Rheumatoid arthritis (RA), an immune-mediated inflammatory disease that targets the synovial lining of the joints, can cause significant hand and wrist damage and dysfunction. Up to 70% of patients with RA report some degree of compromised hand function,1 frequently leading to difficulties performing activities of daily living.2,3 A program of hand exercise may facilitate greater hand function in people with RA.
To provide an overview of the status of hand exercise in RA, Rheumatology Advisor conducted an email interview with Esther Williamson, PhD, and Cynthia Srikesavan, PhD, members of the team at University of Oxford, United Kingdom, who developed the Strengthening And stretching for Rheumatoid Arthritis of the Hand (SARAH) program, a tailored, progressive 12-week exercise program for people with hand problems caused by RA.
Rheumatology Advisor: Which patients with RA are candidates for hand exercise?
Drs Williamson and Srikesavan: People with RA frequently report problems with their hands. The proximal interphalangeal and metacarpophalangeal joints of the hands and the wrists are among the most common joints affected. People with RA may experience joint stiffness, pain, swelling, and reduced grip strength leading to reduced hand function and quality of life. There is evidence that, early after diagnosis, hand grip strength will be reduced in patients with RA and that although it may improve over the first year, it will remain reduced compared with the normal population 5 years later.4 Therefore, any patient who is experiencing problems with their hands or wrists would be a potential candidate for exercises to maintain or improve range of movement and strength.
Rheumatology Advisor: What is the status of hand exercise for people with RA in everyday rheumatology practice in the United Kingdom and other parts of the world? Are rheumatologists incorporating it into their treatment strategies? Should they be?
Drs Williamson and Srikesavan: The UK’s National Institute of Heath and Care Excellence (NICE) recommends that clinicians should consider a tailored strengthening and stretching hand exercise program for adults with RA with pain and dysfunction of the hands or wrists if they are not on a drug regimen for RA, or if they have been on a stable drug regimen for RA for at least 3 months. The tailored hand exercise program for adults with RA should be delivered by a practitioner with training and skills in this area. The NICE guideline for adults with RA are available here: https://www.nice.org.uk/guidance/ng100. However, recommendations about exercise generally are lacking in other clinical guidelines on the management of RA, with a focus on drug management. For example, 2015 American College of Rheumatology Guidelines for the Treatment of Rheumatoid Arthritis5 do not mention exercise at all and neither do the recently updated European guidelines for nurses managing patients with inflammatory arthritis.6 The recent European League Against Rheumatism guidelines on the early management of RA recommend exercise, but do not give any specific advice.7
The NICE recommendations are based on the findings of the Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) trial conducted by our research team.8 We developed a 12-week tailored and progressive exercise program for people with RA affecting their hands and wrists. We evaluated the clinical and cost effectiveness of the SARAH program when added to usual care compared with usual care only in a multicenter randomized controlled trial. A total of 490 adults with self-reported pain and dysfunction of the hands/wrists resulting from RA who were on a stable drug regimen for at least 3 months were recruited across 17 National Health Service trusts and followed for up to 12 months. The trial found that the SARAH program improved hand function and was safe to deliver. It was also cost-effective in terms of health resource use.
The SARAH program includes 7 mobility and 4 strengthening exercises prescribed alongside behavioral support strategies of goal setting, action planning, confidence building, and self-monitoring to encourage long-term exercise adherence.9 Participants who received the SARAH program in addition to usual care attended an initial assessment and 5 supervised exercise training/review sessions with their hand therapist over a 12-week period. Participants were taught to progress or regress the SARAH exercises in response to symptoms, for example, a flare-up, to set goals, plan their home exercise sessions, and use an exercise diary. After 12 weeks, participants continued the SARAH program at home. Usual care included joint protection advice and prescription of splints and assistive devices as required.
In the United Kingdom, patients presenting with hand problems in the rheumatology clinic should be referred to a hand therapist or a physiotherapist or occupational therapist specializing in rheumatology. At some centers in the United Kingdom, they have good provision of hand therapy for this patient group, but this is not always the case. To facilitate the implementation of the SARAH program into routine clinical care and help patients to receive evidence-based care, we have developed an online course to train health professionals to deliver the SARAH program. We have now trained 521 National Health Service occupational therapists and physiotherapists in the United Kingdom to deliver the SARAH program to their patients as part of their usual clinical practice. This training is now available to all health professionals who treat patients with RA: https://isarah.octru.ox.ac.uk/.
Rheumatology Advisor: What recommendations do you have for rheumatologists who would like to recommend hand exercise to their patients with RA?
Drs Williamson and Srikesavan: Good hand function is extremely important. It is needed to carry out everyday activities, such as doing up your buttons, opening a door or lifting a kettle, as well as taking part in sports, hobbies, and work. Once patients are on a stable drug regimen, if they have had reported problems in their hand and wrists, we would recommend that they be prescribed a hand exercise program that focuses on range of movement and strength of the hand, wrist, and arm. Ideally, this should be under the supervision of a therapist who can tailor the exercises to each patient and teach them to learn how to adapt their exercises if they have a flare up. The therapist works with the patient to build their confidence to exercise independently and to help them to stick to the exercises long term. The SARAH program provides a framework for delivering this type of exercise program. Sometimes patients will be reluctant to exercise for fear of causing damage to their joints. The SARAH trial demonstrated that the strengthening and stretching exercise program was safe and it did not cause an increase in pain. If your patients do not have access to a therapist, then provide them with exercise leaflets to help them exercise at home.
1. Romero-Guzmán AK, Menchaca-Tapia VM, Contreras-Yáñez I, Pascual-Ramos V. Patient and physician perspectives of hand function in a cohort of rheumatoid arthritis patients: the impact of disease activity. BMC Musculoskelet Disord. 2016;17(1):392.
2. Srikesavan C, Williamson E, Cranston T, Hunter J, Adams J, Lamb SE. An online hand exercise intervention for adults with rheumatoid arthritis (mySARAH): design, development, and usability testing. J Med Internet Res. 2018:20(6):e10457.
3. Ellegaard K, von Bülow C, Røpke A, et al. Hand exercise for women with rheumatoid arthritis and decreased hand function: an exploratory randomized controlled trial. Arthritis Res Ther. 2019;21(1):158.
4. Rydholm M, Book C, Wikström I, Jacobsson L, Turesson C. Course of grip force impairment in patients with early rheumatoid arthritis over the first five years after diagnosis. Arthritis Care Res (Hoboken). 2018;70(4):491-498.
5. Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol. 2016;68(1):1-26.
6. Bech B, Primdahl J, van Tubergen A, et al. 2018 update of the EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis [published online July 12, 2019]. Ann Rheum Dis. doi:10.1136/annrheumdis-2019-215458
7. Combe B, Landewe R, Daien CI, et al. 2016 update of the EULAR recommendations for the management of early arthritis. Ann Rheum Dis. 2017;76(6):948-959.
8. Lamb SE, Williamson EM, Heine PJ, et al. Exercises to improve function of the rheumatoid hand (SARAH): a randomised controlled trial. Lancet. 2015;385(9966):421-429.
9. Heine PJ, Williams MA, Williamson E, et al. Development and delivery of an exercise intervention for rheumatoid arthritis: strengthening and stretching for rheumatoid arthritis of the hand (SARAH) trial. Physiotherapy. 2012;98(2):121-130.