Upper extremity exercise in people with Rheumatoid Arthritis – does EXTRA help?

It is well known that exercise is good for health and wellbeing – but is it OK to exercise if you have painful joints caused by an inflammatory arthritic condition? This is a question that concerns many people with Rheumatoid Arthritis.

Rheumatoid Arthritis affects about 0.5% population globally and, although advances in drug treatment have revolutionised disease management, most people with Rheumatoid Arthritis still experience joint problems, such as wrist and hand swelling, pain and deformity. These ongoing problems can make a person’s work and leisure activities difficult and impact on their quality of life.

Exercise has the potential to improve physical function, muscle strength and bone mineral density as well as reduce obesity in people with Rheumatoid Arthritis but, until recently, there were concerns that exercise could increase disease activity, pain and swelling and, particularly worryingly, the risk of further joint damage.  Consequently, researchers and clinicians are keen to discover feasible, acceptable and cost-effective rehabilitation programmes to maximise the benefits of drug treatments and help improve the lives of people with Rheumatoid Arthritis.

Our research group at King’s College London worked with patients and health professionals to develop an Education, self-management and upper extremity eXercise Training for people with Rheumatoid Arthritis programme (EXTRA). This brief programme aimed to improve upper extremity pain, disability and confidence in arthritis self-management. It combined a 12-week personalised, daily, strengthening exercise programme, supported by a manual, and exercise diary (available on request), with four group exercise sessions facilitated by a physiotherapist. Each supervised session included a 15-minute patient-led discussion which explored a range of topics such as: understanding arthritis; safety of exercise; self-management and strategies to support exercise in the long term. During these sessions participants also completed their own tailored exercise programme, supervised by physiotherapist.

We studied the effect of EXTRA in a trial which included 108 adults with Rheumatoid Arthritis [1]. We randomly allocated participants to continue with their usual medical care or to receive EXTRA in addition to their usual care.  At 12 weeks, we found that there was a significant between-group difference in the mean change in disability (Effect Size (95% confidence interval) 0.5 (0.1, 0.9)), function (0.6 (0.1, 1.0), nondominant handgrip strength (0.6 [0.2, 1.0) and self-efficacy for arthritis self-management (pain: 0.5 (0.1,1.0), symptoms: 0.5 (0.0,1.0)), all favouring the EXTRA programme. We also found that EXTRA had no adverse effects and disease activity, when measured by the Disease Activity Score 28, was reduced in people who completed EXTRA when compared to those people who continued with their usual medical care only (0.5 (0.0, 1.0).

We also wanted to understand whether EXTRA could be easily included into clinical practice. Our physiotherapists found EXTRA easy to learn and implement. It cost only £68 per patient to deliver and was cost-effective from both a healthcare and societal perspective when assessed against the standards set by the National Institute for Clinical Excellence in the UK [2].

But what did people with rheumatoid arthritis think about doing EXTRA? We completed audio-recorded, semi-structured interviews with 12 participants, selected to reflect a range of ages, upper extremity disability and attendance at EXTRA sessions. We analysed this data thematically and found that most interviewees said that EXTRA was a positive experience which made doing everyday activities easier and provided them with skills, understanding and the confidence to manage their arthritis better.

‘It builds up your confidence, if you know you are doing the right things for your body’

Whilst participants who undertook EXTRA valued the support of the other people they met in the group sessions and the physiotherapist, they also liked the flexibility of doing EXTRA at home. However, some people reported that despite having the knowledge, understanding and confidence to adapt and fit EXTRA into their lives, work, other factors (such as disease flares) and competing priorities influenced whether people could complete EXTRA regularly [3].

Trying to find time to fit them [the exercises] in, and then, and feeling the stress, “oh, ………I’ve just got home from work and I’ve still got my …………. exercises to do”.’

The findings from these studies confirm that well-designed, cost-effective, exercise programmes can be completed safely to improve upper extremity function by people with rheumatoid arthritis. However, longer term follow-up of our participants showed that the effects of the programme diminished and that adherence to the exercises waned over time. It seems that, having developed an acceptable, safe and effective exercise-based rehabilitation programme, we now need to focus on how to encourage and support people with rheumatoid arthritis (and other long-term conditions) to keep exercising so they continue reap the rewards.

About Lindsay Bearne

Lindsay is Physiotherapist and researcher at the Department of Population Heath & Environmental Sciences, King’s College London, United Kingdom. Her research aims to improve function and quality of life of people with long term conditions through the design, testing and implementation of novel rehabilitation interventions. Current research projects investigate rehabilitation programmes which combine exercise with behaviour change strategies to enhance adherence to treatment in people with inflammatory conditions and peripheral arterial disease.

References

[1] Manning V.L, Hurley M.H, Scott D.L, Coker B, Choy E, Bearne L.M. Upper limb Education, self-management and eXercise Training in people with early Rheumatoid Arthritis (the EXTRA programme) – results from randomised controlled trial 2014 Arthritis Care and Research   66, 2, p. 217-227

[2] Manning V.L, Kaambwa B, Ratcliffe J, Scott D.L, Choy E, Hurley M.V, Bearne L.M.  Economic evaluation of a brief Education, Self-management and Upper Limb Exercise Training in People with Rheumatoid Arthritis (EXTRA) programme: a trial-based analysis 1 February 2015, Rheumatology 54, 2, p. 302-309

[3] Bearne L.M., Manning V.L, Choy E. Scott D.L, Hurley M.V. Participant’s experiences of an Education, self-management and upper extremity eXercise Training for people with Rheumatoid Arthritis  programme (EXTRA). 1 Dec 2017 Physiotherapy 103, 4, p. 430-8