Effect of active hand exercise and wax bath treatment in rheumatoid arthritis patients

Preparation and characterization of glyceryl stearate/cassava starch composite for wax therapy

Glyceryl stearate and cassava starch (CS) composites were prepared by an esterification process. Formulations containing starch at various concentrations were prepared, being 1, 1.5, 3, 5, 10, 15, 20, and 30 % by weight, respectively. The characteristics of pH, moisture content, FTIR, melting point, latent heat, thermal energy storage, and specific heat capacity of composites were elucidated. The optimal formulation contained 1 % w/w CS, this indicated that the composite was able to maintain its temperature for 9.4 ± 0.5 min, with a melting temperature of 51.9 ± 0.3 °C, solidification temperature of 36.1 ± 1.6 °C, latent heat of fusion of 120 ± 10 J/g, and latent heat of solidification of 126 ± 3 J/g, and specific heat capacity of 2.6 ± 0.2 J/g.K. New bonds were formed in the composite structure of glyceryl stearate and CS at these levels. The composite had a pH that was safe for contact with human skin and a moisture content that could be kept stable for a prolonged time. The innovation and the advantages of a composite materials: 1. The main components are derived from natural materials. 2. Costs effective 3. Sustainability 4. Safety, and 5. Efficacy. Therefore, composites have a high potential as are replacement for paraffin wax bath therapy.

An Exercise and Educational and Self-management Program Delivered With a Smartphone App (CareHand) in Adults With Rheumatoid Arthritis of the Hands: Randomized Controlled Trial

BACKGROUND

Rheumatoid arthritis (RA) is a prevalent autoimmune disease that usually involves problems of the hand or wrist. Current evidence recommends a multimodal therapy including exercise, self-management, and educational strategies. To date, the efficacy of this approach, as delivered using a smartphone app, has been scarcely investigated.

OBJECTIVE

This study aims to assess the short- and medium-term efficacy of a digital app (CareHand) that includes a tailored home exercise program, together with educational and self-management recommendations, compared with usual care, for people with RA of the hands.

METHODS

A single-blinded randomized controlled trial was conducted between March 2020 and February 2021, including 36 participants with RA of the hands (women: 22/36, 61%) from 2 community health care centers. Participants were allocated to use the CareHand app, consisting of tailored exercise programs, and self-management and monitoring tools or to a control group that received a written home exercise routine and recommendations, as per the usual protocol provided at primary care settings. Both interventions lasted for 3 months (4 times a week). The primary outcome was hand function, assessed using the Michigan Hand Outcome Questionnaire (MHQ). Secondary measures included pain and stiffness intensity (visual analog scale), grip strength (dynamometer), pinch strength (pinch gauge), and upper limb function (shortened version of the Disabilities of the Arm, Shoulder, and Hand questionnaire). All measures were collected at baseline and at a 3-month follow-up. Furthermore, the MHQ and self-reported stiffness were assessed 6 months after baseline, whereas pain intensity and scores on the shortened version of the Disabilities of the Arm, Shoulder, and Hand questionnaire were collected at the 1-, 3-, and 6-month follow-ups.

RESULTS

In total, 30 individuals, corresponding to 58 hands (CareHand group: 26/58, 45%; control group: 32/58, 55%), were included in the analysis; 53% (19/36) of the participants received disease-modifying antirheumatic drug treatment. The ANOVA demonstrated a significant time×group effect for the total score of the MHQ (F_1.62,85.67=9.163; P<.001; η²=0.15) and for several of its subscales: overall hand function, work performance, pain, and satisfaction (all P<.05), with mean differences between groups for the total score of 16.86 points (95% CI 8.70-25.03) at 3 months and 17.21 points (95% CI 4.78-29.63) at 6 months. No time×group interaction was observed for the secondary measures (all P>.05).

CONCLUSIONS

Adults with RA of the hands who used the CareHand app reported better results in the short and medium term for overall hand function, work performance, pain, and satisfaction, compared with usual care. The findings of this study suggest that the CareHand app is a promising tool for delivering exercise therapy and self-management recommendations to this population. Results must be interpreted with caution because of the lack of efficacy of the secondary outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04263974; https://clinicaltrials.gov/ct2/show/NCT04263974.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s13063-020-04713-4.

Effects of physical exercise and body weight on disease-specific outcomes of people with rheumatic and musculoskeletal diseases (RMDs): systematic reviews and meta-analyses informing the 2021 EULAR recommendations for lifestyle improvements in people with RMDs

BACKGROUND

A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs.

METHODS

Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013-2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases.

RESULTS

236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies.

CONCLUSION

The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs.

Beneficial Effects of Paraffin Bath Therapy as Additional Treatment of Chronic Hand Eczema: A Randomized, Single-Blind, Active-Controlled, Parallel-Group Study

Objective: Chronic hand eczema (CHE) is a common inflammatory skin disease with a major psychological and socioeconomic impacts on patients' quality of life (QoL) and work ability. To the best of knowledge, this study is the first randomized-controlled trial conducted to evaluate the effect of paraffin bath therapy in management of hand eczema and its related symptoms. Design: This study was a parallel-group, active-control, randomized clinical trial with measures at pretreatment, 6th week, and 12th week of treatment. Settings: The study took place at the Outpatient Clinic of Faculty of Physical Therapy, Cairo University, and some licensed rehabilitation centers in Cairo for a 1-year period. Subjects: Sixty patients with moderate to severe CHE were randomly assigned into two groups of equal number; the paraffin bath therapy group and the control group. Interventions: The paraffin group received paraffin bath therapy for 5 days a week for 12 weeks, in addition to the routine skin care program, while the control group only received the routine skin care program. Outcome measures: SCORing Atopic Dermatitis (SCORAD) was used to assess the severity of atopic dermatitis and dermatology life quality index (DLQI) to assess the effect of CHE on quality of patients' life. All measurements were obtained before, at the 6th week, and at the 12th week of treatment. Results: Marked improvement in the severity of the disease symptoms was observed, reflected by a highly decrease in objective SCORAD score in the paraffin group over time more than the control group. The percentage of reduction was 28.6% in paraffin group versus 0.41% in control group. Subjective item score (itching and sleepiness) was reduced in the paraffin group more than the control group with a percentage of improvement (47% and 5.5%), respectively. Regarding QoL measure, there were highly positive changes in DLQI in paraffin group more than the control group. The percentage of improvement was 60% in paraffin group and 3.8% in control group. Conclusions: Paraffin bath therapy applied for a 12-week duration seems to be effective, both in reducing severity of eczema symptoms and improving QoL in patients with CHE.

The effect of physical exercise on rheumatoid arthritis: An overview of systematic reviews and meta-analysis

AIMS

To determine which outcomes will be improved by different exercise interventions and the evidence quality for each intervention.

DESIGN

Overview of systematic reviews and meta-analysis.

DATA SOURCES

PubMed, Cochrane, Web of Science, CINAHL, and Embase. Published from the establishment of the database to 3 September 2019.

