Task-Oriented Training with Computer Games for People with Rheumatoid Arthritis or Hand Osteoarthritis: A Feasibility Randomized Controlled Trial

Reporting of Determinants of Health Inequities in Rheumatoid Arthritis Randomized Controlled Trials in Canada: A Scoping Review

OBJECTIVE

More than ever, it is important to consider inclusion and diversity in rheumatology research. We reviewed and synthesized randomized controlled trials (RCTs) for rheumatoid arthritis (RA) in Canada with the aim of characterizing participants and identifying how determinants of health inequities are reported.

METHODS

We conducted a scoping review following the Arksey and O'Malley framework. We searched Medline (1990 to December 2021), Embase (1990 to December 2021), and CENTRAL (inception to December 2021) for articles meeting inclusion criteria of: 1) used an RCT design; 2) evaluated pharmacologic or nonpharmacologic interventions; 3) included participants with RA; and 4) conducted in Canada. Data extraction was guided by the Campbell and Cochrane Equity Methods Group's PROGRESS-Plus framework on determinants that lead to health inequities (e.g., place of residence; race; occupation; gender/sex; religion; education; socioeconomic status; and social capital).

RESULTS

Of 6,290 unique records, 42 were eligible for inclusion. We grouped studies according to 3 time periods: before 2000; 2000-2010; and 2011 to present. Participants of included studies were mostly middle-aged, female, and White. Sex and age were the most widely reported determinants in 41 studies. Other determinants reported were race (15 studies), education (11 studies), socioeconomic status (7 studies), and occupation (6 studies). Religion, features of relationships, and time-dependent relationships were not reported in any study.

CONCLUSION

This scoping review suggests limited reporting on determinants of health inequities in RCTs for RA in Canada. Establishing reporting standards for equity factors in RCTs is important for addressing health inequities and informing accessible research and care for patients with RA.

Digital rehabilitation for hand and wrist pain: a single-arm prospective longitudinal cohort study

Supplemental Digital Content is Available in the Text.

This study supports that a fully remote digital care program is feasible and able to promote high patient engagement in the telerehabilitation of patients with wrist and hand pain.

Introduction:

Wrist and hand represent the third most common body part in work-related injuries, being associated with long-term absenteeism. Telerehabilitation can promote access to treatment, patient adherence, and engagement, while reducing health care–related costs.

Objective:

Report the results of a fully remote digital care program (DCP) for wrist and hand pain (WP).

Methods:

A single-arm interventional study was conducted on individuals with WP applying for a DCP. Primary outcome was the mean change in the Numerical Pain Rating Scale after 8 weeks (considering a minimum clinically important change of 30%). Secondary outcomes were: disability (Quick Disabilities of the Arm, Shoulder, and Hand questionnaire), analgesic intake, surgery intention, mental health (patient health questionnaire [PHQ-9] and generalized anxiety disorder [GAD-7]), fear-avoidance beliefs (FABQ-PA), work productivity and activity impairment, and engagement.

Results:

From 189 individuals starting the DCP, 149 (78.8%) completed the intervention. A significant pain improvement was observed (51.3% reduction (2.26, 95% CI 1.73; 2.78)) and 70.4% of participants surpassing minimum clinically important change. This change correlated with improvements in disability (52.1%), FABQ-PA (32.2%), and activities impairment recovery (65.4%). Improvements were also observed in other domains: surgery intent (76.1%), mental health (67.0% in anxiety and 72.7% in depression), and overall productivity losses (68.2%). Analgesic intake decreased from 22.5% to 7.1%. Mean patient satisfaction score was 8.5/10.0 (SD 1.8).

Conclusions:

These findings support the feasibility and utility of a fully remote DCP for patients with WP. Clinically significant improvements were observed in all health-related and productivity-related outcomes, alongside very high patient adherence rates and satisfaction. This study strengthens that management of WP is possible through a remote DCP, decreasing access barriers and potentially easing health care expenditure.

The effects of exergames on muscle strength: A systematic review and meta-analysis

