# Exercise as it relates to Disease/Does strengthening exercises improve hand strength and functionality in rheumatoid arthritis patients?

This is a critical analysis of “Strengthening exercises to improve hand strength and functionality in rheumatoid arthritis with hand deformities: a randomized, controlled trial” by Cima S, Barone A, Porto J, de Abreu D.

## What is the background to this research?

Rheumatoid Arthritis (RA) is described as a chronic disease of joints, and is characterised by the uncontrolled proliferation of synovial tissue. Although all synovial lined joints are affected, small joints of the hands and feet are the main sites that experience debilitating deformities before it affects other major joints. RA symptoms include fatigue, stiffness, joint pain, reduced muscular strength, and impaired physical function. RA gives rise to disability and causes reduced quality of life when untreated.
At the time of this study, the extent to which physiotherapy may benefit RA patients was unclear. Physiotherapy is likely to improve the physical function and movement of joints that enhance patients health and wellbeing. The purpose of this article was to review the contribution that physiotherapy has on the treatment of RA.

## Where is the research from?

The research was conducted in Brazil and published in the Rheumatology International Journal – an independent journal that was designed to centralise world-wide research, diagnosis, and treatment for rheumatic diseases.
About the authors:
Daniela Abreu, one of the prominent authors in this study, is a reputable Professor from the University of São Paulo. Daniela has experience in the fields of Rehabilitation, Physiotherapy, Bone Mineral Density and Osteoporosis, where she has completed over 100 publications.
Supporting author, Jaqueline Porto, from the School of Medicine of Ribeirão Preto, has experience in Women and Health, Gerontology, Physical Therapy, and Ageing Clinical Experimental Research, where she has completed 26 publications.
Co-authors Adriana Barone and Stephanie Robinson Cima have no previous publications listed.
There were no conflicts of interest or competing interest of the authors identified.

## What kind of research was this?

The study was a randomised controlled trial (RCT), providing strong evidence on the effectiveness of interventions in experimental studies.
One group was required to undertake an exercise programme and the second group received no treatment for their hands (control). This methodology allows for greater comparison of results to determine the physiotherapy programme’s effectiveness through a known experimental and control group.
The evaluator and the research therapists were not blinded during the assessment and intervention phases. Blinding is essential in RCT to prevent biased assessment of outcomes, therefore the methodology used could result in the perception of bias.

## What did the research involve?

This research involved a physiotherapy programme aimed at improving hand grip and pinch strengths, motor coordination, and functionality of the hand. 20 women participated in the study. Participants selected have been diagnosed with RA, and present deformity in at least one of the fingers of each hand. Participants were randomised into two groups. Subjects were excluded if they were presenting other RA-related diseases or had entered the exacerbation phase.
The rehabilitation programme included 20 supervised sessions at 35 minutes each, and at-home exercises to be completed three days a week, over two months. Other studies have predominantly assessed at-home exercises only. Participants undertook exercises focusing on motor-coordination tasks, and strengthening exercises using a digiflex hand exerciser, modelling mass and elastics. Every three weeks the load and intensity of the strengthening exercises were increased by adding more repetitions.
Group one was evaluated after 10 and 20 supervised sessions using the Health Assessment Questionnaire (HAQ) and dynamometry. The first evaluation recorded the progression and was used to identify if 10 sessions were sufficient enough to improve hand grip, pinch strengths, and functionality. The second evaluation allowed for a comparison between the number of sessions and the effects of a longer treatment (20 sessions).

## What were the basic results?

No significant differences identified between groups at baseline.
Group 1 - Experimental (after 20 sessions)
HAQ Scores: Improved functionality observed. The average baseline score was 1.28 (0.82) which reduced to 0.85 (0.7).
Hand grip: 5Kgf (1Kgf ≅ 9.8 Newtons) increase in the hand grip strength in both the dominant and non-dominant hand.
Pinch strength: Dominant Hand (DH) and Non-Dominant Hand (NDH)
| | Index finger and thumb | Third finger and thumb | Fourth finger and thumb | Fifth finger and thumb |
| DH | + 1.5Kgf | + 1.2Kgf | + 1Kgf | + 0.5Kgf |
| NDH | + 1.7Kgf | + 1.2Kgf | + 1Kgf | + 0.6Kgf |
Group 2 - Control
HAQ Scores: No differences observed when comparing initial and final values. The average baseline score was 1.23 (0.67) and final average score after two months was 1.29 (0.29).
Hand grip: No difference observed.
Pinch strength: No difference observed.
Results were interpreted by noting a significant improvement in hand grip after 10 sessions of physiotherapy. Furthermore, pinch strengths in both hands were significant, except for the fourth finger and thumb of the dominant and non-dominant hand, and the fifth finger and thumb of the dominant hand. These were found to be significantly improved after 20 sessions only. Although the authors used graphs to display the results, stronger reflections of the results could have been made in the text rather than stating that significant improvements were made, this would have emphasised their findings.