REVIEW METHODS

AMSTAR 2 and PRISMA were used to evaluate methodological and reporting quality. Evidence quality of the effect of each intervention was assessed according to GRADE guidelines. Meta-analysis of original studies was conducted for comparison of systematic reviews and to explore the effect of different exercise interventions on the same outcome.

RESULTS

Ten systematic reviews were included in the overview. A significant improvement was seen in: aerobic exercise for aerobic capacity; strength training for erythrocyte sedimentation rate and 50-foot walking time; aerobic exercise combined with strength training for aerobic capacity, physical function, and fatigue; hand exercise for hand function.

CONCLUSIONS

For the maximum benefit of rheumatoid arthritis (RA) patients, different exercise methods should be selected according to the symptoms. For RA patients, any exercise is better than no exercise, but the intensity, frequency, and period of exercise for better results are not determined.

IMPACT

What problem did the study address is which outcomes will be improved by different exercise interventions. For maximum benefit for RA patients, different exercise methods should be selected according to symptoms. The research summarized the evidence of exercise rehabilitation of RA and will help RA patients or their caregivers choose the appropriate type of exercise, which will play a positive role on the rehabilitation of patients with RA.

Is dry heat treatment (fluidotherapy) effective in improving hand function in patients with rheumatoid arthritis? A randomized controlled trial

OBJECTIVE:

To evaluate the efficacy of dry heat treatment (fluidotherapy) in improving hand function in patients with rheumatoid arthritis.

DESIGN:

Prospective randomized controlled trial.

SETTING:

Departments of Physical Medicine and Rehabilitation and Rheumatology in a university hospital.

SUBJECTS:

Patients with rheumatoid arthritis.

INTERVENTIONS:

All patients were randomly divided into two groups. Group 1 underwent dry heat treatment (fluidotherapy) and Group 2 was a control group. Patients in both groups participated in a joint protection and exercise program.

MAIN MEASURES:

Primary outcome measures were Health Assessment Questionnaire and Duruoz Hand Index. Secondary outcome measures were pain and stiffness, Grip Ability Test, Disease Activity Score-28, and grip strength. These assessments were performed at the hospital at baseline, week 3, and week 12.

RESULTS:

A total of 93 participants were allocated to Group 1 ( n = 47) and Group 2 ( n = 46). The mean age of these groups was 54.19 ± 11.15 years and 53.00 ± 10.15 years, respectively ( P = 0.592). At baseline, there were no significant differences between the groups in any parameter except significantly poorer Health Assessment Questionnaire score in Group 1 ( P = 0.007). At week 3, there were no significant differences between the groups in any of the parameters ( P > 0.005). At week 12, Duruoz Hand Index scores were significantly better in Group 2 ( P = 0.039).

CONCLUSION:

Dry heat treatment (fluidotherapy) was not effective in improving hand function in patients with rheumatoid arthritis. Moreover, no positive effect on any other clinical parameters was observed.

Effects of a finger exercise program on hand function in automobile workers with hand osteoarthritis: A randomized controlled trial

Hand osteoarthritis reduces a person's ability to perform work activities and return to their occupation. We investigated the effects of a finger exercise program on hand grip strength, pain, physical function, and stiffness in automobile manufacturing workers with hand osteoarthritis. This randomized controlled trial was conducted on 29 subjects. Fifteen experimental subjects received a finger exercise program with paraffin baths, while 14 control subjects received only paraffin baths. Hand grip strength, pain, physical function, and stiffness were assessed at baseline and 8 weeks later. In the experimental group, hand grip strength (P < 0.001) and Australian/Canadian osteoarthritis hand index (AUSCAN) scores (pain, P < 0.001; stiffness, P < 0.001; physical function, P < 0.001) were significantly improved by 3.52 ± 2.03, 21.6 ± 8.3 (pain), 16.8 ± 10.21 (stiffness), and 13.86 ± 4.54 (physical function) compared with preintervention values. In the control group, hand grip strength (P = 0.004) and AUSCAN scores (pain, P < 0.001; stiffness, P = 0.019; physical function, P < 0.001) were significantly improved by 0.57 ± 0.62, 7.85 ± 5.46 (pain) 11.42 ± 7.18 (stiffness), and 10.28 ± 14.41 (physical function) compared with preintervention values. Significant differences between groups were found for postintervention hand grip strength (P = 0.015) and AUSCAN index subscale scores (pain, P < 0.001; physical function, P = 0.020). A combined finger exercise and paraffin bath program is effective in reducing pain, improving physical function, and increasing hand grip strength in workers with hand osteoarthritis.

[Physical therapy options in rheumatic diseases: what is evidence-based?]

Rheumatic diseases usually progress towards morphological and functional deficits and thus cause impairment of physical health and function. Based on this fact, physiotherapeutic options are elementary and indispensable. This article focuses on the significance and importance of physiotherapy in inflammatory and degenerative rheumatic diseases. Furthermore, an overview is presented on the consequences of rheumatic diseases, the reality of supply of physiotherapy, the principles and therapeutic options, and the evidence.

Exercise for rheumatoid arthritis of the hand

BACKGROUND

Rheumatoid arthritis is an inflammatory polyarthritis that frequently affects the hands and wrists. Hand exercises are prescribed to improve mobility and strength, and thereby hand function.

OBJECTIVES

To determine the benefits and harms of hand exercise in adults with rheumatoid arthritis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, Embase, CINAHL, AMED, Physiotherapy Evidence Database (PEDro), OTseeker, Web of Science, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) up to July 2017.

SELECTION CRITERIA

We considered all randomised or quasi-randomised controlled trials that compared hand exercise with any non-exercise therapy.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as outlined by the Cochrane Musculoskeletal Group.

