Background/Purpose:   Upper limb dysfunction occurs early in people with rheumatoid arthritis (RA) and deteriorates as the disease progresses, impacting on independence and work capacity. Exercise is a important component in the management of upper limb disability, however, studies focus on the hand in isolation and do not address potential proximal motor deficits. Individually tailored, home exercise regimens are required to address global upper limb dysfunction which, if completed in the long term, could encourage self management. This study evaluated the efficacy of a gobal, upper limb home exercise programme supplemented with a brief supervised exercise, education and self management (Education and eXercise Training in early Rheumatoid Arthritis (EXTRA)) programme.

Methods:  108 adults with RA of less than 5 years duration (26 males, age mean (SD) 55 (15) years, disease duration 20 (19) months) were randomized to receive either Usual Care (n= 52) or  the EXTRA programme (n=56). This progamme is a tailored home exercise regimen, focused on improving upper limb function, which is supplemented with 4 group supervised exercise, education and self management sessions, aimed at improving self efficacy and disease self management (2 sessions  per week for the first 2 weeks, each session lasting approximately 1 hour, with 4-6 participants per group). Upper limb disability (Disability of Arm, Shoulder, Hand questionnaire (DASH)), grip strength, function (Grip Ability Test (GAT)), self efficacy (Arthritis Self Efficacy Scale – pain subscale (PSE)) and disease activity (Disease Activity Score (DAS 28)) were assessed at baseline, 3 months (primary end point) and 9 months. Intention to treat analysis using full factorial mixed Analysis of Variance (ANOVA) (treatment, time and treatment x time interaction) adjusted for baseline disease duration, disease activity and disability, and  corrected for multiple comparisons, were used to determine between group differences,. Significance was accepted at P<0.05.

Results: Compared to a usual care control group, participants who completed the EXTRA programme demonstrated improved disability, function, non dominant grip strength and self efficacy with no adverse effects on disease activity (Table).

 

Table: Changes in disability, grip strength, function,  self efficacy  and disease activity following the EXTRA programme or Usual Care  

Mean (95% Confidence intervals)		EXTRA programme		Usual Care		Between Group  Differences		Effect size (95% CI)   (P value)
Disability  (DASH)
Baseline		44.6 (37.2,52.0)		40.8 (33.6,48.0)		3.8 (-6.6,14.1)
change at 3 months		-5.3 (-10.4, -0.2)†		1.5 (-3.5, 6.5)		-6.8 (-12.6,-1.0)†		0.5 (-2.3,3.3)               (0.022)†
change at 6 months		-2.7(-9.5, 4.2)		-1.4 (-8.0,5.3)		-1.3 (-9.1,6.5)		0.1 (-3.7,3.9)               (0.730)
Dominant Grip Strength (N)
Baseline		183.3 (150.2,216.5)		220.5 (188.5,252.4)		-37.2 (-83.2, 8.9)
change at 3 months		23.1 (0.8,45.4)		0.3 (-21.2,21.8)		22.9 (-2.4,48.1)		0.35 (-12.0,12.7)          (0.140)
change at 6 months		16.0 (-14.3,46.2)		-3.0 (-32.1,26.2)		18.9 (-15.3,53.2)		0.21 (-16.5,17.0)          (0.480)
Non Dominant Grip strength (N)
Baseline		171.7 (139.9,203.6)		214.2 (183.5,244.9)		-42.5 (-86.7,1.8)
change at 3 months		17.5 (-1.9,36.9)†		-6.8 (-25.5,11.9)		24.3 (2.3,46.3)†		0.43 (-10.3,11.2)           (0.037)†
change at 6 months		6.1 (-22.7,34.9)		-8.4 (-36.1,19.4)		14.5 (-18.2,47.1)		0.17 (-15.8, 16.1)          (0.648)
Function (GAT seconds)
Baseline		23.1 (19.3,26.8)		21.9 (18.3,25.5)		1.1 (-4.0,6.3)
change at 3 months		-1.8 (-5.1,1.5)‡		1.5 (-1.6, 4.7)		-3.3 (-7.0,0.4)†		0.4 (-1.4,2.2)                (0.010)†
change at 6 months		-0.8 (-4.7,3.0)‡		-0.5 (-4.2,3.2)		-0.4 (-4.7,4.0)		0.0 (-2.1,2.1)                (0.130)
Self efficacy (PSE)
Baseline		57.5 (50.7,64.2)		59.2 (52.9,65.6)		-1.7 (-11.0,7.5)
Change at 3 months		4.8 (-3.1,12.8)		-5.7 (-13.2,1.8)		10.5 (1.6,19.5)†		0.53 (-3.8,4.9)              (0.020)†
Change at 6 months		6.6 (-0.8,14.0)		-1.8 (-8.8,5.2)		8.4 (0.1,16.7)†		0.45 (-3.6,4.5)              (0.047)†
Disease Activity (DAS28)
Baseline		5.3 (4.7,5.9)		4.9 (4.4,5.5)		0.4 (-0.4,1.2)
change at 3months		-0.8 (-1.4,-0.2)‡		-0.1 (-0.7,0.4)		-0.7 (-1.4,0.0)†		0.55 (0.2,0.9)               (0.048)†
change at 6 months		-0.8 (-1.4,-0.1)†		-0.2 (-0.8,0.4)		-0.5 (-1.2,0.1)		0.43 (0.1,0.8)                (0.120)
‡ P<0.01            † P0.05

Conclusion: The EXTRA programme improves upper limb disability, grip strength, self efficacy and function in people with early RA, with no detrimental effects on disease activity. This brief intervention may be easily implemented into clinical practice.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/a-brief-exercise-and-self-management-programme-improves-upper-limb-disability-in-people-with-early-rheumatoid-arthritis/