Are exercises beneficial for patients with rheumatoid arthritis of the hand?- A Cochrane review summary with commentary.

Abstract

http://rehabilitation.cochrane.org The aim of this commentary is to discuss the recently published Cochrane review “Exercise for rheumatoid arthritis of the hand”1 by Williams MA et al (This summary is based on a Cochrane review previously published in the Cochrane Database of Systematic Reviews 2018, Issue 7. Art. No.: CD003832. https://doi.org/10.1002/14651858.CD003832.pub3 (see www.cochranelibrary.com for information). Cochrane reviews are regularly updated as new evidence emerges and in response to feedback, and Cochrane Database of Systematic Reviews should be consulted for the most recent version of the review. The views expressed in the summary with commentary are those of the Cochrane Corner author and do not represent the Cochrane Library or Wiley) under the direct supervision of the Cochrane Musculoskeletal Group. This Cochrane Corner is produced in agreement with International Journal of Rheumatic Diseases by Cochrane Rehabilitation. Rheumatoid arthritis (RA) is a chronic immune-mediated inflammatory rheumatic disease resulting from the complex interaction between genetic, constitutional and environmental triggers. It is polyarticular, but typically involves small joints of hands and feet. The disease requires lifelong monitoring and treatment and in the majority of patients limits daily functioning, quality of life and the ability to maintain work. The therapeutic approach to RA patients involves both pharmacological and nonpharmacological treatment aiming at preventing further structural damage, improving signs and symptoms, quality of life and increasing levels of functional independence.2, 3 People with RA are often referred to physical and occupational therapists to achieve these goals. The 3 most common components of the therapies they provide for hands with RA are exercise, joint protection advice, and provision of functional splinting and assistive devices.4-6 Exercises are always individually planned and they are aimed at improving both the mobility and strength of the hand and variety of exercise types may be included (eg increasing and/or maintaining range of motion and strengthening exercises that use resistance). In addition to that, exercise programs may also incorporate the wrist due to the essential involvement of the wrist in functional activities of the hand. The aim of this Cochrane review is to determine the benefits and harms of hand exercise in adult patients with RA (Williams et al 2018).1 The population addressed in this review were adults (male and female), aged 18 years and older, diagnosed with RA lasting 5-14 years. In total, 7 studies involving in total 841 people (aged 20-94 years) were included in the review. Most studies used validated diagnostic criteria and involved home programs. Trials in which exercise for RA of the hand was compared with no treatment, usual care, placebo, medication, surgery, therapeutic modalities, or other non-exercise therapies were taken into account. All forms of exercise such as range of motion, stretching, and strength exercises and functional skills training were considered. Outcomes, assessing benefits and harms, were extracted and defined at 3 time point categories: short term (<3 months), medium term (3-11 months), and long term (12 months or beyond), and at the end of the trial for adverse events. For trials that reported outcomes at multiple time points, the longest follow-up was selected.7 The major outcomes measures included: hand function, pain, hand impairment measures: power grip strength and pinch grip strength (tip-to-tip/tripod pinch grip), American College of Rheumatology 50 (ACR50) response criteria, patient adherence and adverse events due to exercise (eg exercise-induced injuries, increase in pain or in number of swollen or tender joints). The minor outcome measures included: hand impairment measures of range of motion, dexterity, deformity and hand stiffness, function assessed by Health Assessment Questionnaire, Disease Activity Score of 28 joints (DAS28), patient satisfaction, costs and change in splint or assistive device usage. Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, Embase, CINAHL, AMED, Physiotherapy Evidence Database (PEDro), OTseeker, Web of Science, ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) were searched up to July 2017. Very low-quality of evidence (due to risk of bias and imprecision) from 1 study indicated uncertainty about whether exercise improves hand function in the short term (up to 3 months), while moderate-quality evidence (due to risk of bias) from another study indicated that exercise compared to usual care probably slightly improves hand function in the medium term (3-11 months) and in the long term (12 months or beyond). People who did not exercise rated their function at 52.1 points. People who exercised rated their hand function 5 points higher in the medium term (3 to 11 months) and 4 points higher in the long term (12 months or beyond). Very low-quality evidence (due to risk of bias and imprecision) from 2 studies indicated uncertainty about whether exercise compared to no treatment improved pain in the short term. People who did not exercise rated their pain at 51.4 points. On a 0-100-mm pain scale (lower scores mean less pain), people who exercised rated their pain 28 mm lower in the