Effect of an intensive hand exercise programme in patients with rheumatoid arthritis

Transcription

1 Scandinavian Journal of Occupational Therapy. 2008; 15: ORIGINAL ARTICLE Effect of an intensive hand exercise programme in patients with rheumatoid arthritis AUD RØNNINGEN 1 & INGVILD KJEKEN 2 1 Lillehammer Hospital for Rheumatic Diseases, Norway, and 2 National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway Abstract The aim of this study was to test the effect of an intensive hand exercise programme in patients with rheumatoid arthritis (RA). Designed as a clinical controlled trial, the first 30 participants received a conservative exercise programme (CEP), while the next 30 received an intensive exercise programme (IEP). Outcomes were assessed at baseline, and after 2 and 14 weeks. Hand strength, measured as grip strength and pinch strength, was the primary outcome variable. Secondary outcomes were joint mobility, hand pain, and functional ability. After two weeks, there were significant differences between the groups in favour of the IEP in pinch strength in the dominant hand (p0.01), as well as grip and pinch strength in the non-dominant hand (p0.04 and 0.05, respectively). After 14 weeks, there was a significant difference between the two groups in grip strength in the non-dominant hand (p0.04), again in favour of the IEP. There was a trend towards increased pain in the CEP group and towards decreased pain in the IEP group, with significant differences between the groups in several measures of pain after 2 and 14 weeks. However, there were few significant differences between the two groups regarding joint mobility and functional ability. The results indicate that, compared with a traditional programme, an intensive hand exercise programme is well tolerated and more effective in improving hand function in patients with RA. Key words: Controlled trial, hand function, hand strength, occupational therapy, pain, range of motion, rheumatology Introduction Rheumatoid arthritis (RA) is the most common inflammatory rheumatic disease, affecting 0.5 to 1% of the population. It occurs twice as often in women as in men, has an onset age mainly between 45 and 65 years, and the aetiology is still unknown (1). The most commonly involved joints are the hand joints, as the wrists, the metacarpo-phalangeal (MCP) joints, and/or the proximal inter-phalangeal (PIP) joints are affected in more than 90% of all patients, causing decreased hand strength and mobility, and pain and hand deformities (2). Persons with RA report hand function to be of utmost importance for how they cope with their daily life activities (2). These experiences are supported by research, as studies indicate that female patients with RA have on average 21% of the hand strength of healthy women (3), and that many of the activity limitations seen in these patients to a large extent are explained by pain, decreased hand strength and disturbed grip function (2,48). In a study evaluating grip strength and activity limitations in 217 persons with RA 3 years after diagnosis, the authors conclude that hand strength under or above a critical level seems to be the most important explanation for activity limitations. They therefore suggest that increasing grip strength may result in reduced activity limitation (5). In another study investigating correlations between degree of difficulty in performing activities of daily living (ADL), use of assistive devices and different aspects of disability in 55 participants with RA, the highest correlation was found between grip strength and difficulty in ADL. Also, the loss of grip strength was the main indicator for use of assistive devices (9). Further, Nordenskiöld et al. have demonstrated significant correlations between grip strength and difficulties in hand activities such as eating, tying shoelaces, buttoning, Correspondence: Aud Rønningen, Lillehammer Hospital for Rheumatic Diseases, Margrethe Grundtvigs v 6, 2609 Lillehammer, Norway. aud. ronningen@revmatismesykehuset.no (Received 19 September 2007; accepted 4 March 2008) ISSN print/issn online # 2008 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS) DOI: /

2 174 A. Rønningen & I. Kjeken shampooing hair, opening car doors and opening jars in women with RA (8). Thus, hand exercises to improve function have been a recommended and frequently used strategy in this group of patients (10). For many years, the recommendations were that the exercise regimes for patients with RA should be conservative, consisting of gentle concentric exercises aimed at increasing range of motion (11). The hypothesis was that intensive exercises against resistance would increase or prolong the inflammation in the joints, with a potential increased risk of damage of cartilage and bone, and development of deformities. During recent years, however, a number of studies have shown that intensive programmes, consisting of dynamic and strengthening upper and lower limb exercises, are well tolerated and safe for patients with active disease, with regard to disease activity and radiological damage to the hands and feet (1214). Further, it seems that these programmes