## What conclusions can we take from this research?

The authors concluded that a relationship between physiotherapy and improved functionality in the hands exists, with physiotherapy being beneficial for re-establishing articular stability by strengthening the hand muscles. The results from this study suggested that 10 supervised sessions will cause improvements in hand grip strength and 20 supervised sessions will ensure functional gain. Physiotherapy sessions demonstrated positive outcomes; however long-term improvement will require more than 20 sessions. Developing habitual exercise routines may be critical to maintaining functionality. Previous research supports the notion that strengthening exercises for the hand improve the functionality and overall strength.
This study failed to report any additional benefit for participants undertaking the at-home exercises. This could impact the reliability of the results as the authors did not explore whether these at-home sessions were undertaken and completed. Furthermore, the study was only completed by 17 participants. This sample size is relatively small and only composed of females. Therefore, the findings may not be generalised to men or reflect the general population with acceptable precision.
This study did particularly well in demonstrating the benefits of different hand exercises for RA patients presenting with hand deformities. The results after 10 and 20 sessions particularly highlight the ongoing advantages of undertaking physiotherapy.

## Practical advice

This study demonstrated that people with RA experience physical limitations, predominantly in the hands, requiring interventions such as specific physiotherapy programmes. However, ad-hoc performance of similar exercises at home are beneficial to reduce disease progression. Based on the findings, it is advisable for individuals with RA to undertake physiotherapy programmes initially to learn the best exercise mechanisms and maintain an exercise regime in their own time. Before taking on this practical advice, individuals should consult a health professional to ensure the advice is suitable for their disease state.

## Further information/resources

Living with RA
Education and support
Home exercises
Find a Physio

## References

* 1 2 3 4 Cima S, Barone A, Porto J, de Abreu D. Strengthening exercises to improve hand strength and functionality in rheumatoid arthritis with hand deformities: a randomized, controlled trial. Rheumatology International. 2012;33(3):725-732.
* ↑ Guo Q, Wang Y, Xu D, Nossent J, Pavlos N, Xu J. Rheumatoid arthritis: pathological mechanisms and modern pharmacologic therapies. Bone Research. 2018;6(1).
* ↑ Rindfleisch AJ, Muller D. Diagnosis and management of rheumatoid arthritis. American family physician. 2005 Sep 15;72(6):1037-47.
* ↑ Suresh E. Diagnosis of early rheumatoid arthritis: what the non-specialist needs to know. JRSM. 2004;97(9):421-424.
* ↑ Brady TJ, Kruger J, Helmick CG, Callahan LF, Boutaugh ML. Intervention programs for arthritis and other rheumatic diseases. Health Education & Behavior. 2003;30(1):44-63.
* ↑ Ekdahl C, Broman G. Muscle strength, endurance, and aerobic capacity in rheumatoid arthritis: a comparative study with healthy subjects. Annals of the rheumatic diseases. 1992 Jan 1;51(1):35-40.
* ↑ Giles JT, Bartlett SJ, Andersen RE, Fontaine KR, Bathon JM. Association of body composition with disability in rheumatoid arthritis: impact of appendicular fat and lean tissue mass. Arthritis Care & Research: Official Journal of the American College of Rheumatology. 2008 Oct 15;59(10):1407-15.
* ↑ Sharp B. Physiotherapy and physical rehabilitation. InBSAVA manual of canine and feline rehabilitation, supportive and palliative care 2010 Jan 1 (pp. 90-113). BSAVA Library.
* ↑ Rheumatology International [Internet]. ResearchGate. [cited 10 September 2021]. Available from: https://www.researchgate.net/journal/Rheumatology-International-1437-160X
* ↑ ResearchGate [Internet]. Daniela C Abreu. [cited 10 September 2021]. Available from: https://www.researchgate.net/profile/Daniela-Abreu-4
* ↑ ResearchGate [Internet]. Jaqueline Porto. 2021 [cited 10 September 2021]. Available from: https://www.researchgate.net/profile/Jaqueline-Porto
* ↑ Evans D. Hierarchy of evidence: a framework for ranking evidence evaluating healthcare interventions. Journal of clinical nursing. 2003 Jan;12(1):77-84.
* ↑ Karanicolas PJ, Farrokhyar F, Bhandari M. Blinding: who, what, when, why, how?. Canadian journal of surgery. 2010 Oct;53(5):345.
* ↑ Eryukhina NA, Chalenko NS. Measurement of force in newtons (toward introduction of COMECON ST 1052-78). Measurement Techniques. 1979 Nov 1;22(11):1301-3.
* ↑ Mohanty B, Padhan P, Singh P. Comparing the effect of proprioceptive retraining technique against home exercise programme on hand functions in patients with rheumatoid arthritis. Indian J Physiother Occup Ther. 2018 Jul;12:48-53.
* ↑ Khedekar S, Shimpi AP, Shyam A, Sancheti P. Use of art as therapeutic intervention for enhancement of hand function in patients with rheumatoid arthritis: A pilot study. Indian Journal of Rheumatology. 2017 Apr 1;12(2):94.