Exercise therapy in the management of upper limb dysfunction in ...
Exercise therapy in the management of upper limb dysfunction in ...
Exercise therapy in the management of upper limb dysfunction in ...
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<strong>Exercise</strong> <strong><strong>the</strong>rapy</strong> <strong>in</strong> <strong>the</strong> <strong>management</strong> <strong>of</strong> <strong>upper</strong><br />
<strong>limb</strong> <strong>dysfunction</strong> <strong>in</strong> people with Rheumatoid<br />
Arthritis<br />
Speaker declaration: no conflicts <strong>of</strong> <strong>in</strong>terest
<strong>Exercise</strong><br />
‘a planned, structured and repetitive bodily<br />
movement done to improve or ma<strong>in</strong>ta<strong>in</strong> one or<br />
more components <strong>of</strong> physical fitness’<br />
(Caspersen et al 1985)<br />
Common component <strong>of</strong> <strong>management</strong> <strong>of</strong> people<br />
with rheumatoid arthritis
NICE guidel<strong>in</strong>es (2009)<br />
…..access to specialist physio<strong><strong>the</strong>rapy</strong> to<br />
improve general fitness and encourage regular<br />
exercise<br />
learn exercises for enhanc<strong>in</strong>g jo<strong>in</strong>t flexibility,<br />
muscle strength and manag<strong>in</strong>g o<strong>the</strong>r functional<br />
impairments
<strong>Exercise</strong><br />
Strength<br />
Fitness<br />
Function<br />
? Balance<br />
(Metsios 2008, Hurkmans 2009, K<strong>in</strong>g 2010)<br />
? Flexibility
<strong>Exercise</strong> <strong><strong>the</strong>rapy</strong><br />
Global exercise<br />
(Hall, 1996, DeJong 2003)<br />
Lower <strong>limb</strong><br />
(Lyngberg 1994, Bearne 2002)<br />
Upper <strong>limb</strong> exercise<br />
few high quality studies<br />
(Wessel 2004)
Conservative hand <strong><strong>the</strong>rapy</strong> treatments <strong>in</strong> rheumatoid<br />
arthritis – a randomised controlled trial (O’Brien 2006)<br />
n=67 adults with RA<br />
Jo<strong>in</strong>t protection,<br />
mobility &<br />
Jo<strong>in</strong>t<br />
protection<br />
streng<strong>the</strong>n<strong>in</strong>g<br />
Jo<strong>in</strong>t protection,<br />
mobility &<br />
streng<strong>the</strong>n<strong>in</strong>g<br />
exercises<br />
exercises<br />
Jo<strong>in</strong>t protection &<br />
mobility exercises<br />
Improvement <strong>in</strong> disability (AIMS2), key grip strength at 6/12
The effect <strong>of</strong> an <strong>in</strong>tensive hand exercise programme<br />
<strong>in</strong> patients with rheumatoid arthritis (Ronn<strong>in</strong>gen 2008)<br />
Controlled cl<strong>in</strong>ical trial (n=60)<br />
Conservative (ROM)<br />
exercise programme<br />
n=30<br />
Intensive exercise programme<br />
Intensive exercise<br />
programme<br />
n = 30<br />
Improvement <strong>in</strong> hand grip strength at 14 weeks
Upper <strong>limb</strong> exercise <strong><strong>the</strong>rapy</strong><br />
Proximal stability and motor control required for<br />
effective manual dexterity<br />
Proximal jo<strong>in</strong>ts associated with <strong>upper</strong> <strong>limb</strong><br />
<strong>dysfunction</strong><br />
(Bearne 2003)
Upper <strong>limb</strong> exercise <strong><strong>the</strong>rapy</strong><br />
Short term, supervised programmes<br />
Once exercise ceases, many benefits decl<strong>in</strong>e<br />
(Hakk<strong>in</strong>en 1997, Lemmey 2012)<br />
Behaviour change / self <strong>management</strong> strategies
Education and eXercise <strong>upper</strong> <strong>limb</strong><br />
Tra<strong>in</strong><strong>in</strong>g <strong>in</strong> early Rheumatoid Arthritis<br />
(EXTRA study)<br />
Bearne L.M, Mann<strong>in</strong>g V.L , Scott D.L , Choy E , Hurley M.V.<br />
Funded by Physio<strong><strong>the</strong>rapy</strong> Research Foundation
Aims<br />
• Investigate <strong>the</strong> efficacy <strong>of</strong> home exercise<br />
supplemented with group exercise and self<br />
<strong>management</strong> on <strong>upper</strong> <strong>limb</strong> <strong>dysfunction</strong><br />
• Evaluate <strong>the</strong> acceptability and experience<br />
• Conduct a health economic evaluation
Participants<br />
Inclusion criteria<br />
Adults with RA <strong>of</strong> less than 5 years duration<br />
Exclusion criteria:<br />
unstable disease<br />
steroid <strong>in</strong>jection dur<strong>in</strong>g <strong>the</strong> previous 4 weeks<br />
<strong>upper</strong> <strong>limb</strong> surgery or physio<strong><strong>the</strong>rapy</strong> dur<strong>in</strong>g<br />
<strong>the</strong> previous 6 months<br />
unable to exercise or give <strong>in</strong>formed consent
Study Pathway<br />
Basel<strong>in</strong>e assessment<br />
Usual Care + Education<br />
and eXercise Tra<strong>in</strong><strong>in</strong>g<br />
(EXTRA) programme<br />
Usual care control<br />
group<br />