are more effective in improving general muscle strength, joint mobility and functional ability, compared with programmes consisting of exercises with low intensity (15,16). However, few studies have specifically examined the effect of hand exercises in patients with RA. In 2004, a systematic review concluded that there is limited evidence that long-term hand exercise may increase strength in patients with RA (17). In a recent study, comparing the effectiveness of three different hand therapy treatments, the authors conclude that a programme of home strengthening hand exercises is more efficient in improving arm function than a programme with simple stretches, or advice alone (18). When designing hand exercise programmes, the intensity of the programme will depend on the type of muscle contractions and amount of tension required in the selected exercises, the duration of holding the contractions, the number of repetitions of each exercise, and the daily/weekly exercise frequency (19). Over a long period, the hand exercise programme at Lillehammer Hospital was designed according to former recommendations that the exercise regimes should be conservative and gentle. Thus, the main aims of the traditional programme were to increase joint mobility and maintain hand strength. The effect of this programme had, however, not been systematically evaluated. Based on newer knowledge that persons with RA tolerate more intensive exercising, one wanted to implement these principles in a new programme designed to increase hand strength. Thus, the aims of this study were to evaluate and compare the effect of an intensive hand exercise programme and a conservative hand exercise programme on hand strength, joint mobility, pain, and functional ability in patients with RA. Materials and methods Study design Participants were recruited from a 32-bed inpatient rheumatology department at Lillehammer Hospital for Rheumatic Diseases, Norway. Designed as a clinical controlled trial, the first 30 consenting participants were consecutively included in a group receiving a conservative hand exercise programme (CEP). Thereafter the programme was changed, and the next 30 were consecutively included in a group receiving an intensive hand exercise programme (IEP) (see Figure 1). Hand strength in Newtons (N) was the primary outcome (3). A difference of 20% in mean grip strength between the groups after 2 weeks was considered clinically relevant. Based on results from previous studies (3,20), we calculated that a sample size of 30 patients for each treatment regimen group was required to detect a difference of 16 Newtons (N) with a significance level of 0.05 and a power of 80%, assuming that the mean grip strength in the dominate hand was 80 N at baseline, with a standard deviation (SD) of 22 N. Patients After informed written consent, patients were included in the study within the first two days after admission to the hospital. Inclusion criteria were RA according to the classification criteria of the American College of Rheumatology (21), disease duration 1 year, age between 18 and 70 years, and ability to communicate well in Norwegian. Exclusion criteria were functional problems related to diseases other than RA, pregnancy, hand surgery 6 months before inclusion or during study period, mental or cognitive deficits, or attendance at less than five training sessions during the hospital stay. Patients were evaluated at the start of their hospital stay, at discharge (approximately 2 weeks after admission), and 12 weeks after discharge. A total of four occupational therapists were involved in the assessment process and as instructors in the exercise groups. However, for each patient, the same therapist conducted all assessments. Due to the clinical setting, neither patients nor therapists were blinded to the group allocation. Interventions As has already been stated, the hand exercise programme at Lillehammer Hospital had for a long time complied with recommendations that the

3 Hand exercises in patients with RA 175 exercise regimes should be conservative and gentle. Thus, the main aims of the CEP were to increase joint mobility and maintain hand strength. However, based on results from new research, it was decided to design a new intensive exercise programme (IEP), aimed at increasing hand strength. The most important difference between the two programmes was an increased number of repetitions in the IEP, especially of the finger flexion and extension exercises. For more detailed descriptions of the programmes, see Appendix A. Instructions in the respective exercise programmes were organized as a daily group session led by an occupational therapist. At discharge, the patients in the CEP group were instructed to exercise according to their usual training routines, while the patients in the IEP group were encouraged to exercise once a day for a minimum of five days a week until returning for the 14-week assessment. Participation in training sessions during the hospital stay were registered by the occupational therapists, while the patients kept a diary at home in the study period. The study did not interfere with the routine