MAIN RESULTS

We included seven studies involving 841 people (aged 20 to 94 years) in the review. Most studies used validated diagnostic criteria and involved home programmes.Very low-quality evidence (due to risk of bias and imprecision) from one study indicated uncertainty about whether exercise improves hand function in the short term (< 3 months). On a 0 to 80 points hand function test (higher scores mean better function), the exercise group (n = 11) scored 76.1 points and control group (n = 13) scored 75 points.Moderate-quality evidence (due to risk of bias) from one study indicated that exercise compared to usual care probably slightly improves hand function (mean difference (MD) 4.5, 95% confidence interval (CI) 1.58 to 7.42; n = 449) in the medium term (3 to 11 months) and in the long term (12 months or beyond) (MD 4.3, 95% CI 0.86 to 7.74; n = 438). The absolute change on a 0-to-100 hand function scale (higher scores mean better function) and number needed to treat for an additional beneficial outcome (NNTB) were 5% (95% CI 2% to 7%); 8 (95% CI 5 to 20) and 4% (95% CI 1% to 8%); 9 (95% CI 6 to 27), respectively. A 4% to 5% improvement indicates a minimal clinical benefit.Very low-quality evidence (due to risk of bias and imprecision) from two studies indicated uncertainty about whether exercise compared to no treatment improved pain (MD -27.98, 95% CI -48.93 to -7.03; n = 124) in the short term. The absolute change on a 0-to-100-millimetre scale (higher scores mean more pain) was -28% (95% CI -49% to -7%) and NNTB 2 (95% CI 2 to 11).Moderate-quality evidence (due to risk of bias) from one study indicated that there is probably little or no difference between exercise and usual care on pain in the medium (MD -2.8, 95% CI - 6.96 to 1.36; n = 445) and long term (MD -3.7, 95% CI -8.1 to 0.7; n = 437). On a 0-to-100 scale, the absolute changes were -3% (95% CI -7% to 2%) and -4% (95% CI -8% to 1%), respectively.Very low-quality evidence (due to risk of bias and imprecision) from three studies (n = 141) indicated uncertainty about whether exercise compared to no treatment improved grip strength in the short term. The standardised mean difference for the left hand was 0.44 (95% CI 0.11 to 0.78), re-expressed as 3.5 kg (95% CI 0.87 to 6.1); and for the right hand 0.46 (95% CI 0.13 to 0.8), re-expressed as 4 kg (95% CI 1.13 to 7).High-quality evidence from one study showed that exercise compared to usual care has little or no benefit on mean grip strength (in kg) of both hands in the medium term (MD 1.4, 95% CI -0.27 to 3.07; n = 400), relative change 11% (95% CI -2% to 13%); and in the long term (MD 1.2, 95% CI -0.62 to 3.02; n = 355), relative change 9% (95% CI -5% to 23%).Very low-quality evidence (due to risk of bias and imprecision) from two studies (n = 120) indicated uncertainty about whether exercise compared to no treatment improved pinch strength (in kg) in the short term. The MD and relative change for the left and right hands were 0.51 (95% CI 0.13 to 0.9) and 44% (95% CI 11% to 78%); and 0.82 (95% CI 0.43 to 1.21) and 68% (95% CI 36% to 101%).High-quality evidence from one study showed that exercise compared to usual care has little or no benefit on mean pinch strength of both hands in the medium (MD 0.3, 95% CI -0.14 to 0.74; n = 396) and long term (MD 0.4, 95% CI -0.08 to 0.88; n = 351). The relative changes were 8% (95% CI -4% to 19%) and 10% (95% CI -2% to 22%).No study evaluated the American College of Rheumatology 50 criteria.Moderate-quality evidence (due to risk of bias) from one study indicated that people who also received exercise with strategies for adherence were probably more adherent than those who received routine care alone in the medium term (risk ratio 1.31, 95% CI 1.15 to 1.48; n = 438) and NNTB 6 (95% CI 4 to 10). In the long term, the risk ratio was 1.09 (95% CI 0.93 to 1.28; n = 422).Moderate-quality evidence (due to risk of bias) from one study (n = 246) indicated no adverse events with exercising. The other six studies did not report adverse events.

AUTHORS' CONCLUSIONS

It is uncertain whether exercise improves hand function or pain in the short term. It probably slightly improves function but has little or no difference on pain in the medium and long term. It is uncertain whether exercise improves grip and pinch strength in the short term, and probably has little or no difference in the medium and long term. The ACR50 response is unknown. People who received exercise with adherence strategies were probably more adherent in the medium term than who did not receive exercise, but with little or no difference in the long term. Hand exercise probably does not lead to adverse events. Future research should consider hand and wrist function as their primary outcome, describe exercise following the TIDieR guidelines, and evaluate behavioural strategies.

Short-term efficacy of paraffin therapy and home-based exercise programs in the treatment of symptomatic hand osteoarthritis

Objectives

This study aims to investigate the effects of a home-based exercise program in combination with paraffin therapy on pain, functional status, grip strength, and quality of life (QoL) and to compare the outcomes of these two treatment modalities.

Patients and methods

This prospective, single-blind, randomized-controlled study included a total of 61 patients (8 males, 53 females, mean age 59.22 years; range, 35 to 78 years) who were diagnosed with hand osteoarthritis (HOA) according to the American College of Rheumatology criteria between November 2016 and February 2017. The first group (group 1) (n=31) received paraffin therapy + home-based exercise program and the second group (group 2) (n=30) received home-based exercise program alone. All patients were assessed using the Visual Analog Scale (VAS), Australian/Canadian (AUSCAN) Osteoarthritis Hand Index, Health Assessment Questionnaire (HAQ), Hand Grip Strength (HGS), and Finger Pinch Strength (FPS) at baseline and at two and six weeks after the intervention.

Results

In group 1, there were statistically significant improvements in all parameters at two and six weeks (p<0.05). Statistically significant differences were observed in the HGS and AUSCAN Osteoarthritis Hand Index scores in group 2 at two and six weeks (p<0.05). Inter-group analysis showed statistically significant differences in favor of group 1 in the VAS, HAQ, AUSCAN Osteoarthritis Hand Index, HGS, and FPS scores at two and six weeks compared to baseline scores (p<0.05).

Conclusion

Paraffin therapy combined with home-based exercise program in patients with symptomatic HOA provides effective pain control and is effective in improving functional status, HGS, FPS, and QoL in short term.

Mediating Effect of Changes in Hand Impairments on Hand Function in Patients With Rheumatoid Arthritis: Exploring the Mechanisms of an Effective Exercise Program

OBJECTIVE

To determine whether the effect of the Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) exercise program on hand function was mediated by changes in the proposed active ingredients: strength, dexterity, and/or range of motion.

METHODS

The SARAH intervention included exercises hypothesized to improve potential mediators of grip strength, pinch strength, wrist flexion, wrist extension, finger flexion, finger extension, thumb opposition, and dexterity, which would theoretically improve self-reported hand function. All variables were measured at baseline and at 4 and 12 months. Structural equation modeling was used to assess mediation on change in hand function via change in potential mediators.

RESULTS

Change in grip strength partially mediated change in hand function. Grip strength mediated 19.4% (95% confidence interval 0.9%, 37.8%) of the treatment effect.

CONCLUSION

Improvements in grip strength at 4 months are likely to mediate improved hand function at 12 months. The role of joint mobility exercises is less clear and is likely influenced by the choice of measurement tools for both mobility and function outcomes. More robust measurements of wrist and hand mobility for patients with rheumatoid arthritis may be necessary to determine the relationship between this variable and self-reported hand function. Using a large trial data set, we have demonstrated that techniques used to target grip strength are key active ingredients of the SARAH exercise program and mediate its effect.

Hand exercises for patients with rheumatoid arthritis: an extended follow-up of the SARAH randomised controlled trial

OBJECTIVES

The Stretching And strengthening for Rheumatoid Arthritis of the Hand (SARAH) randomised controlled trial evaluated the effectiveness of a hand exercise programme and demonstrated it was clinically effective and cost-effective at 12 months. The aim of this extended follow-up was to evaluate the effects of the SARAH programme beyond 12 months.