Assessment at 3<br />
months<br />
Assessment at 3<br />
months<br />
Assessment at 9<br />
months<br />
Assessment at 9<br />
months
Outcome Measures<br />
Primary outcome measure<br />
Disability <strong>of</strong> Arm, Shoulder and Hand questionnaire (DASH)<br />
– 30 item<br />
Please rate your ability to do <strong>the</strong> follow<strong>in</strong>g activities <strong>in</strong> <strong>the</strong><br />
last week by circl<strong>in</strong>g <strong>the</strong> number below <strong>the</strong> appropriate<br />
response.<br />
Place an<br />
object on a<br />
shelf above<br />
your head.<br />
No difficulty<br />
Mild<br />
difficulty<br />
Moderate<br />
difficulty<br />
Severe<br />
difficulty<br />
Unable<br />
1 2 3 4 5
Outcome Measures<br />
Secondary outcomes <strong>in</strong>cluded<br />
• Hand grip strength (N)<br />
• Self efficacy – Arthritis Self Efficacy Scale<br />
• Function – Grip Ability Test (seconds)<br />
• Disease Activity Score (DAS 28)<br />
• Pa<strong>in</strong> (0-100mm VAS)
EXTRA programme<br />
Simple, personalized, daily home exercise<br />
regimen (6 exercises)<br />
Supplemented by 4 group discussion and exercise<br />
sessions (2 x 2 weeks)<br />
15 m<strong>in</strong>utes <strong>the</strong>med discussion<br />
Warm up/ stretch<strong>in</strong>g/ <strong>in</strong>dividualised <strong>upper</strong> <strong>limb</strong><br />
exercise circuit
<strong>Exercise</strong> Menu<br />
Consensus - expert op<strong>in</strong>ion<br />
- exist<strong>in</strong>g literature<br />
16 <strong>upper</strong> <strong>limb</strong> exercise identified<br />
Wall Wash Squares<br />
Arm Curl<br />
Putty ball squeeze
Self <strong>management</strong> topics<br />
Session<br />
Topics<br />
1 Aims and objectives <strong>of</strong> <strong>the</strong> programme<br />
<strong>Exercise</strong> and rheumatoid arthritis<br />
2 <strong>Exercise</strong> and cop<strong>in</strong>g with pa<strong>in</strong> and tiredness<br />
Manag<strong>in</strong>g flare-ups<br />
3 Monitor<strong>in</strong>g exercise <strong>in</strong>tensity<br />
Personal objectives and goal sett<strong>in</strong>g<br />
4 Modify<strong>in</strong>g exercise <strong>in</strong>tensity<br />
Ma<strong>in</strong>ta<strong>in</strong><strong>in</strong>g motivation and manag<strong>in</strong>g relapse
Participant handbook
Participant handbook
Study Participants Characteristics<br />
108 participants (26 Males)<br />
Age 55 years (sd 15)<br />
Disease duration 20 months (sd 19)
Basel<strong>in</strong>e Characteristics<br />
Mean (95% CI)<br />
EXTRA group<br />
n=52<br />
Usual Care group<br />
n= 56<br />
DASH (0 – 100) 46 (39, 53) 42(35, 49)<br />
Self efficacy (ASES pa<strong>in</strong>) 5.7 (5.1, 6.4) 5.9 (5.3, 6.6)<br />
function (seconds) 23 (20, 26) 22 (19, 26)<br />
Hand grip strength (N)<br />
Dom<strong>in</strong>ant * 175 (144, 205) 219 (177, 261)<br />
Non Dom<strong>in</strong>ant* 168 (139, 197) 216 (175, 257)<br />
Disease Activity (DAS28) 5.2 (4.8, 5.7) 4.7 (4.2, 5.2)<br />
Pa<strong>in</strong> (0-100mm) 46 (38, 53) 43 (35, 50)<br />
* difference between group at basel<strong>in</strong>e assessment
Disability<br />
12<br />
10<br />
P
Function<br />
4<br />
P
Grip strength<br />
40<br />
Non dom<strong>in</strong>ant hand<br />
P
Grip strength<br />
50<br />
Dom<strong>in</strong>ant hand<br />
40<br />
30<br />
20<br />
Change <strong>in</strong> 10<br />
strength (N)<br />
0<br />
EXTRA programme<br />
Usual Care<br />
-10<br />
-20<br />
-30<br />
-40<br />
Basel<strong>in</strong>e 3 Months 9 Months
Self efficacy<br />
15<br />
P
Disease Activity<br />
7<br />
6<br />
P
Pa<strong>in</strong><br />
60<br />
P
Conclusions<br />
• The EXTRA programme improves <strong>upper</strong> <strong>limb</strong><br />
disability, strength, function and self efficacy<br />
• Self efficacy improved throughout <strong>the</strong> study<br />
although <strong>the</strong> effect <strong>of</strong> <strong>the</strong> programme dim<strong>in</strong>ished <strong>in</strong><br />
o<strong>the</strong>r outcomes<br />
• It is safe <strong>in</strong> people with early RA
Cl<strong>in</strong>ical Implications<br />
• Cl<strong>in</strong>ically applicable, personalised, global <strong>upper</strong> <strong>limb</strong><br />
exercise and self <strong>management</strong> programme<br />
• Challenge <strong>of</strong> susta<strong>in</strong><strong>in</strong>g exercise long term
Acknowledgements<br />
Study participants<br />
Co –researchers<br />
• Ms Victoria Mann<strong>in</strong>g<br />
• Pr<strong>of</strong> Michael Hurley<br />
• Pr<strong>of</strong> David L. Scott<br />
• Pr<strong>of</strong> E Choy<br />
Collaborators<br />
• Multidiscipl<strong>in</strong>ary teams at K<strong>in</strong>gs College, Guys, St Thomas’ and<br />
Lewisham Hospitals<br />
• Pr<strong>of</strong> Andrew Cope<br />
• Dr Gabrielle K<strong>in</strong>gsley<br />
Physio<strong><strong>the</strong>rapy</strong> Research Foundation