treatment, but medications at baseline and follow up were recorded, as were physical therapy, occupational therapy, and steroid injections during hospital stay. The study was approved by the regional Ethical Committee. Process and outcome assessments Primary outcome measures. For both hands, grip strength and three-pod pinch strength (thumb, index, and long finger) were measured in Newtons (N) by the Grippit electronic instrument (3,22). Force recordings are displayed on the Grippit electronic unit every 0.5 seconds during a 10-second period. The means of the 20 registrations were recorded. Secondary outcome measures. Hand pain was measured on a 100 mm visual analogue scale (VAS) ranging from 0 to 100 (0no pain), by asking the patient to mark the amount of pain experienced during the Grippit recording of, respectively, grip strength and pinch strength for each hand. Joint mobility was measured as (1) flexion deficit of digits IIV as the distance in mm from the palmar crease to the distal point of the digits, (2) extension deficits of digits IIV as the distance in mm from the distal point of the nail bed of the extended fingers to a table where the patients rested their hand in a supinated position, (3) opposition deficit of digit I as the distance between the tip of the thumb and the base of digit V, and (4) wrist mobility as palmar and dorsal flexion of the wrist measured with a goniometer (23). Grip ability was measured with the Grip Ability Test (GAT), which consists of the following three standardized items: put a flexigrip stocking over the non-dominant hand, put a paper clip on an envelope, and pour water from a jug (24). The GAT score is based on time consumption, with lower scores indicating good function. Self-estimated hand function (SEHF) was recorded on a VAS scale, ranging from 0 to 100 (0very poor hand function) (25). However, to make interpretation easier, the scale was aligned with the other VAS scales by inverting the numbers, before presenting the results in tables. Function in daily activities was measured using a modified version of the Stanford Health Assessment Questionnaire (MHAQ). MHAQ is a questionnaire developed to measure physical function in activities of daily living in patients with arthritis. In MHAQ, the patients rate their ability to perform the following eight activities on a scale ranging from 1 to 4 (1 is best function): dress yourself (including tying shoelaces and doing buttons), get in and out of bed, lift a full cup or glass to your mouth, walk outdoors on flat ground, wash and dry your entire body, bend down to pick up clothing from the floor, turn taps on and off, get in and out of a car (26). Disease variables. The patients global assessments of pain, fatigue, and disease activity were recorded on 100 mm visual-analogue scales (VAS), ranging from 0 to 100 (0no pain, fatigue or disease activity). Patients experiences. To gain more insight into patients experiences with the intensive programme and how they managed to exercise at home, six participants from the IEP group (four women and two men) were interviewed at the 14-week assessment. The patients were asked if they would participate in the interview after the assessments were completed, and those consenting were thereafter interviewed the same day. All interviews were audiotaped. For interview guide, see Appendix B. Data analysis and statistics Differences in clinical and demographic variables at baseline between patients in the two treatment groups, as well as differences between patients who were lost to follow-up during the study period and the patients who completed the study, were examined by chi-squared tests or by a two-sample t-test. All outcome measures were analysed on an intention-to-treat basis. Before conducting the analyses of changes over time, the patients who were lost to

4 176 A. Rønningen & I. Kjeken follow-up were given estimates according to the following principles: baseline values were prolonged throughout the whole study period for patients who were lost to follow-up at discharge. At week 14, the values for the patients who withdrew or dropped out for reasons not known were computed equivalent to the poorest values (within 2 SD of group mean) in their treatment group. The values for the patients who were unable to attend assessment at week 14 due to reasons not related to the study were computed as the mean of their values at baseline and week 2. Within-group differences were calculated as baseline results minus results at 2 or 14 weeks, respectively, and examined by paired-samples t-test. Between-group differences were calculated as mean difference in the IEP group minus mean difference in the CEP group, and examined by a Univariate General Linear Model (ANCOVA), adjusted for disease duration (all analyses of between-group differences) and extension deficit (analyses of between-group differences in bilateral and dominant hand variables), as there were significant differences in disease duration and extension deficit in the dominant hand between the two groups at baseline. The interviews concerning patients experiences were transcribed before a first analysis was carried