METHODS

Using postal questionnaires, we collected the Michigan Hand Questionnaire hand function (primary outcome), activities of daily living and work subscales, pain troublesomeness, self-efficacy and health-related quality of life. All participants were asked how often they performed hand exercises for their rheumatoid arthritis. Mean difference in hand function scores were analysed by a linear model, adjusted for baseline score.

RESULTS

Two-thirds (n=328/490, 67%) of the original cohort provided data for the extended follow-up. The mean follow-up time was 26 months (range 19-40 months).There was no difference in change in hand function scores between the two groups at extended follow-up (mean difference (95% CI) 1.52 (-1.71 to 4.76)). However, exercise group participants were still significantly improved compared with baseline (p=0.0014) unlike the best practice usual care group (p=0.1122). Self-reported performance of hand exercises had reduced substantially.

CONCLUSIONS

Participants undertaking the SARAH exercise programme had improved hand function compared with baseline >2 years after randomisation. This was not the case for the control group. However, scores were no longer statistically different between the groups indicating the effect of the programme had diminished over time. This reduction in hand function compared with earlier follow-up points coincided with a reduction in self-reported performance of hand exercises. Further intervention to promote long-term adherence may be warranted.

TRIAL REGISTRATION NUMBER

ISRCTN89936343; Results.

Integration of occupation based intervention in hand injury rehabilitation: A Randomized Controlled Trial

STUDY DESIGN

Randomized Controlled Trial (RCT).

INTRODUCTION

Engagement in daily occupations and day to day activities helps to restore function in individuals with injured hands and provides a platform to practise selected occupations.

PURPOSE

The purpose of this study was to investigate the effectiveness of a combination of Occupation Based Intervention (OBI) and Therapeutic Exercise (TE) compared to TE alone for the rehabilitation of hand injuries.

METHOD

A single center RCT, parallel group was conducted at the Kuala Lumpur General Hospital (KLGH), Malaysia. Forty-six adult clients with hand injuries who consented to participate were randomly allocated to either the OBI + TE group or to the TE group.

RESULTS

Following a ten week intervention program, statistical significance differences were found in DASH score (TE = 18.64 ± 14.84 vs OBI + TE = 9.50 ± 9.14, p = 0.02); total active motion (TE = 1035.85 ± 179.84 vs OBI + TE = 1203.65 ± 133.60, p = 0.01); neuropathic pain (TE = 2.90 ± 2.79 vs OBI + TE = 1.05 ± 2.01, p = 0.02); COPM performance (TE = 7.62 ± 2.03 vs OBI + TE = 9.53 ± 0.64, p < 0.001); and COPM satisfaction (TE = 7.60 ± 2.11 vs OBI + TE = 9.49 ± 0.76, p < 0.001) in favor of OBI + TE group.

CONCLUSION

This study highlighted the integration of OBI into hand injury rehabilitation improved outcomes for clients.

The effectiveness of home hand exercise programmes in rheumatoid arthritis: a systematic review

INTRODUCTION

Rheumatoid arthritis (RA) commonly reduces hand function. We systematically reviewed trials to investigate effects of home hand exercise programmes on hand symptoms and function in RA.

SOURCES OF DATA

We searched: Medline (1946-), AMED, CINAHL, Physiotherapy Evidence Database, OT Seeker, the Cochrane Library, ISI Web of Science from inception to January 2016.

AREAS OF AGREEMENT

Nineteen trials were evaluated. Only three were randomized controlled trials with a low risk of bias (n = 665). Significant short-term improvements occurred in hand function, pain and grip strength, with long-term improvements in hand and upper limb function and pinch strength.

AREAS OF CONTROVERSY

Heterogeneity of outcome measures meant meta-analysis was not possible.

GROWING POINTS

Evaluation of low and moderate risk of bias trials indicated high-intensity home hand exercise programmes led to better short-term outcomes than low-intensity programmes. Such programmes are cost-effective.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further research is required to evaluate methods of helping people with RA maintain long-term home hand exercise.

Strengthening And stretching for Rheumatoid Arthritis of the Hand (SARAH). A randomised controlled trial and economic evaluation

BACKGROUND

The effectiveness of exercise for improving hand and wrist function in people with rheumatoid arthritis (RA) is uncertain.

OBJECTIVES

The study aims were (1) to estimate the clinical effectiveness and cost-effectiveness of adding an optimised exercise programme for hands and upper limbs to standard care for patients with RA; and (2) to qualitatively describe the experience of participants in the trial with a particular emphasis on acceptability of the intervention, exercise behaviours and reasons for adherence/non-adherence.

DESIGN

A pragmatic, multicentred, individually randomised controlled trial with an embedded qualitative study. Outcome assessors were blind to group assignment and independent of treatment delivery.

SETTING

Seventeen NHS trusts in England comprising 21 rheumatology and therapy departments.

PARTICIPANTS

Adults with RA who had pain and dysfunction of the hands and/or wrists and had been on stable medication for at least 3 months. Patients were excluded if they were under 18 years old, had undergone upper limb surgery/fracture in the last 6 months, were on a waiting list for upper limb surgery or were pregnant.

INTERVENTIONS

Usual care or usual care plus an individualised exercise programme. Usual care consisted of joint protection education, general exercise advice and functional splinting if required. The exercise programme consisted of six sessions of strengthening and stretching exercises with a hand therapist, daily home exercises and strategies to maximise adherence.

MAIN OUTCOME MEASURES

The primary outcome was the Michigan Hand Outcome Questionnaire (MHQ) overall hand function subscale score at 12 months. Secondary outcome measures included the full MHQ, pain, health-related quality of life (Short Form questionnaire-12 items), impairment (grip strength, dexterity and range of motion) and self-efficacy. European Quality of Life-5 Dimensions, medication and health-care use were collected for the health economics evaluation. Follow-up was at 4 and 12 months post randomisation. Analysis was performed on an intention-to-treat basis.

RESULTS

We randomised 490 patients (244 to usual care, 246 to exercise programme). Compliance with the treatments was very good (93% of usual care participants and 75% of exercise programme participants completed treatment). Outcomes were obtained for 89% of participants at 12 months (222 for usual care, 216 for exercise programme). There was a statistically significant difference in favour of the exercise programme for the primary outcome at 4 and 12 months [mean difference 4.6 points, 95% confidence interval (CI) 2.2 to 7.0 points; and mean difference 4.4 points, 95% CI 1.6 to 7.1 points, respectively]. There were no significant differences in pain scores or adverse events. The estimated difference in mean quality-adjusted life-years (QALYs) accrued over 12 months was 0.01 greater (95% CI -0.03 to 0.05) in the exercise programme group. Imputed analysis produced incremental cost-effectiveness ratio estimates of £17,941 (0.59 probability of cost-effectiveness at willingness-to-pay threshold of £30,000 per QALY). The qualitative study found the exercise programme to be acceptable and highlighted the importance of the therapist in enabling patients to establish a routine and incorporate the exercises into their lives.

