strength and strength-endurance
should also be seen as limitations to the this study.
4.6. Recommendations for future research
In the future, more innovative and proactive strategies are
required as suggested previously (Phipps et al., 2010; Rongen et al.,
2014), and future studies would benefit by conducting intervention
mapping (Bartholomew et al., 1998; McEachan et al., 2008), which
is a comprehensive framework for health promotion program
development. Intervention mapping is composed of five steps that,
in brief, target program objectives with theory-based and practical
strategies, and specify adaptation and implementation plans ac-
cording to the specific setting and the needs of potential study
participants (Bartholomew et al., 1998; McEachan et al., 2008).
Furthermore, we recommend a focus on the organizational level, as
organizational changes are needed in order to achieve a long-term
effect (Bredahl et al., 2014). Lack of time due to work is often cited
as one of the major reasons for not being compliant to a training
intervention at the workplace (Andersen, 2011; Pedersen et al.,
2013a; Bredahl et al., 2014; Rongen et al., 2014). By implementing
organizational changes, being compliant becomes more legitimate
for the study participants and research has shown that employees
were more likely to participate when they felt that their supervisor
or colleagues expected them to participate (Rongen et al., 2014).
5. Conclusion
Different strength training schedules in terms of different
training frequency and session duration showed similar results
regarding compliance and the effects on the health, behavior and
performance outcomes. These findings provide evidence that a
great degree of flexibility is legitimate for companies and em-
ployees in planning future implementation of physical exercise
programs at the workplace. Further, extensive training supervision
was not found to be essential as long as simple exercises were
performed with careful initial instruction.
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