out separately by the authors, who read through the interviews before categorizing and grouping the patients statements (27). Thereafter the two analyses were compared and discussed until agreement was reached. Results Sample The demographic and clinical characteristics of the patients, as well as medication during the study period, are presented in Table I. There were no significant differences in demographic or disease variables between the two groups at baseline, except for disease duration, which was significantly longer in the CEP group. The mean level of disease activity, fatigue, and pain in both groups was moderate at baseline, and improved slightly and significantly in both groups over the first two weeks (data not shown). However, there were no significant changes in disease variables within the groups from baseline to 14 weeks, or between the groups in the study period, except for a significant decrease in fatigue in the IEP group after 14 weeks (p0.01). Also, the two groups were comparable concerning function at baseline, except for extension deficit in the dominant hand, which was significantly larger in the CEP group (Table II). Of the initial 60 participants, a total of 50 participants completed the study, 24 in the CEP group and 26 in the IEP group. The reasons why patients did not attend the assessments at two and 14 weeks are outlined in Figure 1. There were no statistically significant differences in demographic and clinical variables at baseline between the patients who completed the trial, and those who did not (data not shown), except for a significant higher mean grip strength in the Table I. Demographic and disease variables, and number of patients using different medications at baseline in 60 patients with rheumatoid arthritis. Conservative Intensive p-values a Demographic variables Gender, % women 24 (80) 26 (87) 0.49 Age in years 57.1 (8.4) 55.8 (12.3) 0.64 Still working, % yes 15 (50) 11 (37) 0.30 Disease variables Disease duration, years 13.3 (9.0) 7.7 (7.1) 0.01 Comorbidity, % yes 7 (23) 5 (17) 0.52 Disease activity (0100, 0no activity) 48.8 (22.3) 45.2 (22.6) 0.54 Fatigue (0100, 0no fatigue) 43.3 (27.0) 49.3 (23.5) 0.36 Pain (0100, 0no pain) 47.7 (23.6) 45.7 (20.1) 0.73 Medication 0 w (n30) 2 w (n29) 14 w (n24) 0 w (n30) 2 w (n29) 14 w (n26) DMARDs b biological DMARDs others NSAIDs c Steroids Others Notes: Values are number (%) or mean (SD). a Differences between groups (independent samples t-test for means and chi-square for proportions). b Disease-modifying anti-rheumatic drugs. c Non-steroidal anti-inflammatory drug.

5 Table II. Function at baseline in 60 patients with rheumatoid arthritis. Values are number (%) or mean (SD). Hand exercises in patients with RA 177 Conservative Intensive Conservative p-values a Intensive p-values a Bilateral function Right hand dominance, % yes 26 (87) 27 (90) 0.67 Grip ability test (GAT) (seconds) 28 (18) 24 (9) 0.35 Self-rated hand function (mm) 51 (22) 53 (23) 0.71 (0very poor hand function) Physical function (MHAQ) (14, 1good function) 1.8 (0.49) 1.7 (0.33) 0.34 Hand function Dominant hand Non-dominant hand Hand strength Mean grip strength (N) 90 (66) 104 (68) (72) 101 (65) 0.90 Mean pinch strength (N) 29 (27) 27 (17) (22) 28 (18) 0.85 Hand pain Pain-resisted grip (mm) 33 (25) 33 (24) (21) 31 (23) 0.84 Pain-resisted pinch (mm) 29 (24) 29 (23) (19) 31 (24) 0.13 Joint mobility Flexion deficit (mm) 30 (45) 14 (26) (55) 21 (38) 0.47 Extension deficit (mm) 33 (48) 10 (19) (33) 15 (41) 0.77 Opposition deficit thumb (mm) 15 (21) 8 (11) (12) 6 (9) 0.25 Wrist motion (8) 70 (34) 84 (25) (21) 92 (38) 0.15 Note: a Differences between groups (independent samples t-test for means and chi-square for proportions). dominant hand in patients who completed the study, compared with the patients who did not complete (104 N and 62 N respectively) (p0.04). Interventions The median number of organized training sessions attended during hospital stay was 7 in both groups, while median number of self-reported training sessions during follow-up were 39 in the CEP group and 49 in the IEG group (p0.04). There were no statistically significant differences between the two groups in physical therapy (p 0.83), occupational therapy (p 0.91), or steroid injections during hospital stay (p0.50), or in medication at baseline or in the study period. Conservative exercise group (CEG) 30 first eligible patients included Intensive exercise group (IEG) 30 next eligible patients included assessments 30 assessments 30 Received treatment according to protocol 30 Received treatment according to protocol 29 Attended < 5 training sessions 1 Assessed at two weeks 29 Left hospital before assessment 1 Assessed at two weeks 29 Assessed at 14 weeks 24 Lost to follow-up 5 Withdrew due to great improvement (1) Dropped out, reasons unknown (4) Assessed at 14 weeks 26 Lost to follow-up 3 Withdrew due to travelling (1) Withdrew due to busy at work (1) Withdrew, reason unknown (1) Figure 1. Flow chart of the number of patients who completed the study according to the protocol and the number of patients who did not complete allocated treatment and why they were lost to follow-up.