This systematic review and meta-analysis examined studies on the chronic effects of exergames on muscle strength in humans. PubMed, Scopus, CENTRAL, Web of Science, SciELO, Biblioteca Virtual em Saúde, and Google Scholar were searched, and manual searches of the reference lists of included studies and hand-searches on Physiotherapy Evidence Database and ResearchGate were conducted from inception to August 10, 2020. Randomized and non-randomized exergame intervention studies with or without a non-exercise group and/or a "usual care intervention group" (any other intervention that did not incorporate exergames), which evaluated muscle strength through direct measurements, were included. Forty-seven and 25 studies were included in the qualitative review and meta-analysis, respectively. The between-groups meta-analyses showed no significant differences between exergames and non-exercise control groups for handgrip strength in heathy/unhealthy middle-aged/older adults or knee extension maximum voluntary isometric contraction (MVIC) in healthy older adults. However, exergames provided a greater increase in handgrip strength, knee flexion MVIC, and elbow extension MVIC, but not knee extension MVIC or elbow flexion MVIC, in individuals with different health statuses when compared to usual care interventions. Also, there was a greater increase in handgrip strength in children with hemiplegic cerebral palsy favouring usual care plus exergames compared to usual care interventions. These results suggest that exergames may improve upper and lower limb muscle strength in individuals with different heath statuses compared to usual care interventions, but not muscle strength in middle age/older adults after accounting for random error. Also, exergames appear to be a useful tool for improving handgrip strength in children with hemiplegic cerebral palsy when added to usual care. However, as the exergame interventions were applied in different populations and there currently are many different approaches to perform exergames, future randomized controlled trials with high methodological quality and large sample sizes are needed to provide more compelling evidence in favour of a specific exergame protocol, or to elucidate exergame protocol design principles that appear to strongly influence outcomes.

Digital Self-Management Interventions for People With Osteoarthritis: Systematic Review With Meta-Analysis

BACKGROUND

Osteoarthritis (OA) is not curable, but the symptoms can be managed through self-management programs (SMPs). Owing to the growing burden of OA on the health system and the need to ensure high-quality integrated services, delivering SMPs through digital technologies could be an economic and effective community-based approach.

OBJECTIVE

This study aims to analyze the effectiveness of digital-based structured SMPs on patient outcomes in people with OA.

METHODS

A total of 7 web-based and 3 gray literature databases were searched for randomized controlled trials assessing digital-based structured SMPs on self-reported outcomes including pain, physical function, disability, and health-related quality of life (QoL) in people with OA. Two reviewers independently screened the search results and reference lists of the identified papers and related reviews. Data on the intervention components and delivery and behavioral change techniques used were extracted. A meta-analysis, risk of bias sensitivity analysis, and subgroup analysis were performed where appropriate. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used to assess the quality of evidence.

RESULTS

A total of 8 studies were included in this review involving 2687 patients with knee (n=2); knee, hip, or both (n=5); and unspecified joint (n=1) OA. SMPs were delivered via telephone plus audio and video, internet, or mobile apps. Studies reported that digital-based structured SMPs compared with the treatment as usual control group (n=7) resulted in a significant, homogeneous, medium reduction in pain and improvement in physical function (standardized mean difference [SMD] -0.28, 95% CI -0.38 to -0.18 and SMD -0.26, 95% CI -0.35 to -0.16, respectively) at posttreatment. The digital-based structured SMP effect on pain and function reduced slightly at the 12-month follow-up but remained to be medium and significant. The posttreatment effect of digital-based structured SMPs was small and significant for disability, but nonsignificant for QoL (SMD -0.10, 95% CI -0.17 to 0.03 and SMD -0.17, 95% CI -0.47 to 0.14, respectively; each reported in 1 study only). The 12-month follow-up effect of the intervention was very small for disability and QoL. The quality of evidence was rated as moderate for pain and physical function and low and very low for disability and QoL, respectively, using the GRADE approach.

CONCLUSIONS

Digital-based structured SMPs may result in improvement in pain and physical function that is largely sustained at the 12-month follow-up in people with knee and hip OA. The effects on disability and QoL are smaller and less clear. The quality of evidence is moderate to low, and further research is required to confirm the findings of the review and assess the effects of digital-based structured SMPs on other health-related outcomes.

Effects of Video Games-Based Task-Oriented Activity Training (Xbox 360 Kinect) on Activity Performance and Participation in Patients With Juvenile Idiopathic Arthritis: A Randomized Clinical Trial

OBJECTIVE

The aim of the study was to compare the effects of two different task-oriented activity training programs on activity performance and participation in children/adolescents with juvenile idiopathic arthritis.

DESIGN

Sixty-two patients were randomized into group I and group II for task-oriented activity training. In group I, activities of daily living were practiced using real materials from daily life, and in group II, activities of daily living were practiced using video-based games (Xbox 360 Kinect) for 3 d/wk for 8 wks. Pain by the Numeric Rating Scale, upper limb muscle, grip, and pinch strengths by a dynamometer, activity performance and participation by the Childhood Health Assessment Questionnaire, Canadian Occupational Performance Measure, and Duruoz Hand Index were evaluated.

