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.
ANTECEDENTES: La osteoartritis es la principal causa de discapacidad en los adultos mayores. La evidencia de la efectividad de la autogestión de osteoartritis de la mano que falta.
MÉTODOS: En este estudio aleatorizado, factorial, que evaluaron la eficacia de la protección conjunta versus ninguna protección de las articulaciones, y el ejercicio mano versus ningún ejercicio de la mano en los adultos, de 50 años de edad o más, con osteoartritis de la mano. A raíz de una encuesta de población (n = 12 297), las personas elegibles se asignaron al azar (1: 1: 1: 1) a: folleto y asesoramiento; protección de las articulaciones; ejercicio de la mano; protección de las articulaciones más ejercicio mano. Ejercicios de protección conjunta y de la mano fueron entregados por nueve terapeutas ocupacionales, en cuatro sesiones de grupo. El resultado primario fue el criterio de respuesta OARSI / OMERACT a los 6 meses. Los resultados se recogen cegados a la asignación (3, 6, 12 m). El análisis fue por intención de tratar.
RESULTADOS: De 257 participantes asignados al azar (65: 62: 65: 65) (edad media (SD) 66 años (9,1); la hembra 66%) de seguimiento fue de 85% a los 6 m (n = 212). Las características basales y la pérdida durante el seguimiento fueron similares entre los grupos. No hubo efectos secundarios del tratamiento reportados. A los 6 m 33% de protección conjunta asignado eran respondedores frente al 21% sin protección conjunta (p = 0,03). De los ejercicios de manos asignados, 28% eran respondedores frente al 25% sin ejercicios (ns). Las diferencias en los resultados secundarios no fueron estadísticamente significativas, a excepción de mejoría en el dolor auto-eficacia de la protección conjunta (3 mp = 0,002; 6 mp = 0,001; 12 mp = 0,03).
CONCLUSIONES: Estos resultados muestran que los terapeutas ocupacionales pueden apoyar la autogestión en los adultos mayores con osteoartritis de la mano, y que la protección conjunta proporciona una intervención efectiva para el resultado a medio plazo. (Financiado por el ISRCTN Arthritis Research UK 33870549).
Abstract: OBJECTIVE: To evaluate the efficacy of paraffin bath therapy on pain, function, and muscle strength in patients with hand osteoarthritis. DESIGN: Prospective single-blinded randomized controlled trial. SETTING: Department of physical medicine and rehabilitation in a university hospital. Participants: Patients with bilateral hand osteoarthritis (N=56). INTERVENTIONS: Patients were randomized into 2 groups with a random number table by using block randomization with 4 patients in a block. Group 1 (n=29) had paraffin bath therapy (5 times per week, for 3-week duration) for both hands. Group 2 (n=27) was the control group. All patients were informed about joint-protection techniques, and paracetamol intake was recorded. MAIN OUTCOME MEASURES: The primary outcome measures were pain (at last 48h) at rest and during activities of daily living (ADL), assessed with a visual analog scale (0–10cm) at 12 weeks. The secondary outcome measures were the Australian Canadian Osteoarthritis Hand Index (AUSCAN) and the Dreiser Functional Index (DFI), used for subjective functional evaluation, loss of range of motion (ROM), grip and pinch strength, painful and tender joint counts, and paracetamol intake. A researcher blind to group allocation recorded the measures for both hands at baseline, 3 weeks, and 12 weeks at the hospital setting. RESULTS: At baseline, there were no significant differences between groups in any of the parameters (P>.05). After treatment, the paraffin group exhibited significant improvement in pain at rest and during ADL, ROM of the right hand, and pain and stiffness dimensions of the AUSCAN (P<.05). There was no significant improvement in functional dimension of the AUSCAN and the DFI (P>.05). The control group showed a significant deterioration in right hand grip and bilateral lateral pinch and right chuck pinch strength (P<.05), but there was no significant change in the other outcome measures. When the 2 groups were ...
OBJETIVOS: Reumatología directrices recomiendan que las personas con AR recibir educación para el autocuidado de comportamiento. En este estudio se desarrolló un programa modular de comportamiento en grupo y evaluar sus efectos a largo plazo sobre el dolor, el estado físico y psicológico.
MÉTODOS: Las personas con artritis reumatoide o psoriásica fueron asignados al azar a un programa de educación de la información centrada en modular la conducta o norma, tanto entregada por expertos en reumatología con experiencia en un gran hospital general de distrito. Las medidas de resultado fueron el dolor, la autoeficacia, la fatiga, la capacidad funcional, estado psicológico y el uso de los comportamientos de salud (ejercicio, protección de las articulaciones, la fatiga y los síntomas cognitivos). Con la intención de tratar el análisis de los resultados se compararon a los 6 y 12 meses con el análisis de covarianza.