short term, while those who did not exercise rated their pain at 68 mm. On a 0-100-point scale (lower scores mean less pain), people who exercised rated their pain 3 points lower in the medium and 4 points lower in the long term. Moderate-quality evidence (due to risk of bias) from 1 study indicated there is probably little or no difference between exercise and usual care on pain in the medium and long term. On a 0-100 scale, the absolute changes were −3% (95% CI −7% to 2%) and −4% (95% CI −8% to 1%), respectively. Very low-quality evidence (due to risk of bias and imprecision) from 3 studies (n = 141) indicated uncertainty about whether exercise compared to no treatment improved grip strength in the short term. People who exercised had 3% and 4% improvement in the left- and right-hand grip strength in the short term. People who did not exercise measured 14.3 kg and 15.6 kg, respectively. People who exercised had 1% improvement in the average grip strength of both hands in both medium and long term. People who did not exercise measured 13.2 kg. High-quality evidence from one study showed that exercise compared to usual care has little or no benefit on mean grip strength (in kg) of both hands in the medium term, relative change 11% (95% CI −2% to 13%) and in the long term, relative change 9% (95% CI −5% to 23%). Very low-quality evidence (due to risk of bias and imprecision) from 2 studies (n = 120) indicated uncertainty about whether exercise compared to no treatment improved pinch strength (in kg) in the short term. People who exercised had 4% and 6% improvement in the left- and right-hand pinch strength in the short term. People who did not exercise measured 1.2 kg and 1.2 kg, respectively. People who exercised had 2% and 3% improvement in the average pinch strength of both hands in the medium and long term. People who did not exercise measured 4 kg. High-quality evidence from 1 study showed that exercise compared to usual care has little or no benefit on mean pinch strength of both hands in the medium and long term. The relative changes were 8% (95% CI −4% to 19%) and 10% (95% CI −2% to 22%). Moderate-quality evidence (due to risk of bias) from 1 study indicated that people who also received exercise with strategies for adherence were probably more adherent than those who received routine care alone in the medium term (risk ratio 1.31, 95% CI 1.15 to 1.48; n = 438) and number needed to treat to benefit 6 (95% CI 4 to 10). In the long term, the risk ratio was 1.09 (95% CI 0.93 to 1.28; n = 422). Based on the available data, it is not possible to estimate potential risks or adverse events. Based on the result, it is uncertain whether exercise improves hand function or pain in short, medium and long term. Furthermore, based on the evidence it is also uncertain if exercise improves grip and pinch strength in the short term and probably has little or no difference in the medium and long term. The ACR50 response is unknown. People who received exercise with adherence strategies were probably more adherent in the medium term than those who did not receive exercise, but with little or no difference in the long term. Based on the evidence, the risk of any adverse effects is uncertain. The quality of the evidence was very low to high across different outcomes. The quality of the evidence was lowered due to several problems: lack of blinding of participants to their allocated treatment and measurements, methods of allocation and small study sizes. Future research should consider hand and wrist function as their primary outcome, describe exercise following the template for intervention description and replication (TIDieR) guidelines and evaluate behavioral strategies. In order to prevent disability in RA patients, it is important to prevent structural damage (eg joint, cartilage, muscle, synovium) by early diagnosis and introduction of both pharmacological and nonpharmacological treatment modalities. Functional disability is mainly associated with disease activity in early RA or with radiographic joint damage in patients with established disease and is often used as an outcome measure to assess the impact of disease over time. Due to the variable quality of current evidence, future studies should face higher quality standards in terms of conducting and reporting in order to evaluate the effectiveness of exercise therapy for the RA hand. Development of a core set of outcomes for conservative treatment for RA would improve the ability to synthesize evidence in this and similar areas. In addition to that, research to ascertain the clinically important change in hand function is also required. Another important issue in improving upon existing reporting of trials of exercise therapy is how authors should attempt to define, control, and report dosage of exercise and related adherence in accordance with the TIDieR guidelines.8 With the majority of the studies included in this review evaluating short term effectiveness, there is a need for incorporating evaluation of long term effectiveness, especially for a chronic health condition such as RA. Future research to evaluate the efficacy of different modes of exercise intensity, frequency, and duration would therefore be a welcome addition to the evidence base. The author thanks Cochrane Rehabilitation and Cochrane Musculoskeletal Group for reviewing the contents of the Cochrane Corner. The author declares no conflicts of interest.