6 178 A. Rønningen & I. Kjeken Grip strength Dominant hand Grip strength Non dom. hand between the groups in favour of the IEP in three out of four measures after 2 weeks and in one out of four after 14 weeks (see Table III) Mean Strength CEP Mean Strength IEP Joint mobility. The analyses of changes within each group revealed some significant improvements in the measures of joint mobility, mostly in the dominant hand, and all but one in the IEP group (see Table III). However, there were few significant differences between the two groups, but again the significant differences were in favour of the IEP Pinch strength Dominant hand Pinch strength Non dom. hand Figure 2. Mean grip and pinch strength in Newtons for each hand, recorded at baseline, 2 and 14 weeks in the Conservative exercise programme (CEP) group and the Intensive exercise programme (IEP) group. Primary outcome measures Hand strength. Hand strength in the groups is displayed in Table II (baseline), and in Figure 2 (baseline, 2 and 14 weeks). In general, there were few significant changes in the CEP group, although there was a trend towards improvement in the dominant hand after 14 weeks (Table III). In the IEP group, there were significant improvements in all measures of hand strength after 2 and 14 weeks. When comparing the results in the two groups after two weeks, there were significant differences in favour of the IEP in mean pinch strength in both hands (p 0.01 for dominant hand and 0.05 for non-dominant hand), and also in mean grip strength in the non-dominant hand (p 0.04) (see Table III). After 14 weeks, there were significant differences between the two groups in mean grip strength in the non-dominant hand (p0.04), again in favour of the IEP. Secondary outcome measures Hand pain. During the study period, there was a general trend towards increased pain in the CEP group and towards decreased pain in the IEP group, with significant improvement in half of the pain measures in the non-dominant hand in the IEP group after 2 and 14 weeks (see Table III and Figure 3). Also, there were significant differences Bilateral measures of function. There were significant improvements in most measures of bilateral function within the two groups after 2 weeks; in the IEP group there also were significant positive changes after 14 weeks in the MHAQ and GAT scores (see Table III). However, there were no significant differences between the two groups at 2 or 14 weeks, except for the GAT scores, which significantly improved in the IEG after 2 weeks (see Table III). Patients experiences In general, the six interviewed patients described participating in the study as a positive experience. They commented that it was a push to get started, and that the close follow-up during the study period made them feel important. One woman expressed it like this: Participating in the study was an eye opener, it made me realise that exercising is important and motivated me for further exercising. They were also content with the exercise programme, and half of the patients spontaneously commented that the finger flexion exercises were most important. However, while all participants experienced exercising in a group at the hospital as positive, some found it challenging to find time to exercise at home, especially when days were busy. Common among those who experienced exercising at home as unproblematic was that they had succeeded in integrating it into their daily routines. One strategy was to make exercising a break from other daily activities, another to combine it with other activities, such as watching television, or doing the hand flexion exercises while taking a walk. The participants also described how they adjusted the programme by adding or removing exercises, by exercising in hot water, or by using a sponge instead of the dough. Half of the patients had experienced periods with flare and/or pain, but they all continued to follow the programme as they felt that the exercises did not influence the pain or disease activity negatively. None of the patients had experienced any negative effects of the programme, and

7 Table III. Intention-to-treat analysis of mean change with p-values in variables of hand function in 60 patients participating in either a conservative or an intensive hand exercise programme. Mean change Conservative Mean change Intensive Mean difference between groups a Mean change Conservative Mean change Intensive Mean difference between groups a Bilateral MHAQ D week D week Grip ability test (seconds) D week D week Self-rated hand function (mm) (0100, 0 is very good hand function) D week D week Dominant hand Non-dominant hand Mean grip strength (N) D week D week Mean pinch strength (N) D week D week Pain- resisted grip (mm) (0100, 0 is no pain) D week D week Pain- resisted pinch (mm) (0100, 0 is very good hand function) D week D week Vertical flexion deficit (mm) D week D week Extension deficit (mm) D week D week Opposition deficit thumb (mm) D week D week Wrist motion (8) D week D week Notes: Mean change scores within groups were examined with paired samples t-test, and mean difference in change scores between groups were examined with a univariate general linear model, adjusted for differences in disease duration and extension deficit in the dominant hand between the two groups at baseline. D week 2 mean change between baseline and 2 weeks, calculated as values at week 2 minus baseline values. D week 14 mean change between baseline and 14 weeks, calculated as values at week 14 minus baseline values. a Mean differences between groups are calculated as mean difference in the IEP group minus mean difference in the CEP group. Hand exercises in patients with RA 179