Resultados: De los 498 pacientes remitidos, 218 aceptaron participar, se reunieron los criterios de inclusión y fueron asignados al azar, 51 se retiraron antes de la educación. De los pacientes restantes, 86 asistieron a las de los programas estándar de comportamiento y 81. Los participantes tenían entre 55,4 años (sd 12.42), con duración de la enfermedad de 7,39 (sd 6,88) años (53% <5 años). A los 6 meses, el grupo tuvo un mejor comportamiento del dolor (p = 0,01), fatiga (P = 0,01), la capacidad funcional (p = 0,05) y la autoeficacia (P = 0,01) resultados y un mayor uso de los comportamientos de salud. A los 12 meses, que sigue teniendo mejor el dolor (p = 0,03), la autoeficacia (P = 0,001) y el estado psicológico (p = 0,0001) resultados y un mayor uso de algunos comportamientos de salud.
CONCLUSIÓN: Asistir a un programa modular de educación conductual es eficaz durante al menos 1 año para que las personas con AR y PSA para reducir el dolor, mejorar el estado psicológico y la auto-controlar su enfermedad.
OBJETIVO: Evaluar el efecto sobre la salud y el estado funcional de un programa de grupo-educación de 8 semanas para la artritis reumatoide (AR), además de la atención médica habitual.
Se pidió a todos los pacientes hospitalizados y ambulatorios consecutivos con (criterios ACR) RA para participar en este estudio aleatorizado, prospectivo, controlado: MÉTODOS. La intervención educativa consistió en 8 sesiones ambulatorias semanales, con una duración de 6 horas. Seguimiento se llevó a cabo después de 1 año. El principal criterio para juzgar la eficacia fue la (HAQ) puntuación en el Cuestionario de Evaluación de la Salud; criterios secundarios consistieron en la que se maneja, el conocimiento médico, la satisfacción global del paciente, y de calidad de vida antes de la intervención y después de 1 año.
Resultados: Se les pide 1.242 pacientes hospitalizados y ambulatorios para participar en el estudio: 208 (16,75%) está de acuerdo (104 en cada grupo). Al inicio del estudio, no hubo diferencia estadísticamente significativa entre los 2 grupos. Después de 1 año, no se observaron diferencias estadísticamente significativas entre los 2 grupos en el cambio en la puntuación del HAQ: -0,04 +/- 0,46 (grupo de educación) vs -0,06 +/- 0,47 (grupo de control) (p = 0,79). Se encontraron diferencias estadísticamente significativas en 3 dominios: afrontamiento del paciente (-1,22 +/- 5,55 vs -0,22 +/- 3,81; p = 0,03), conocimiento (3,42 +/- 4,73 vs 0,73 +/- 3,78; p <0,0001), y la satisfacción (10,07 +/- 11,70 vs 5,72 +/- 13,77; p = 0,02), todos los cuales eran mejores para el grupo de asistir a las sesiones de educación.
CONCLUSIÓN: A pesar de las mejoras en el afrontamiento del paciente, el conocimiento y la satisfacción, el programa de educación no se ha encontrado para ser eficaz en 1 año. Puede que haya habido problemas metodológicos relativos a la sensibilidad de los cuestionarios y la selección de pacientes, y las intervenciones educativas adaptadas deben ser considerados.
The aim of this study was to asses the effects on pain, disability, and health status of an educational-behavioral joint protection program in a group of moderate-severe rheumatoid arthritis (RA) patients. Eighty-five subjects with RA in treatment with anti-tumor necrosis factor alpha (TNFalpha) drugs (infliximab) were enrolled into the study and randomized into either an experimental group (46, EG) or a control group (39, CG). We organized four EG meetings, which included information on pathophysiology and evolution of RA, joint protection during normal activities of daily living, suggestions on how to adapt the surrounding environment, and self-learning exercises to perform at home. Sociodemographic characteristics and degree of knowledge of the disease, measured by the Health Service Interview (HSI), were recorded at baseline. The outcome measures included the Visual Analogue Scale (VAS), the Arthritis Impact Measurement Scale 2 (AIMS2), and the Health Assessment Questionnaire (HAQ), which were administered at the beginning and end of the trial. Thirty-six patients from the EG (7 men and 29 women; mean age 54.2 years) and 34 from the CG (6 men and 28 women; mean age 52.2 years) completed the trial. No statistical differences in baseline evaluations were found between the two groups. According to the answers given on the HSI, the majority of our patients had poor knowledge of RA and its consequences. After a mean time of 8 months, the patients receiving educational training displayed a significant decrease, compared to the CG, in the VAS (p = 0.001), HAQ (p = 0.000), and physical (p =0.000), symptoms (p = 0.049), and social interaction (p = 0.045) scores on the AIMS2, but not in other items. Our study showed that 8 months after attending an educational-behavioral joint protection program, subjects with moderate-severe RA presented less pain and disability and thus an enhanced health status. This approach may efficiently complement drug therapy in these patients.
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.
OBJETIVO: Evaluar los efectos a largo plazo de la protección de las articulaciones en el estado de salud de las personas con artritis reumatoide (AR).
