Prescribing hand strengthening exercise for patients with rheumatoid arthritis; clinical cues influencing occupational therapists' and physiotherapists' judgements

OBJECTIVE

To explore the clinical judgements of therapists in prescribing the intensity of hand strengthening exercise in rheumatoid arthritis (RA).

METHODS

Phase I: Eleven therapists knowledgeable in treating patients with RA subjectively identified seven clinical cues. These were incorporated into 54 hypothetical patient case scenarios.

PHASE II

Therapists with ≥2 years post-registration experience and current or recent experience in treating patients with RA were asked to assess 69 case scenarios in total (54 + 15 repeats) and judge what intensity of hand strengthening exercise they would prescribe using the OMNI-Resistance Exercise Scale of perceived exertion. Using responses to the repeated cases, the Cochran-Weiss-Shanteau index of expertise was used to identify therapists who prescribed more consistently. Multiple regression was used to determine which clinical cues were most strongly associated with the intensity of exercise prescribed. A sub-group analysis explored differences between consistent and inconsistent prescribers.

RESULTS

Fifty-three therapists took part. Thirty completed all 69 case scenarios. Across all therapists, the three most important clinical cues associated with lower intensity of exercise prescribed were (1) Patient's reported pain intensity whilst practising the exercise (β = -1.150, p < 0.001), (2) Disease activity (β = -0.425, p < 0.001) and (3) average hand pain over the last week (β = -0.353 p < 0.001). Twelve therapists were categorised as consistent prescribers. This group relied on fewer clinical cues (three vs. seven) when judging what intensity of exercise to prescribe.

CONCLUSION

This study provides insights into how therapists prescribe hand exercises. Intensity of hand strengthening exercise was influenced by three key clinical cues, including pain intensity and disease activity.

Systematic review and meta-analysis of preoperative interventions to support the maturation of arteriovenous fistulae in patients with advanced kidney disease

BACKGROUND

There is great potential to improve outcomes of arteriovenous fistulas (AVFs) by focusing more on the preoperative period of AVF creation. We aim to systematically review the evidence on safety and efficacy of various preoperative interventions that have been tried to improve AVF maturation and success rate.

METHODS

We searched five databases: PubMed, Embase, CINAHL, Cochrane Library and King's Fund Library. Experimental studies that investigated the effect of various preoperative interventions to improve AVF outcomes among advanced chronic kidney disease (CKD) patients were searched. The effect size for primary outcome was calculated as the weighted mean difference in the final vessel calibre, rate of AVF maturation or primary failure between the intervention and control arm. We also assessed adverse effects and dropout rates. This review was preregistered in the International Prospective Register of Systematic Reviews (CRD42020193257).

RESULTS

Eight eligible studies were identified involving three types of intervention: hand exercise (n = 6), cholecalciferol supplementation (n = 1) and pneumatic compression of the arm using a Fist Assist device (n = 1). The overall effect size of hand exercise on distal cephalic vein calibre was 0.24 mm [95% confidence interval (CI) 0.03-0.45] on meta-analysis of hand exercise studies. On restricting analysis to two randomized controlled trials (RCTs) that had independent control groups, the effect size was higher, at 0.29 mm (95% CI 0.11-0.47). Hand exercise was a well-tolerated intervention, especially when confined to the first 4 weeks.

DISCUSSION

Hand exercise is the predominant intervention tried in the preoperative period of AVF creation, although there is methodological heterogeneity. Intermittent pneumatic compression using a Fist Assist device is a novel intervention that has shown some promise. Well-designed prospective RCTs are needed on preoperative interventions among advanced CKD patients, aimed at improving AVF outcomes.

Understanding prescribed dose in hand strengthening exercise for rheumatoid arthritis: A secondary analysis of the SARAH trial

OBJECTIVE

1) To identify therapist or participant characteristics associated with prescribed dose of hand strengthening exercise in adults with rheumatoid arthritis and 2) To determine the impact of dose prescribed on outcome (hand function and grip strength).

METHODS

Overall dose was calculated using area under the curve (AUC). Analysis 1 assessed the association between therapist professional background, therapist grade, baseline participant physical and psychological characteristics and prescribed dose. Analyses 2 and 3 estimated the relationship between prescribed dose and overall hand function and grip strength. Generalised estimating equation linear regression analysis was used.

RESULTS

Analysis 1: Being treated by an occupational therapist (β = -297.0, 95% CI -398.6, -195.4), metacarpophalangeal joint deformity (β = -24.1, 95% CI -42.3, -5.9), a higher number of swollen wrist/hand joints (β = -11.4, 95% CI -21.6, -1.2) and the participant feeling downhearted and low all of the time (β = -293.6, 95% CI -436.1, -151.1) were associated with being prescribed a lower dose. Being treated by a grade 6 therapist (β = 159.1, 95% CI 65.7, 252.5), higher baseline grip strength (β = 0.15, 95% CI 0.02, 0.28) and greater participant confidence to exercise without fear of making symptoms worse (β = 18.9, 95% CI 1.5, 36.3) were associated with being prescribed a higher dose. Analyses 2 and 3: Higher dose was associated with greater overall hand function (β = 0.005, 95% CI 0.001, 0.010) and full-hand grip strength (β = 0.014, 95% CI 0.000, 0.025) at 4-month.