CONCLUSIONS

The results of the Strengthening And stretching for Rheumatoid Arthritis of the Hand trial suggest that the addition of an exercise programme for RA hands/wrists to usual care is clinically effective and cost-effective when compared with usual care alone. No adverse effects were associated with the exercise programme. The economic analysis suggests that the intervention is likely to be cost-effective.

STUDY REGISTRATION

Current Controlled Trials ISRCTN 89936343.

Noninvasive and alternative management of chronic low back pain (efficacy and outcomes)

OBJECTIVES

The goal of this article is to provide a thorough literature review of available noninvasive and alternative treatment options for chronic low back pain. In particular, the efficacy of each therapy is evaluated and pertinent outcomes are described.

MATERIALS AND METHODS

A comprehensive search for available literature was done through PubMed and Cochrane data base for topics discussed in this paper.

RESULTS

Relevant current and past references were reviewed and presented to reflect the efficacy of each therapy and related outcomes.

CONCLUSIONS

There are a wide variety of noninvasive and alternative therapies for the treatment of chronic low back pain. Those with the strongest evidence in the literature for good efficacy and outcomes include exercise therapy with supervised physical therapy, multidisciplinary biopsychosocial rehabilitation, and acupuncture. Therapies with fair evidence or moderately supported by literature include yoga, back schools, thermal modalities, acupressure, and cognitive-behavioral therapy. Those therapies with poor evidence or little to no literature support include manipulation, transcutaneous electrical nerve stimulation, low-level laser therapy, reflexology, biofeedback, progressive relaxation, hypnosis, and aromatherapy. Providers delivering care for patients with chronic low back pain must carefully evaluate these available treatment options related to their efficacy or lack thereof as well as relevant outcomes.

Outcome measures for hand function naturally reveal three latent domains in older adults: strength, coordinated upper extremity function, and sensorimotor processing

Understanding the mapping between individual outcome measures and the latent functional domains of interest is critical to a quantitative evaluation and rehabilitation of hand function. We examined whether and how the associations among six hand-specific outcome measures reveal latent functional domains in elderly individuals. We asked 66 healthy older adult participants (38F, 28M, 66.1 ± 11.6 years, range: 45–88 years) and 33 older adults (65.8 ± 9.7 years, 44–81 years, 51 hands) diagnosed with osteoarthritis (OA) of the carpometacarpal (CMC) joint, to complete six functional assessments: hand strength (Grip, Key and Precision Pinch), Box and Block, Nine Hole Pegboard, and Strength-Dexterity tests. The first three principal components suffice to explain 86% of variance among the six outcome measures in healthy older adults, and 84% of variance in older adults with CMC OA. The composition of these dominant associations revealed three distinct latent functional domains: strength, coordinated upper extremity function, and sensorimotor processing. Furthermore, in participants with thumb CMC OA we found a blurring of the associations between the latent functional domains of strength and coordinated upper extremity function. This motivates future work to understand how the physiological effects of thumb CMC OA lead upper extremity coordination to become strongly associated with strength, while dynamic sensorimotor ability remains an independent functional domain. Thus, when assessing the level of hand function in our growing older adult populations, it is particularly important to acknowledge its multidimensional nature—and explicitly consider how each outcome measure maps to these three latent and fundamental domains of function. Moreover, this ability to distinguish among latent functional domains may facilitate the design of treatment modalities to target the rehabilitation of each of them.

To evaluate the efficacy of Mobilization Techniques in Post-Traumatic stiff ankle with and without Paraffin Wax Bath

OBJECTIVE

Mobilization techniques are frequently used by physiotherapists to reduce pain, improve joint movement and facilitate return to activities after injury. The objective of this study was to explore differences in the efficacy of Mobilization Techniques in Post-Traumatic stiff ankle with and without Paraffin Wax Bath.

METHODS

Thirty seven patients of Post Traumatic stiff ankle were recruited for the study at Sajid Physiotherapy & Rehabilitation center, Multan from March 2011 to February 2013. It was a randomized controlled trial and the patients with equal grades of severity were placed in control and study groups. Group A had nineteen patients and Group B had 18 patients. The inclusion criteria were age range from 20-60 years, pain, loss of ROM, with history of trauma and fracture of ankle. The patients with similar complaints but with surgical treatment were excluded. Group A was given mobilization techniques with paraffin wax bath while group B was treated without paraffin wax bath. Improvement was observed by EscolaPaulista de Medicina Range of Motion (EPM-ROM) scale and visual analogue scale (VAS). After ten weeks of treatment, the patients were re-evaluated by an orthopedic surgeon and a Physiotherapist for their symptoms and ROM. t-test was applied to compare outcome between two groups and p < 0.05 was considered to be statistically significant.

RESULTS

Group A had nineteen patients and Group B had 18 patients and both were treated for ten weeks. There were 12 male and 7 female patients in group A and 10 male and 8 female in group B. At the start of treatment the basic characteristic were similar in both the groups. Deficits in dorsiflexion, planterflexion, inversion, eversion pain and stiffness were measured before and after the treatment period. Pain relief was found better in both groups which were considered statistically significant with p=0.001, group A (1.135 ± 0.359) vs. group B (1.135 ± 0.359). ROM in pre and post treatment degrees showed that dorsiflexion was significantly increased in group A (1.135 ± 0.359) vs. group B (1.135 ± 0.0359).) and planterflexion was in group A (1.337 ± 0.422) vs. group B (0.841 ± 0.264). Functional movement showed improvement in inversion in group A (0.875 ± 0.276) vs. group B (0.966 ± 0.305) and in eversion in group A (0.948 ± 0.300) vs. group B (0.674 ± 0.213). Mobilization Techniques followed by wax bath resulted in significant improvements of range of motion (ROM), clinical and functional changes. Wax bath alone had no significant effect. After ten weeks intervention treatment, t-test was applied to compare outcome between the two groups and p=0.001to 0.004 in group A and p= 0.104 to 0.168 in group B, (p<0.05) was obtained which shows statistical significance.

CONCLUSION

Joint mobilization and wax bath therapy is an effective and beneficial tool to improve the symptoms and quality of life in post traumatic stiff ankle patients. Joint mobilization techniques combined with wax bath are more effective in the management of post-traumatic stiff ankle as compared to wax therapy alone.

Task-oriented training with computer gaming in people with rheumatoid arthritisor osteoarthritis of the hand: study protocol of a randomized controlled pilot trial

Background

Significant restriction in the ability to participate in home, work and community life results from pain, fatigue, joint damage, stiffness and reduced joint range of motion and muscle strength in people with rheumatoid arthritis or osteoarthritis of the hand. With modest evidence on the therapeutic effectiveness of conventional hand exercises, a task-oriented training program via real life object manipulations has been developed for people with arthritis. An innovative, computer-based gaming platform that allows a broad range of common objects to be seamlessly transformed into therapeutic input devices through instrumentation with a motion-sense mouse has also been designed. Personalized objects are selected to target specific training goals such as graded finger mobility, strength, endurance or fine/gross dexterous functions. The movements and object manipulation tasks that replicate common situations in everyday living will then be used to control and play any computer game, making practice challenging and engaging.