DISEÑO: Un niño de cuatro años de seguimiento de un estudio aleatorizado, controlado, asesor ciego ensayo se llevó a cabo.
Escenario: Dos departamentos de consultas externas de reumatología.
PARTICIPANTES: Las personas con artritis reumatoide de menos de cinco años desde el diagnóstico.
INTERVENCIONES: Dos de 8 horas en comparación con las intervenciones fueron originalmente: un programa de la artritis, incluyendo la educación normal 2 (1/2) horas de protección conjunta basada en la práctica de terapia ocupacional típica del Reino Unido (+ 5 (1/2) horas en la AR, el ejercicio, el dolor gestión, la dieta y el cuidado de los pies), y un programa de protección de las articulaciones, utilizando la educación-conductual de entrenamiento.
MEDIDAS PRINCIPALES: El mantenimiento de la protección de las articulaciones, dolor, dolor de la mano de la actividad, la artritis escalas de medición del impacto 2 y artritis auto-eficacia se registraron a 0 y 4 años.
RESULTADOS: Sesenta y cinco personas asistieron a la protección de las articulaciones y 62 de los programas estándar. Los grupos en la entrada eran similares en edad (51 años, 49 años), duración de la enfermedad (21 meses: 17,5 meses) y el uso de antiinflamatorios no esteroideos antiinflamatorios y modificadores de la enfermedad. A los cuatro años, el grupo de protección de las articulaciones siguen teniendo mucho mejor: la adhesión protección de las articulaciones (p = 0,001), rigidez matutina (p = 0,01); AIMS2 actividades de la vida diaria (AVD) puntuaciones (p = 0,04) en comparación con el estándar grupo. El grupo de protección de las articulaciones también tuvieron significativamente menos deformidades de la mano: metacarpofalángicas (MCP) (p = 0,02) y las articulaciones de la muñeca (p = 0,04).
CONCLUSIÓN: Asistir a un programa educativo-conductual protección de las articulaciones mejora significativamente la adherencia protección de las articulaciones y mantiene la capacidad a largo plazo, funcional. Este enfoque es más eficaz que los métodos estándar de la formación y debe ser adoptado más ampliamente.
OBJETIVO: Determinar el efecto de los ejercicios conjuntos de protección y de origen en función de la mano de los pacientes con osteoartritis de la mano (OA).
MÉTODOS: Ensayo clínico aleatorizado, controlado, prueba de 3 meses con un evaluador cegado. Parámetro de resultado primario fue la fuerza de agarre; parámetros secundarios fueron el Cuestionario de Evaluación de Salud y escalas visuales analógicas (EVA) para el dolor y la función global mano. Cuarenta pacientes con artrosis de mano fueron asignados aleatoriamente a 2 grupos: Un grupo recibió instrucciones para protección de las articulaciones y los ejercicios en casa de mano (grupo JPE), el grupo de control recibió una sesión informativa sobre la OA mano.
RESULTADOS: la fuerza de agarre mejorado en un 25% en el grupo de JPE (mano derecha, P <0,0001; mano izquierda, P = 0,0005), pero no en el grupo control. Función de la mano Global (por VAS) mejoró en mayor proporción (65%) de los pacientes en el grupo de JPE (P <0,05).
CONCLUSIONES: ejercicios de protección conjunta y caseros mano y de fácil gestión e intervenciones fácilmente aceptables, se encontraron para aumentar la fuerza de prensión y la función global mano.
Joint protection is a major part of rheumatology occupational therapy. Recent research emphasises that an educational-behavioural approach is more effective than current practice in enabling people with rheumatoid arthritis (RA) to increase their use of joint protection and benefit from reduced pain and inflammation and improved function. The aim of this study was to evaluate whether occupational therapists, following a 2-day training course in delivering an educational-behavioural joint protection programme, could enable people with RA to improve use of joint protection significantly and obtain similar results to previous clinical trials. This tested whether it would be feasible to introduce the programme into clinical practice. Three occupational therapists attended a 'Looking After Your Joints' training course for leaders. A single-blind crossover trial was conducted. Three centres participated, with each therapist delivering two or three joint protection programmes. Thirty participants with RA attended: 27 women and 3 men, with a mean age of 52.3 years (SD 12.08) and a mean disease duration of 6.76 years (SD 7.02). The primary outcome measure was an observational assessment of use of joint protection, the Joint Protection Behaviour Assessment (JPBA; Hammond and Lincoln 1999b). The median baseline JPBA score for all 30 participants was 15.39% (IQR 11.45-26.82%), which rose significantly to 35% (IQR 25-42.40%) (Z = -3.97; p = 0.0001) at 6 months following the programme. Both participants and therapists expressed positive views of the efficacy of this training approach. Sixteen participants increased use of joint protection by 20% or more. The findings highlight that the 2-day training course facilitated therapists in delivering the programme effectively and they could gain similar behavioural improvements to previous clinical trials. (PsycInfo Database Record (c) 2021 APA, all rights reserved)
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.