8 180 A. Rønningen & I. Kjeken 45 Dominant hand Non-dominant hand Pain Grip strength CEP Pain Grip strength IEP Pain Pinch Strength CEP Pain Pinch Strength IEP 20 Figure 3. Patient reported hand pain at baseline, 2 and 14 weeks in the Conservative exercise programme (CEP) group and the Intensive exercise programme (IEP) group. Pain was recorded on 100 mm visual analogue scales ranging from 0 to 100 (0no pain) after Grippit recordings of, respectively, grip and pinch strength for each hand. four of the six informants commented that the IEP had made their joint more flexible. Regarding ways of improving the programme one patient suggested that instructions on a CD or a cassette could be helpful. Concerning encouragement for exercising regularly, the responses were somewhat ambivalent. Although the participants appreciated the advice, they sometimes found it hard to implement. The following statement made by one of the interviewed women illustrates this: It is not a burden, but it is hard to motivate yourself for exercising when things are busy. You feel that you could always exercise even more. Discussion This study demonstrates that a programme with intensive hand exercises is superior to a conservative exercise programme in terms of improving hand strength. In contrast to the CEP group, the participants in the IEP also experienced a significant decrease in pain, and described in interviews how they adhered to the programme even in periods with high disease activity. Thus, it seems that intensive hand exercises are effective and well tolerated by patients with RA. However, the differences in hand function between the two groups were not reflected in the measures of overall hand function, as there were few significant differences in improvement between the two groups concerning MHAQ, grip ability and selfrated hand function. One reason for this may be the fact that the threshold levels of hand strength for limitation of daily activities vary. Thus, what might be a clinically relevant improvement when performing one activity may still not be enough to constitute an important difference when trying to perform another task. Therefore, the increased hand strength in the IEP group may not have manifested as improved performance in the activities listed in the outcome measures used in this study. Also, it has been demonstrated that patients vary considerably in how they rate the personal impact of limited performance of the activities listed in the MHAQ (28), and as half of the items in the MHAQ are activities related mostly to function in the spine and lower limbs, this measure may be less sensitive for capturing what patients consider important changes due to improved hand function. Future studies should therefore include measures of hand-related activity performance, and also use individualized instruments that capture patients preferences for functional improvement (29). Further, studies analysing what minimum levels of hand strength are needed to perform a spectrum of basic activities are needed. Patients with RA are often encouraged to exercise regularly. In the follow-up period, the participants in the CEP group exercised approximately three times a week, compared with four times a week in the IEP group. This indicates that it was the content of the programmes rather than the weekly exercise frequency that determined the differences in hand function between the two groups. However, the interviews revealed that the participants found it challenging to exercise regularly over longer periods. A strategy might be to alternate between short but intensive exercising periods aimed at improving

9 Hand exercises in patients with RA 181 function, and longer periods with a short programme aimed at maintaining hand function. In the IEP, concentric isotonic exercises against moderate resistance were combined with an increased number of repetitions of each exercise, and also an increased weekly frequency of exercising. However, to determine more accurately what exercise regimes are the most effective to maintain or improve different aspects of hand function, future studies should also explore the use of different kinds of exercises, such as isometric versus concentric strengthening, and variations in resistance, holdings, repetitions, and weekly frequency (11). In the interviews, the participants expressed distinct opinions regarding which exercises were the most effective, and described how they adapted the programme to fit their needs and daily routines. Thus, to enhance patients adherence to exercising, one should tailor programmes according to individual preferences and discuss how the programme may be adjusted to allow for fluctuations in disease or capacity to exercise. At baseline, there were significant differences between the two exercise groups regarding disease duration and extension deficit in the dominant hand. One reason