Methods/Design

The ongoing study is a 6-week, single-center, parallel-group, equally allocated and assessor-blinded pilot randomized controlled trial. Thirty people with rheumatoid arthritis or osteoarthritis affecting the hand will be randomized to receive either conventional hand exercises or the task-oriented training. The purpose is to determine a preliminary estimation of therapeutic effectiveness and feasibility of the task-oriented training program. Performance based and self-reported hand function, and exercise compliance are the study outcomes. Changes in outcomes (pre to post intervention) within each group will be assessed by paired Student t test or Wilcoxon signed-rank test and between groups (control versus experimental) post intervention using unpaired Student t test or Mann–Whitney U test.

Discussion

The study findings will inform decisions on the feasibility, safety and completion rate and will also provide preliminary data on the treatment effects of the task-oriented training compared with conventional hand exercises in people with rheumatoid arthritis or osteoarthritis of the hand.

Trial registration

ClinicalTrials.gov: NCT01635582

Strengthening and stretching for rheumatoid arthritis of the hand (SARAH): design of a randomised controlled trial of a hand and upper limb exercise intervention--ISRCTN89936343

BACKGROUND

Rheumatoid Arthritis (RA) commonly affects the hands and wrists with inflammation, deformity, pain, weakness and restricted mobility leading to reduced function. The effectiveness of exercise for RA hands is uncertain, although evidence from small scale studies is promising. The Strengthening And Stretching for Rheumatoid Arthritis of the Hand (SARAH) trial is a pragmatic, multi-centre randomised controlled trial evaluating the clinical and cost effectiveness of adding an optimised exercise programme for hands and upper limbs to best practice usual care for patients with RA.

METHODS/DESIGN

480 participants with problematic RA hands will be recruited through 17 NHS trusts. Treatments will be provided by physiotherapists and occupational therapists. Participants will be individually randomised to receive either best practice usual care (joint protection advice, general exercise advice, functional splinting and assistive devices) or best practice usual care supplemented with an individualised exercise programme of strengthening and stretching exercises. The study assessors will be blinded to treatment allocation and will follow participants up at four and 12 months. The primary outcome measure is the Hand function subscale of the Michigan Hand Outcome Questionnaire, and secondary outcomes include hand and wrist impairment measures, quality of life, and resource use. Economic and qualitative studies will also be carried out in parallel.

DISCUSSION

This paper describes the design and development of a trial protocol of a complex intervention study based in therapy out-patient departments. The findings will provide evidence to support or refute the use of an optimised exercise programme for RA of the hand in addition to best practice usual care.

The comparative effectiveness of tendon and nerve gliding exercises in patients with carpal tunnel syndrome: a randomized trial

OBJECTIVE

: The aim of this study was to investigate the effectiveness of tendon and nerve gliding exercises as a part of combined treatments for carpal tunnel syndrome.

DESIGN

: Patients with carpal tunnel syndrome were randomized into three groups. All patients received conventional treatments (splint and paraffin therapy, as in group 3), but group 1 underwent additional tendon gliding exercises and group 2 underwent additional nerve gliding exercises. Each patient received a package of questionnaires and underwent physical examinations and nerve conduction study of the upper limbs before and after treatment for 2 mos.

RESULTS

: Sixty patients were recruited, and 53 completed the study. There were significant improvements in symptom severity and pain scale scores in all groups. However, only group 1 showed significant improvements in their scores on functional status; the Disabilities of the Arm, Shoulder, and Hand questionnaire; and the physical domain of the World Health Organization Quality of Life Questionnaire Brief Version. After adjusting for baseline data, we found significant differences in the functional status scores among the groups. Post hoc analyses detected a significant difference in functional status scores between groups 1 and 2.

CONCLUSIONS

: The combination of tendon gliding exercises with conventional treatments may be more effective than that of nerve gliding exercises with conventional treatments.

Thermal effectiveness of different IR radiators employed in rheumatoid hand therapy as assessed by thermovisual examination

We conducted a thermovisual comparison of mean hand surface temperature changes upon local heating with two different IR sources. Sixty-six patients with rheumatoid arthritis (47 women and 19 men; average age, 56.1 ± 8.6 years) were subjected to topical heat therapy for one hand with either the standard IR radiator (SIR) or the water filter IRA (wIRA). The surface temperature of the dorsal side of both hands was measured, and thermal images were taken before and up to 2 h after treatment. At 1 min after treatment, SIR application increased the surface skin temperature of the heated hand from 31.5 ± 1.9 to 35.0 ± 1.9 °C (P<0.05), while wIRA increased it from 32.1 ± 1.6 to 34.2 ± 1.1 °C (P<0.05). Constant decline in temperature was observed immediately after treatment, with the temperatures reaching baseline in about 30 and 120 min after wIRA and SIR treatment, respectively. Similar temperature changes were observed in the heated hands for wIRA and SIR, except at 1 min after treatment. Changes in the untreated hands indicated contralateral reaction. The temperature of the warmed hand showed a correlation to the body mass index.

Occupational therapy-based and evidence-supported recommendations for assessment and exercises in hand osteoarthritis

AIMS

The aims of this study were to develop recommendations for occupational therapy assessment and design of hand exercise programmes in patients with hand osteoarthritis.

METHODS

An expert group followed a Delphi procedure to reach consensus for up to 10 recommendations for assessment and exercises, respectively. Thereafter, an evidence-based approach was used to identify and appraise research evidence supporting each recommendation, before the recommendations were validated by the expert group.

RESULTS

The process resulted in 10 recommendations for assessment and eight for design of exercise programmes. The literature search revealed that there is a paucity of clinical trials to guide recommendations for hand osteoarthritis, and the evidence for the majority of the recommendations was based on expert opinions. Also, even if a systematic review demonstrates some evidence for the efficacy of strength training exercises in hand OA, the evidence for any specific exercise is limited to expert opinions.

CONCLUSIONS

A first set of recommendations for assessment and exercise in hand osteoarthritis has been developed. For many of the recommendations there is a paucity of research evidence. High-quality studies are therefore needed to establish a high level of evidence concerning functional assessment and the effect of hand exercises in hand osteoarthritis.

Evaluation of paraffin bath treatment in patients with systemic sclerosis

OBJECTIVE

To investigate the effects of treatment with paraffin bath in patients with systemic sclerosis (scleroderma).

METHODS

In 17 patients with scleroderma one hand was treated daily with paraffin bath in combination with hand exercise. The other hand was treated with exercise only and was considered a control. Hand function was estimated before treatment and after 1 month of treatment, concerning hand mobility and grip force, and perceived pain, stiffness and skin elasticity.

RESULTS

At the follow-up, finger flexion and extension, thumb abduction, volar flexion in the wrist, and perceived stiffness and skin elasticity had improved significantly in the paraffin-treated hand compared with the baseline values. The improved hand function was independent of skin score and disease duration. Improvements in function were significantly greater in the hand which was treated with paraffin bath and exercise than in the hand treated with exercise only concerning extension deficit, perceived stiffness and skin elasticity.