CONCLUSION

Higher dose was associated with better clinical outcomes. Prescription of hand strengthening exercise is associated with both therapist and participant characteristics.

Determining Isolated Thumb Forces in Osteoarthritic and Healthy Persons

Carpometacarpal (CMC) osteoarthritis (OA) can dramatically impair thumb function resulting in the inability to complete basic tasks. Development of a method to detect thumb forces changes is essential to understand of the progression of carpometacarpal osteoarthritis and the effects of treatment. The goals of this study were to (1) develop a method to measure thumb forces in multiple directions, (2) perform an initial demonstration of this method on three populations, young healthy (YH), older healthy (OH), and older participants with carpometacarpal osteoarthritis, and (3) determine the effects of short-term exercises on thumb force production in these pilot groups. A multi-axis load cell with a custom-built apparatus and a hand grip dynamometer were used to measure thumb and grip forces. Forces were collected in four directions: radial abduction and adduction, and palmar abduction and adduction. All participants completed thumb and grip testing prior to (week 0), during (week 2), and following (week 6), a hand exercise regimen. Group differences and the effects of exercise on force production were determined. Hand exercises improved thumb forces in young healthy female participants during radial (p = 0.017) and palmar abduction (p = 0.031) and female participants with osteoarthritis during palmar abduction (p = 0.010). Exercise improved grip strength in young healthy males (p = 0.028), young healthy females (p = 0.041), and females with osteoarthritis (p = 0.027). This research demonstrates the successful use of a new device to determine isolated thumb forces, and its clinical utility to identify changes after a short exercise regimen.

[Using Interdisciplinary Cooperation to Improve the Rate of Proper Performance of a Hand Exercise Among Hemodialysis Patients With Arteriovenous Fistula Construction]

BACKGROUND & PROBLEMS

Patients who undergo new arteriovenous fistula (AVF) construction as part of their hemodialysis treatment program are required to perform hand exercises properly in order to maintain AVF function. However, poor performance of these hand exercises currently results in the failure of many patients to preserve AVF function.

PURPOSE

To increase the rate of performing this hand exercise properly from 55% to 80%.

RESOLUTION

A comprehensive investigation identified the following five main problems: (a) Insufficient muscular endurance; (b) Resistance was not labeled on the ball; (c) Difficulties with maintaining a grip on the ball during the exercise; (d) Lack of standardized education procedures; and (e) Nurses lack latest knowledge on the hand exercise. The strategies used to improve the situation included: (a) Interdisciplinary team cooperation with physiotherapists to design individualized resistance training regimens; (b) Exercise tool improvement; (c) Standardized AVF care; (d) Continuous education for nursing staffs; and (e) Seed teacher program for hand exercise.

RESULTS

The rate of proper hand exercise performance increased from 55% to 93%.

CONCLUSIONS

This nursing project involved an interdisciplinary team that included physiotherapists in order to successfully improve the rate at which the hand exercise was performed properly. This positive experience may be applied to other hemodialysis departments in the treatment of patients with AVF.

Hand exercise intervention in patients with polymyositis and dermatomyositis: a pilot study

OBJECTIVE

The aim of the present study was to develop a 12-week hand exercise intervention for patients with polymyositis (PM) and dermatomyositis (DM) and evaluate adherence, patients' opinions of the programme design and overall feasibility, and the effect on hand function and activity limitation after the intervention.

METHOD

A pilot hand exercise intervention was conducted on a convenience sample of 15 patients with reduced handgrip strength and established, inactive PM and DM. Acceptable adherence was set at 75%. The programme was evaluated based on patients' opinions regarding exertion, the movements involved and overall feasibility. Hand- and pinch-grip strength, grip ability, dexterity and activity limitation were assessed.

RESULTS

Eleven of 15 patients completed the intervention, with acceptable adherence of 78-100%. Measures of handgrip strength, dexterity and activity limitation were reduced at baseline compared with normative data from the literature. Throughout the intervention, rates of perceived exertion were scored between 'moderate' and 'fairly strong'. Finger abduction and adduction were excluded from the hand exercise programme because they were not feasible to perform. Repetitions of the exercise increased gradually to a maximum of 30 per movement. Patients regarded this as too time-consuming and suggested ten repetitions daily or 10-20 repetitions 2-4 times per week. There were some individual, clinically meaningful improvements in hand function and activity limitation. A comparison between baseline and after the intervention showed that the three-jaw (tripod) pinch-grip strength (left hand) had increased (p < 0.007; z = -2.7).

CONCLUSION

A hand exercise programme was found to be feasible to perform by patients with established PM or DM. The effect was limited, with few individual improvements in hand function and activity limitation, indicating a need to increase the resistance in the movements and to limit the duration of each exercise session.