for the difference in disease duration could have been that the patients in the two groups were included at different times during the year, and that older patients with presumably longer disease duration were also more willing to be admitted during holidays. However, a review of the patient records did not confirm this hypothesis, as inclusion in each of the groups lasted for approximately one year. Further, there were no significant differences in mean age between the groups. As the two groups were also comparable in all other demographic and disease-related variables, we reason that the differences are coincidences, which probably would have been avoided with a randomized controlled design. The differences were, however, controlled for in the statistical analysis. Also, the estimates for the dropouts in the intention to treat analysis were rather conservative, to avoid any overestimation of possible positive effects. The main aim of our study was to examine and compare the effect of two treatment modalities. Thus, the best design would have been a randomized controlled trial (30). However, as the study was carried out in a small hospital unit with 32 beds, we reasoned that there was great potential for a carryover effect between two parallel exercise groups, as the patients in the two groups could have exchanged experiences and exercises, thereby possibly diminishing the differences between the two exercise programmes. Further, organizing two groups would be a challenge due to limited staff resources. Another limitation of the study is the lack of blinded assessors. Although strict blinding is impossible with exercise interventions, the fact that the occupational therapists assessing the patients knew which exercise programme the patients were following may have influenced the measurements. The main outcome variable was measured by the Grippit instrument, which is considered an objective measure of grip strength. Thus, we consider the chances to be small that the assessor s knowledge of group allocation may have influenced the main results. However, in an estimation of true power in the study, based on a mean grip strength of 97 N (SD 67 N), and a mean difference of 28 N between the two groups at two weeks, we found that the power to detect this difference was 62% in the study population of 60 patients. Therefore, the possibility of not detecting clinically important differences between the two groups is larger than calculated initially. Clinical practice should as far as possible be evidence based (31). To be able to give more specific recommendations regarding hand exercises, we need to know which programmes are the most effective when it comes to improve hand strength, joint mobility, and function in daily activities. Future studies should also investigate to what degree improvements in body functions are transferred in to better function in performance of daily activities. Based on the results of this study, we conclude that an intensive hand exercise programme is well tolerated and more effective in improving hand strength compared with a traditional programme with low-intensity exercises in patients with RA. Acknowledgements The authors would like to thank the Norwegian Foundation for Health and Rehabilitation, who financially supported the study. They would also like to thank the occupational therapists at Lillehammer Hospital for Rheumatic Diseases, Lise Klem, Anlaug Brandslien, Elisabeth Hasselknippe, and Åse Skarbø, for their help during the study. References 1. Uhlig T, Kvien TK. Is rheumatoid arthritis disappearing? Ann Rheum Dis. 2005;/64:/ Dellhag B, Burckhardt CS. Predictors of hand function in patients with rheumatoid arthritis. Arthritis Care Res. 1995;/8: / 1620.

10 182 A. Rønningen & I. Kjeken 3. Nordenskiold UM, Grimby G. Grip force in patients with rheumatoid arthritis and fibromyalgia and in healthy subjects: A study with the Grippit instrument. Scand J Rheumatol. 1993;/22:/ Jones E, Hanly JG, Mooney R, Rand LL, Spurway PM, Eastwood BJ, et al. Strength and function in the normal and rheumatoid hand. J Rheumatol. 1991;/18:/ Thyberg I, Hass UA, Nordenskiold U, Gerdle B, Skogh T. Activity limitation in rheumatoid arthritis correlates with reduced grip force regardless of sex: The Swedish TIRA Project. Arthritis Rheum. 2005;/53:/ Dellhag B, Hosseini N, Bremell T, Ingvarsson PE. Disturbed grip function in women with rheumatoid arthritis. J Rheumatol. 2001;/28:/ Shipham I, Pitout SJ. Rheumatoid arthritis: Hand function, activities of daily living, grip strength and essential assistive devices. Curationis. 2003;/26:/ Nordenskiold U, Grimby G. Assessments of disability in women with rheumatoid arthritis in relation to grip force and pain. Disabil Rehabil. 1997;/19:/ Shipham I, Pitout SJ. Rheumatoid arthritis: Hand function, activities of daily living, grip strength and essential assistive devices. Curationis. 2003;/26:/ Malcus Johnson P, Carlquist C, Sturesson AL, Eberhardt K. Occupational therapy during the first 10 years of rheumatoid arthritis. Scand J Occup Ther. 2005;/12:/ Chadwick A. A review of the history of hand exercises in rheumatoid arthritis. Musculoskeletal Care. 2004;/2:/ Van den Ende CH, Vliet Vlieland TP, Munneke M, Hazes JM. Dynamic exercise therapy in rheumatoid arthritis: A systematic review. Br J Rheumatol. 