CONCLUSIONS

In this pilot study hand exercise in combination with paraffin bath seemed to improve mobility, perceived stiffness and skin elasticity. However, further studies with larger sample size are needed to attain more reliable results of the effect of paraffin bath treatment in patients with scleroderma.

Rehabilitation in rheumatoid arthritis: a critical review

This article considers the evidence for effectiveness and timing of rehabilitation for people with rheumatoid arthritis (RA). The Cochrane Library, DARE, Medline, Embase, CINAHL and AMED were searched to identify systematic reviews and randomized controlled trials evaluating rehabilitation interventions for people with rheumatoid arthritis. Many trials identified had methodological limitations (e.g. short follow-up periods, small sample sizes). Evidence to date is that symptomatic relief results from thermotherapy, laser therapy, acupuncture and assistive devices. In the short-term, comprehensive occupational therapy (in established rheumatoid arthritis), orthoses, and mind-body approaches can help maintain function. Over at least a one-year period, the following are effective in reducing pain and maintaining function: patient education and joint protection training using behavioural approaches; dynamic exercise therapy, hand exercises and hydrotherapy; and cognitive-behavioural therapy (in people with poorer psychological status). Many trials have recruited people with moderate to severe, established RA and relatively little is known about the long-term effectiveness of early rehabilitation, although this is becoming much more common in practice. Despite the increased availability of guidelines and systematic reviews, most conclude there is insufficient evidence for many areas of rheumatology rehabilitation. Further well-designed clinical trials are needed recruiting people with early disease using patient-centred outcomes.

Physical agents used in the management of chronic pain by physical therapists

Evidence supporting the use of specific physical agents in the management of chronic pain conditions is not definitive; it is largely incomplete and sometimes contradictory. However, the use of agents in chronic pain management programs is common. Within the broad use of physical agents, they are rarely the sole modality of treatment. A 1995 American Physical Therapy Association position statement asserts that "Without documentation which justifies the necessity of the exclusive use of physical agents/modalities, the use of physical agents/modalities, in the absence of other skilled therapeutic or educational intervention, should not be considered physical therapy". Physical agents may serve as useful adjunctive modalities of pain relief or to enhance the effectiveness of other elements in therapy geared toward resolution of movement impairments and restoration of physical function. Given that a conclusive aggregate of findings is unlikely to exist for all permutations of patient conditions, combined with interacting therapeutic modalities, an evidence-based approach to pain management is not always possible or beneficial to the patient. In the face of inconclusive evidence, a theory-based approach may help determine if the therapeutic effect ofa given physical agent has the possibility of being a useful clinical tool in the context of treating a particular patient's mechanism of pain generation. Until controlled efficacy findings are definitive, careful individual patient response monitoring of thoughtful theoretical application of adjunctive physical agents may be a prudent approach to the management of chronic pain.

A Geriatrician's Guide to the Use of the Physical Modalities in the Treatment of Pain and Dysfunction

The use of the physical modalities in the treatment of musculoskeletal conditions has a long and rich history. This article explores the various physical modalities and their indications, precautions, and contraindications, especially in their applied use in pain management. It also highlights the role of the physical modalities as agents for the management of pain in the geriatric population.

Occupational therapy during the first 10 years of rheumatoid arthritis

OBJECTIVE

To describe disease development and occupational therapy during the first 10 years of rheumatoid arthritis (RA), and to assess patients' experiences of occupational therapy and comprehensive care.

METHODS

A total of 168 early RA patients with variable disease severity were followed up with regular team visits. The occupational therapist evaluated hand function and activity and performed the necessary interventions. These were recorded and the number of visits generating interventions was calculated. Semi-structured interview of 11 patients regarding their views of occupational therapy and team contact was performed.

RESULTS

Impairments of hand function were in general mild to moderate and remained fairly unchanged over time. Activity limitations increased slowly. Half of the follow-up visits generated interventions. Most common were prescriptions of assistive devices and orthoses, hand-training instructions and patient education. The patients interviewed were positive regarding occupational therapy and felt safe with comprehensive care.

CONCLUSION

RA patients in all stages of the disease benefit from regular contact with an occupational therapist and team care.

Conservative hand therapy treatments in rheumatoid arthritis--a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of three different physiotherapeutic approaches in the management of the rheumatoid hand.

METHODS

In a randomized controlled trial, participants with rheumatoid arthritis (RA) recruited from a rheumatology department in Mid-Staffordshire, UK (February 1999 to January 2001) were randomized to three groups. All received joint protection (JP) information delivered by a therapist at baseline. Group 1 participants received a set of additional hand-strengthening and mobilizing home exercises, group 2 a different set of additional hand-stretching exercises and group 3 the JP information alone. The primary outcome was the Arthritis Impact Measurement Scales II (AIMS II) (upper limb; hand and finger function subscales). Outcomes were assessed at baseline and 1, 3 and 6 months. Analysis was by intention to treat.

RESULTS

Sixty-seven participants (mean age 59.6 yr) were recruited: group 1 n = 21, group 2 n = 24 and group 3 n = 22. A 78% follow-up was achieved at 6 months. There was a mean fall (SD) in AIMS II upper limb function 0-6 month change scores in group 1 of 1.00 (1.07). In groups 2 and 3 there was a mean increase in AIMS II scores of 0.18 (1.54) and 0.30 (1.22), respectively. The differences in AIMS change scores between group 1 and groups 2 and 3 were statistically significant (P = 0.007) and remained so after adjustment for multiple testing (P = 0.012).

CONCLUSION

Statistically significant improvements in arm function have been demonstrated following a programme of home-strengthening hand exercises in RA patients compared with simple stretches or advice alone.

The effectiveness of hand exercises for persons with rheumatoid arthritis: a systematic review

A systematic review was conducted to evaluate the efficacy of hand exercises for persons with rheumatoid arthritis. The databases Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, PEDro, and Cochrane were used to search for articles on exercise and hand and rheumatoid arthritis (and their synonyms). Any articles that evaluated the effects of exercise on the hand were included in the review and evaluated for quality on a form specifically developed for the reviews in this issue. Only nine studies evaluated the effect of hand exercise or a program that included hand exercise. Quality scores ranged from 21 to 39 out of a possible 48. Few studies used psychometrically sound measures or reported on changes to everyday function. Although some significant results were obtained, they may have been due to multiple outcome measures, lack of blinding, and within-group rather than between-group comparisons. Impairment and dexterity were frequent outcomes, but measurement of self-report function was lacking. Long-term exercise may increase strength, but results on range of motion are inconsistent across studies, subjects, and joints. There is a need for randomized controlled trials with goal-specific exercise, measurement of outcomes appropriate to the goals, adequate sample size, and comparison with an appropriate control condition.

