Exercise therapy in the management of upper limb dysfunction in people with Rheumatoid Arthritis. Speaker declaration: no conflicts of interest

Transcription

1 Exercise therapy in the management of upper limb dysfunction in people with Rheumatoid Arthritis Speaker declaration: no conflicts of interest

2 Exercise a planned, structured and repetitive bodily movement done to improve or maintain one or more components of physical fitness (Caspersen et al 1985) Common component of management of people with rheumatoid arthritis

3 NICE guidelines (2009)..access to specialist physiotherapy to improve general fitness and encourage regular exercise learn exercises for enhancing joint flexibility, muscle strength and managing other functional impairments

4 Exercise Strength Fitness Function? Balance (Metsios 2008, Hurkmans 2009, King 2010)? Flexibility

5 Exercise therapy Global exercise (Hall, 1996, DeJong 2003) Lower limb (Lyngberg 1994, Bearne 2002) Upper limb exercise few high quality studies (Wessel 2004)

6 Conservative hand therapy treatments in rheumatoid arthritis a randomised controlled trial (O Brien 2006) n=67 adults with RA Joint protection, mobility & Joint protection strengthening Joint protection, mobility & strengthening exercises exercises Joint protection & mobility exercises Improvement in disability (AIMS2), key grip strength at 6/12

7 The effect of an intensive hand exercise programme in patients with rheumatoid arthritis (Ronningen 2008) Controlled clinical trial (n=60) Conservative (ROM) exercise programme n=30 Intensive exercise programme Intensive exercise programme n = 30 Improvement in hand grip strength at 14 weeks

8 Upper limb exercise therapy Proximal stability and motor control required for effective manual dexterity Proximal joints associated with upper limb dysfunction (Bearne 2003)

9 Upper limb exercise therapy Short term, supervised programmes Once exercise ceases, many benefits decline (Hakkinen 1997, Lemmey 2012) Behaviour change / self management strategies

10 Education and exercise upper limb Training in early Rheumatoid Arthritis (EXTRA study) Bearne L.M, Manning V.L, Scott D.L, Choy E, Hurley M.V. Funded by Physiotherapy Research Foundation

11 Aims Investigate the efficacy of home exercise supplemented with group exercise and self management on upper limb dysfunction Evaluate the acceptability and experience Conduct a health economic evaluation

12 Participants Inclusion criteria Adults with RA of less than 5 years duration Exclusion criteria: unstable disease steroid injection during the previous 4 weeks upper limb surgery or physiotherapy during the previous 6 months unable to exercise or give informed consent

13 Study Pathway Baseline assessment Usual Care + Education and exercise Training (EXTRA) programme Usual care control group Assessment at 3 months Assessment at 3 months Assessment at 9 months Assessment at 9 months

14 Outcome Measures Primary outcome measure Disability of Arm, Shoulder and Hand questionnaire (DASH) 30 item Please rate your ability to do the following activities in the last week by circling the number below the appropriate response. Place an object on a shelf above your head. No difficulty Mild difficulty Moderate difficulty Severe difficulty Unable

15 Outcome Measures Secondary outcomes included Hand grip strength (N) Self efficacy Arthritis Self Efficacy Scale Function Grip Ability Test (seconds) Disease Activity Score (DAS 28) Pain (0-100mm VAS)

16 EXTRA programme Simple, personalized, daily home exercise regimen (6 exercises) Supplemented by 4 group discussion and exercise sessions (2 x 2 weeks) 15 minutes themed discussion Warm up/ stretching/ individualised upper limb exercise circuit

17 Exercise Menu Consensus - expert opinion - existing literature 16 upper limb exercise identified Wall Wash Squares Arm Curl Putty ball squeeze

18 Self management topics Session Topics 1 Aims and objectives of the programme Exercise and rheumatoid arthritis 2 Exercise and coping with pain and tiredness Managing flare-ups 3 Monitoring exercise intensity Personal objectives and goal setting 4 Modifying exercise intensity Maintaining motivation and managing relapse

19 Participant handbook

20 Participant handbook

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23 Study Participants Characteristics 108 participants (26 Males) Age 55 years (sd 15) Disease duration 20 months (sd 19)

24 Baseline Characteristics Mean (95% CI) EXTRA group n=52 Usual Care group n= 56 DASH (0 100) 46 (39, 53) 42(35, 49) Self efficacy (ASES pain) 5.7 (5.1, 6.4) 5.9 (5.3, 6.6) function (seconds) 23 (20, 26) 22 (19, 26) Hand grip strength (N) Dominant * 175 (144, 205) 219 (177, 261) Non Dominant* 168 (139, 197) 216 (175, 257) Disease Activity (DAS28) 5.2 (4.8, 5.7) 4.7 (4.2, 5.2) Pain (0-100mm) 46 (38, 53) 43 (35, 50) * difference between group at baseline assessment

25 Disability P< Usual Care Change in DASH Score EXTRA programme Baseline 3 Months 9 Months

26 Function 4 P< Change in GAT (seconds) Usual Care EXTRA programme Baseline 3 months 9 months

27 Grip strength 40 Non dominant hand P<0.05 Change in handgrip strength (N) Baseline 3 Months 9 Months EXTRA programme Usual Care

28 Grip strength 50 Dominant hand Change in 10 strength (N) 0 EXTRA programme Usual Care Baseline 3 Months 9 Months

29 Self efficacy 15 P<0.05 P< Usual Care Change in ASES (pain) 0 EXTRA programme Baseline 3 Months 9 Months

30 Disease Activity 7 6 P< DAS Usual care EXTRA programme Baseline 3 months 9 months

31 Pain 60 P< Pain VAS 30 Usual Care 20 EXTRA programme 10 0 Baseline 3 months 9 months

32 Conclusions The EXTRA programme improves upper limb disability, strength, function and self efficacy Self efficacy improved throughout the study although the effect of the programme diminished in other outcomes It is safe in people with early RA

33 Clinical Implications Clinically applicable, personalised, global upper limb exercise and self management programme Challenge of sustaining exercise long term

34 Acknowledgements Study participants Co researchers Ms Victoria Manning Prof Michael Hurley Prof David L. Scott Prof E Choy Collaborators Multidisciplinary teams at Kings College, Guys, St Thomas and Lewisham Hospitals Prof Andrew Cope Dr Gabrielle Kingsley Physiotherapy Research Foundation