1998;/37:/ De Jong Z, Munneke M, Zwinderman AH, Kroon HM, Ronday KH, Lems WF, et al. Long term high intensity exercise and damage of small joints in rheumatoid arthritis. Ann Rheum Dis. 2004;/63:/ De JZ, Vlieland TP. Safety of exercise in patients with rheumatoid arthritis. Curr Opin Rheumatol. 2005;/17:/ Van den Ende CH, Breedveld FC, le CS, Dijkmans BA, de Mug AW, Hazes JM. Effect of intensive exercise on patients with active rheumatoid arthritis: A randomised clinical trial. Ann Rheum Dis. 2000;/59:/ Hakkinen A. Effectiveness and safety of strength training in rheumatoid arthritis. Curr Opin Rheumatol. 2004;/16:/ Wessel J. The effectiveness of hand exercises for persons with rheumatoid arthritis: A systematic review. J Hand Ther. 2004;/ 17:/ O Brien AV, Jones P, Mullis R, Mulherin D, Dziedzic K. Conservative hand therapy treatments in rheumatoid arthritis: A randomized controlled trial. Rheumatology (Oxford). 2006;/45:/ Jackson J, McLaughlin Grey J, Zemke R. Optimizing abilities and capacities: Range of motion, strength, and endurance. In: Trombly C, Radomski MV, editors. Occupational therapy for physical dysfunction, 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; p Dellhag B, Wollersjo I, Bjelle A. Effect of active hand exercise and wax bath treatment in rheumatoid arthritis patients. Arthritis Care Res. 1992;/5:/ Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988;/31:/ Massy-Westropp N, Rankin W, Ahern M, Krishnan J, Hearn TC. Measuring grip strength in normal adults: Reference ranges and a comparison of electronic and hydraulic instruments. J Hand Surg [Am]. 2004;/29:/ American Academy of Orthopaedic Surgeons. Measurement of joints. Joint motion: Method of measuring and recording. Edinburgh and London: Churchill Livingstone; p Dellhag B, Bjelle A. A Grip Ability Test for use in rheumatology practice. J Rheumatol. 1995;/22:/ Dellhag B, Bjelle A. A five-year follow-up of hand function and activities of daily living in rheumatoid arthritis patients. Arthritis Care Res. 1999;/1:/ Pincus T, Summey JA, Soraci SAJ, Wallston KA, Hummon NP. Assessment of patient satisfaction in activities of daily living using a modified Stanford Health Assessment Questionnaire. Arthritis Rheum. 1983;/26:/ Kvale S. Interviews: An introduction to qualitative research interviewing, 1st ed. Thousand Oaks, CA: Sage Publications; Hewlett S, Smith AP, Kirwan JR. Values for function in rheumatoid arthritis: Patients, professionals, and public. Ann Rheum Dis. 2001;/60:/ Donnelly C, Carswell A. Individualized outcome measures: A review of the literature. Can J Occup Ther. 2002;/69:/ Nelson DL, Mathiowetz V. Randomized controlled trials to investigate occupational therapy research questions. Am J Occup Ther. 2004;/58:/ Rappolt S. The role of professional expertise in evidencebased occupational therapy. Am J Occup Ther. 2003;/57:/ Appendix A: Conservative hand exercise programme (CEP) The programme consisted of the following gentle exercises performed against resistance of a soft dough: ulnar deviation of the wrist (with fingers flexed), flexing the fingers into a fist, extending the fingers, touching the tip of each finger with the thumb, rolling a ball with the palm on the table with extended fingers, radial finger walking with the four ulnar fingers moving towards the thumb, and abduction of the thumb with the IP joint flexed. Additionally, the following exercises were performed without resistance: Volar and dorsal flexion of the wrist, pronation and supination of the hand and forearm, opposition of the thumb, and flexion of the IP joint of the thumb. All together, the programme contained 11 different exercises. Each exercise in the programme was repeated three times. At discharge, the patients were given a leaflet with descriptions and pictures of the exercise programme and were instructed to exercise according to their usual training routines. Intensive hand exercise programme (IEP) The exercises in the intensive hand programme were to a large degree identical to those in the conservative programme, except for the following changes: opposition of the thumb was performed against

11 Hand exercises in patients with RA 183 resistance, while the exercises of touching the tip of each finger with the thumb and rolling a ball with the palm on the table were removed, as these do not influence grip force. Also, each exercise was repeated 10 times, except for the radial finger walking, which was repeated five times. Additionally, the section with finger flexion and extension exercises was repeated three times during the training session. At discharge, the patients were given a leaflet with descriptions and pictures of the exercise and instructed to exercise once a day for a minimum of five days a week until returning for the 14-week assessment. Appendix B: Interview guide Can you describe your experiences of participating in the study? What do you think of the exercise programme? What are your experiences with doing the exercise programme at home? Have you experienced any negative or positive effects of the programme, and if yes, what are they? Do you have any suggestions on how the programme could be adjusted or improved? Patients with arthritis are often advised to exercise regularly. How do you react to this advice?