RESULTS

After treatment in both groups, significant changes were found in the Numeric Rating Scale, muscle strength, grips strength, Childhood Health Assessment Questionnaire, Canadian Occupational Performance Measure, and Duruoz Hand Index (P < 0.05). Group II was statistically superior to group I in changes of almost all upper limb muscle strengths, palmar pinch strength, Canadian Occupational Performance Measure satisfaction, and Duruoz Hand Index scores (P < 0.05).

CONCLUSION

Video games-based task-oriented activity training is an alternative and feasible treatment for children/adolescents with juvenile idiopathic arthritis. This new method may have widespread applicability in future research, given the rapidly growing interest in virtual reality-based therapy in rehabilitation.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Understand the rehabilitation benefits of task-oriented activity in patients with neurologic and musculoskeletal conditions; (2) Appreciate the role of video games-based task oriented activity in rehabilitation; and (3) Appropriately incorporate video games-based task oriented activity in the rehabilitation program of individuals with Juvenile Idiopathic Arthritis.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

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.

A Web-Based Training Resource for Therapists to Deliver an Evidence-Based Exercise Program for Rheumatoid Arthritis of the Hand (iSARAH): Design, Development, and Usability Testing

Background

The Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) is a tailored, progressive exercise program for people having difficulties with wrist and hand function due to rheumatoid arthritis (RA). The program was evaluated in a large-scale clinical trial and was found to improve hand function, was safe to deliver, and was cost-effective. These findings led to the SARAH program being recommended in the UK National Institute for Health and Care Excellence guidelines for the management of adults with RA. To facilitate the uptake of this evidence-based program by clinicians, we proposed a Web-based training program for SARAH (iSARAH) to educate and train physiotherapists and occupational therapists on delivering the SARAH program in their practice. The overall iSARAH implementation project was guided by the 5 phases of the analysis, design, development, implementation, and evaluation (ADDIE) system design model.

Objective

The objective of our study was to conduct the first 3 phases of the model in the development of the iSARAH project.

Methods

Following publication of the trial, the SARAH program materials were made available to therapists to download from the trial website for use in clinical practice. A total of 35 therapists who downloaded these materials completed an online survey to provide feedback on practice trends in prescribing hand exercises for people with RA, perceived barriers and facilitators to using the SARAH program in clinical practice, and their preferences for the content and Web features of iSARAH. The development and design of iSARAH were further guided by a team of multidisciplinary health professionals (n=17) who took part in a half-day development meeting. We developed the preliminary version of iSARAH and tested it among therapists (n=10) to identify and rectify usability issues and to produce the final version.

Results

The major recommendations made by therapists and the multidisciplinary team were having a simple Web design and layout, clear exercise pictures and videos, and compatibility of iSARAH on various browsers and devices. We rectified all usability issues in the preliminary version to develop the final version of iSARAH, which included 4 short modules and additional sections on self-assessment, frequently asked questions, and a resource library.

Conclusions

The use of the ADDIE design model and engagement of end users in the development and evaluation phases have rendered iSARAH a convenient, easy-to-use, and effective Web-based learning resource for therapists on how to deliver the SARAH program. There is also huge potential for adapting iSARAH across different cultures and languages, thus opening more opportunities for wider uptake and application of the SARAH program into practice.

The Effectiveness of a Computer Game-Based Rehabilitation Platform for Children With Cerebral Palsy: Protocol for a Randomized Clinical Trial

BACKGROUND

It is difficult to engage young children with cerebral palsy (CP) in repetitive, tedious therapy. As such, there is a need for innovative approaches and tools to motivate these children. We developed the low-cost, computer game-based rehabilitation platform CGR that combines fine manipulation and gross movement exercises with attention and planning game activities appropriate for young children with CP.

OBJECTIVE

The objective of this study is to provide evidence of the therapeutic value of CGR to improve upper extremity (UE) motor function for children with CP.

METHODS

This randomized controlled, single-blind, clinical trial with an active control arm will be conducted at 4 sites. Children diagnosed with CP between the ages of 4 and 10 years old with moderate UE impairments and fine motor control abnormalities will be recruited.

RESULTS

We will test the difference between experimental and control groups using the Quality of Upper Extremity Skills Test (QUEST) and Peabody Developmental Motor Scales, Second Edition (PDMS-2) outcome measures. The parents of the children and the therapist experiences with the interventions and tools will be explored using semi-structured interviews using the qualitative description approach.

CONCLUSIONS

This research protocol, if effective, will provide evidence for the therapeutic value and feasibility of CGR in the pediatric rehabilitation of UE function.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02728375; http:https://clinicaltrials.gov/ct2/show/NCT02728375 (Archived by WebCite at http://www.webcitation.org/6qDjvszvh).