BIRMINGHAM, ENGLAND – Patients with hand or wrist problems from rheumatoid arthritis can significantly benefit from a hand-specific exercise program beyond what is achieved with usual care.
"There was a significant difference in the primary outcome measure [the Michigan Hand Outcomes Questionnaire] in favor of the exercise program and this was actually maintained over the 12-month follow period as well," study investigator Dr. Mark Williams said at the annual meeting of the British Society for Rheumatology. Dr. Williams is a research fellow in the Clinical Trials Unit at the University of Warwick, England, where the trial is being coordinated.
Dr. Mark Williams
In the randomized, controlled trial called SARAH (Strengthening and Stretching for Rheumatoid Arthritis of the Hand), mean Michigan Hand Outcomes Questionnaire (MHQ) scores at 4 months’ assessment improved from 52.1 at baseline in both groups to 61.1 in the exercise group (n = 246) and 56.6 in the usual care group (n = 244), giving a mean difference in hand function improvement of 4.5 (P less than .0002) in favor of the exercise program.
The effects of the 12-week and home-based intervention were sustained at 12 months’ follow-up, with mean MHQ scores of 60.7 (n = 216) and 56.4 (n = 222) in the exercise and usual care groups, respectively, giving a mean difference of 4.3 (P less than .002).
Clinical guidelines in England and Wales state that patients with RA should have access to specialist hand therapy to help increase strength, movement, and function. Prior to the results of the SARAH trial, however, the evidence upon which this recommendation is based was "rather weak," Dr. Williams observed.
The aims of the study were therefore to determine the clinical effectiveness of an exercise program developed to specifically target the hands and upper limbs in patients with RA hand dysfunction, and then to examine its cost-effectiveness.
The study was performed within 17 National Health Service Trusts in England and included RA patients with pain or dysfunction of the hands or wrist joints who were not taking disease-modifying antirheumatic therapy, or if they were, had been stable on treatment for at least 3 months. The 490 patients randomized in the trial had a median age of 63 years and 10 years’ RA disease duration.
Usual care consisted of one-on-one sessions with a hand therapist and information about joint protection and general exercise advice, with functional splinting if there was a clinical need. In addition to this, the patients who were randomized to the SARAH exercise program received a further five sessions of supervised exercises over a 12-week period; sessions included 11 exercises designed to help with stretching and strengthening of the hand, guidance on a daily exercise program to be performed by patients at home, and strategies to encourage adherence (Physiotherapy 2012;98:121-30).
"In order to get patients to adhere to this exercise plan, which is fairly key, we used behavioral strategies, including an exercise diary and a behavioral action plan," Dr. Williams explained. "This was like a contract between the patient and [his or her] therapist." A total of 438 (89%) patients were followed up at 12 months.
Patient-reported self-efficacy was higher with the exercise program, compared with usual care. Indeed, in a letter recently sent to all the patients who participated in the trial, Dr. Williams noted that, "43% of the patients receiving the SARAH exercise programme and 20% of patients receiving usual care reported some or much improvement."
There was no difference in pain scores between groups, with trends for all participants to report some improvement in pain over time. There was also no difference in the number of adverse events between the groups.
Importantly, the SARAH exercise program was shown to be cost effective, incurring only an additional £100 per patient (approximately US$150) to provide. This means existing health care staff could potentially deliver the program, and with relative ease, the SARAH trial team believes.
Their next step is to see if the intervention’s benefits are extended beyond 12 months. The researchers are also looking at how to best to train healthcare professionals to deliver the program in routine practice in the United Kingdom.
The U.K. National Institute for Health Research Health Technology Assessment Program funded the trial. Dr. Williams had no conflicts of interest.