Exercise therapy in the management of upper limb dysfunction in ...

Exercise therapy in the management of upper
limb dysfunction in people with Rheumatoid
Arthritis
Speaker declaration: no conflicts of interest

Exercise
‘a planned, structured and repetitive bodily
movement done to improve or maintain one or
more components of physical fitness’
(Caspersen et al 1985)
Common component of management of people
with rheumatoid arthritis

NICE guidelines (2009)
…..access to specialist physiotherapy to
improve general fitness and encourage regular
exercise
learn exercises for enhancing joint flexibility,
muscle strength and managing other functional
impairments

Exercise
Strength
Fitness
Function
? Balance
(Metsios 2008, Hurkmans 2009, King 2010)
? Flexibility

Exercise therapy
Global exercise
(Hall, 1996, DeJong 2003)
Lower limb
(Lyngberg 1994, Bearne 2002)
Upper limb exercise
few high quality studies
(Wessel 2004)

Conservative hand therapy treatments in rheumatoid
arthritis – a randomised controlled trial (O’Brien 2006)
n=67 adults with RA
Joint protection,
mobility &
Joint
protection
strengthening
Joint protection,
mobility &
strengthening
exercises
exercises
Joint protection &
mobility exercises
Improvement in disability (AIMS2), key grip strength at 6/12

The effect of an intensive hand exercise programme
in patients with rheumatoid arthritis (Ronningen 2008)
Controlled clinical trial (n=60)
Conservative (ROM)
exercise programme
n=30
Intensive exercise programme
Intensive exercise
programme
n = 30
Improvement in hand grip strength at 14 weeks

Upper limb exercise therapy
Proximal stability and motor control required for
effective manual dexterity
Proximal joints associated with upper limb
dysfunction
(Bearne 2003)

Upper limb exercise therapy
Short term, supervised programmes
Once exercise ceases, many benefits decline
(Hakkinen 1997, Lemmey 2012)
Behaviour change / self management strategies

Education and eXercise upper limb
Training in early Rheumatoid Arthritis
(EXTRA study)
Bearne L.M, Manning V.L , Scott D.L , Choy E , Hurley M.V.
Funded by Physiotherapy Research Foundation

Aims
• Investigate the efficacy of home exercise
supplemented with group exercise and self
management on upper limb dysfunction
• Evaluate the acceptability and experience
• Conduct a health economic evaluation

Participants
Inclusion criteria
Adults with RA of less than 5 years duration
Exclusion criteria:
unstable disease
steroid injection during the previous 4 weeks
upper limb surgery or physiotherapy during
the previous 6 months
unable to exercise or give informed consent

Study Pathway
Baseline assessment
Usual Care + Education
and eXercise Training
(EXTRA) programme
Usual care control
group
Assessment at 3
months
Assessment at 3
months
Assessment at 9
months
Assessment at 9
months

Outcome Measures
Primary outcome measure
Disability of Arm, Shoulder and Hand questionnaire (DASH)
– 30 item
Please rate your ability to do the following activities in the
last week by circling the number below the appropriate
response.
Place an
object on a
shelf above
your head.
No difficulty
Mild
difficulty
Moderate
difficulty
Severe
difficulty
Unable
1 2 3 4 5

Outcome Measures
Secondary outcomes included
• Hand grip strength (N)
• Self efficacy – Arthritis Self Efficacy Scale
• Function – Grip Ability Test (seconds)
• Disease Activity Score (DAS 28)
• Pain (0-100mm VAS)

EXTRA programme
Simple, personalized, daily home exercise
regimen (6 exercises)
Supplemented by 4 group discussion and exercise
sessions (2 x 2 weeks)
15 minutes themed discussion
Warm up/ stretching/ individualised upper limb
exercise circuit

Exercise Menu
Consensus - expert opinion
- existing literature
16 upper limb exercise identified
Wall Wash Squares
Arm Curl
Putty ball squeeze

Self management topics
Session
Topics
1 Aims and objectives of the programme
Exercise and rheumatoid arthritis
2 Exercise and coping with pain and tiredness
Managing flare-ups
3 Monitoring exercise intensity
Personal objectives and goal setting
4 Modifying exercise intensity
Maintaining motivation and managing relapse

Participant handbook

Participant handbook

Study Participants Characteristics
108 participants (26 Males)
Age 55 years (sd 15)
Disease duration 20 months (sd 19)

Baseline Characteristics
Mean (95% CI)
EXTRA group
n=52
Usual Care group
n= 56
DASH (0 – 100) 46 (39, 53) 42(35, 49)
Self efficacy (ASES pain) 5.7 (5.1, 6.4) 5.9 (5.3, 6.6)
function (seconds) 23 (20, 26) 22 (19, 26)
Hand grip strength (N)
Dominant * 175 (144, 205) 219 (177, 261)
Non Dominant* 168 (139, 197) 216 (175, 257)
Disease Activity (DAS28) 5.2 (4.8, 5.7) 4.7 (4.2, 5.2)
Pain (0-100mm) 46 (38, 53) 43 (35, 50)
* difference between group at baseline assessment

Disability
12
10
P

Function
4
P

Grip strength
40
Non dominant hand
P

Grip strength
50
Dominant hand
40
30
20
Change in 10
strength (N)
0
EXTRA programme
Usual Care
-10
-20
-30
-40
Baseline 3 Months 9 Months

Self efficacy
15
P

Disease Activity
7
6
P

Pain
60
P

Conclusions
• The EXTRA programme improves upper limb
disability, strength, function and self efficacy
• Self efficacy improved throughout the study
although the effect of the programme diminished in
other outcomes
• It is safe in people with early RA

Clinical Implications
• Clinically applicable, personalised, global upper limb
exercise and self management programme
• Challenge of sustaining exercise long term

Acknowledgements
Study participants
Co –researchers
• Ms Victoria Manning
• Prof Michael Hurley
• Prof David L. Scott
• Prof E Choy
Collaborators
• Multidisciplinary teams at Kings College, Guys, St Thomas’ and
Lewisham Hospitals
• Prof Andrew Cope
• Dr Gabrielle Kingsley
Physiotherapy Research Foundation