A randomised controlled trial of occupational therapy for people with early rheumatoid arthritis

BACKGROUND

Occupational therapy (OT) aims at improving performance of daily living tasks, facilitating successful adjustments in lifestyle, and preventing losses of function.

OBJECTIVE

To evaluate the effects of a pragmatic, comprehensive OT programme on self management and health status of people with early rheumatoid arthritis (RA) (<2.5 years).

METHODS

A randomised, controlled "assessor blinded" trial was conducted with assessments made at entry, 6, 12, and 24 months. Main outcomes were AIMS2: physical function (PF), pain visual analogue scale (VAS), and Arthritis Self-Efficacy Scale (ASES).

RESULTS

Groups had similar disease duration (9 months OT (n = 162) v 10 months control (n = 164)). The OT group received 7.57 (SD 3.04) hours of therapy. Self management significantly increased in the OT group. Otherwise, there were no significant differences in any outcome measures, or between groups, by ACR functional class: AIMS2: PF (F = 0.04; p = 0.96); pain VAS (F = 0.29; p = 0.74); total ASES score (F = 0.93; p = 0.39).

CONCLUSIONS

OT improved self management but not health status in early RA. Functional ability remains reasonably good for many in the first five years, so preventive benefits of self management may not yet be apparent and longer follow up is needed. Although many considered the education and therapy useful, insufficient numbers in the OT group used self management sufficiently to make a difference. Behavioural approaches can improve adherence and, potentially, the long term benefits. Future research should evaluate OT as a complex intervention and develop programmes from a theoretical and evidence base.

Occupational therapy for rheumatoid arthritis

BACKGROUND

For persons with rheumatoid arthritis (RA) the physical, personal, familial, social and vocational consequences are extensive. Occupational therapy (OT), with the aim to facilitate task performance and to decrease the consequences of rheumatoid arthritis for daily life activities, is considered to be a cornerstone in the management of rheumatoid arthritis. Till now the efficacy of occupational therapy for patients with rheumatoid arthritis on functional performance and social participation has not been systematically reviewed.

OBJECTIVES

To determine whether OT interventions (classified as comprehensive therapy, training of motor function, training of skills, instruction on joint protection and energy conservation, counseling, instruction about assistive devices and provision of splints) for rheumatoid arthritis patients improve outcome on functional ability, social participation and/or health related quality of life.

SEARCH STRATEGY

Relevant full length articles were identified by electronic searches in Medline, Cinahl, Embase, Amed, Scisearch and the Cochrane Musculoskeletal group Specialised Register. The reference list of identified studies and reviews were examined for additional references. Date of last search: December 2002.

SELECTION CRITERIA

Controlled (randomized and non-randomized) and other than controlled studies (OD) addressing OT for RA patients were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

The methodological quality of the included trials was independently assessed by two reviewers. Disagreements were resolved by discussion. A list proposed by Van Tulder et al. (Van Tulder 1997) was used to assess the methodological quality. For outcome measures, standardized mean differences were calculated. The results were analysed using a best evidence synthesis based on type of design, methodological quality and the significant findings of outcome and/or process measures.

MAIN RESULTS

Thirty-eight out of 58 identified occupational therapy studies fulfilled all inclusion criteria. Six controlled studies had a high methodological quality. Given the methodological constraints of uncontrolled studies, nine of these studies were judged to be of sufficient methodological quality. The results of the best evidence synthesis shows that there is strong evidence for the efficacy of "instruction on joint protection" (an absolute benefit of 17.5 to 22.5, relative benefit of 100%) and that limited evidence exists for comprehensive occupational therapy in improving functional ability (an absolute benefit of 8.7, relative benefit of 20%). Indicative findings for evidence that "provision of splints" decreases pain are found (absolute benefit of 1.0, relative benefit of 19%).

REVIEWER'S CONCLUSIONS

There is evidence that occupational therapy has a positive effect on functional ability in patients with rheumatoid arthritis.

Efficacy of rehabilitative therapy in regional musculoskeletal conditions

This chapter reviews the best evidence for the rehabilitation of regional musculoskeletal conditions. Evidence-based efficacy of different modalities for treatment of musculoskeletal pain is presented, and the value of the patient's active participation in the rehabilitation programme is emphasized. The following modalities are commonly included in the holistic approach to patient-centred care and are reviewed: exercise therapy, thermotherapy, transcutaneous electrical nerve stimulation (TENS), and alternative therapies such as acupuncture, massage and yoga. A review of cognitive-behavioural strategies in pain management to prevent or treat fear-avoidance behaviour is also presented. Furthermore, the application of biomechanics in treating and preventing musculoskeletal disorders is illustrated. Moreover, the evidence for pain self-management to improve symptoms, health status and decrease the utilization of health care resources and cost is outlined. Finally, an overview will be presented, concerning the application of the evidence for treatment modalities to patient care, with focus on patient-centred, holistic treatment in a supportive setting. The following key questions/issues are addressed. What are the relevant therapeutic modalities for musculoskeletal pain disorders? What is the evidence of efficacy of these modalities in regional musculoskeletal conditions? What is the importance of understanding biomechanics? What is the importance of understanding fear-avoidance beliefs? What is the evidence for 'alternative' therapies such as acupuncture, massage or yoga? What is the evidence for 'pain self-management?' How does one apply the evidence for rehabilitation in regional musculoskeletal conditions into clinical practice?

Physical and exercise therapy for treatment of the rheumatoid hand

OBJECTIVE

To study the short-term effects of physical therapy (ice massage or wax packs, thermal baths, and faradic hand baths) and exercise therapy on the rheumatoid hand.

METHODS

The effect of individual physical therapy and exercise therapy programs was evaluated in 50 randomly selected rheumatoid arthritis inpatients (38 women and 12 men). Mean patient age (+/- SD) was 47.94 +/- 11.22 years, and mean disease duration was 5.04 +/- 4.80 years. The control group consisted of 50 randomly selected rheumatoid arthritis outpatients (37 women and 13 men; mean age 48.46 +/- 10.65 years, mean duration of disease 5.23 +/- 4.89 years) who at the time of the investigation were not receiving any physical or exercise therapy. The clinical indices used for evaluation of inflammation included erythrocyte sedimentation rate (ESR), pain intensity, proximal interphalangeal (PIP) joint size, and Ritchie articular index. Hand grip strength, palmar tip-to-tip and key pinch finger strength, finger range of motion, and activities of daily living (ADL) were the parameters used to assess the functional hand status. The study was single-blinded and of 3 weeks duration.

RESULTS

In the physical therapy treated group, there was an improvement for most of the observed indices from baseline parameters that achieved statistical significance (P < 0.01 and P < 0.005) after the 3-week study period. ESR and PIP joint size improved clinically but failed to reach statistical significance. Patients had a more significant improvement in hand pain, joint tenderness, and ADL score (P < 0.005) than in range of motion (P < 0.01). All parameters in the control group slightly deteriorated over the study period.

CONCLUSION

At least in the short term, physical and, particularly, exercise therapy produce a favorable improvement in the functional status of the rheumatoid hand.