Journal Article Review May 2017

Do hand exercises help patients with rheumatoid arthritis over extended time?

Williamson E et al: Hand exercises for patients with rheumatoid arthritis: an extended follow-up of the SARAH randomised controlled trial.  BMJ Open. 2017 Apr 12;7(4):e013121  free full text.

Investigators from the United Kingdom extended a previous study to determine the long-term benefits of a hand exercise program for patients with rheumatoid arthritis. The original study was called SARAH (Stretching And strengthening for Rheumatoid Arthritis in the Hand) and involved 490 patients studied at baseline and after four and twelve months.

In the original study, the control group received joint protection education, advice on total body mobility exercises, and if necessary, functional splinting over a maximum of three visits. The intervention group received the same best practices care as well as individually tailored exercise programs in up to six sessions spread over three months. The stretching and strengthening exercises were moderate to high intensity. The therapists provided advice and checked tolerability, progress, and adherence to the exercise program at each session.

Results at four and twelve months showed that the intervention improved hand function and was cost effective compared with usual care. The present study revisited the subjects over a year after the completion of the original study.

Two-thirds of the original study cohort provided mailed-questionnaire data for the extended follow-up, which occurred 26 months after the SARAH study was initiated. The groups remained equal for baseline characteristics including age, sex, disease duration, ethnicity, medications, and hand function scores.

Seventy-one percent of the intervention group reported performing their exercises at home three times weekly after four months into the original study, whereas 31% continued with this frequency of exercises after two years, which was statistically equal to the number of subjects in the control group performing regular exercises.

At two years, hand function remained improved in both groups over baseline measurements, but no significant differences were noted between the intervention and control groups.

The authors note that the reduction in hand function at 26 months compared to four and twelve months coincided with a reduction in self-reported adherence with the hand exercise program. In their discussion they raise the important question about how patients might be supported to maintain an exercise regimen over the long term. They note a need to educate patients, their primary care doctors, and the patients’ other health care professionals about the importance of regular exercise.

COMMENT: The response rate for the extended study was only two thirds of the original study, and the extended study was conducted only by mail, so examination measurements such as grip strength, dexterity, and ranges of motion were not included. None-the-less, the investigators showed a long-term, albeit diminished benefit of exercise. Logically because the patients did not maintain their self therapy.

Health maintenance seems to always be more difficult than disease intervention, yet avoidance of medical problems always wins out over treatment. Now that I am aware of the results of this extended study, I will make it a point to encourage my patients with rheumatoid arthritis to perform regular stretching and strengthening exercises. I will also send them to a hand therapist periodically for a refresher program. You may wish to similarly inform your patients and your referral sources about the benefits of sustained exercise.