Development of an evidence-based exercise programme for people with hand osteoarthritis.

Scandinavian Journal of Occupational Therapy. 2014; Early Online, 1–14

ORIGINAL ARTICLE

Scand J Occup Ther Downloaded from informahealthcare.com by UMEA University Library on 10/13/14 For personal use only.

Development of an evidence-based exercise programme for people with hand osteoarthritis

INGVILD KJEKEN1,2, MARGRETH GROTLE1,3,4, KÅRE BIRGER HAGEN1,2 & NINA ØSTERÅS1,2 1

National Advisory Unit on Rehabilitation in Rheumatology, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway, 2Department of Health Sciences, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway, 3Oslo and Akershus University College of Applied Sciences, Faculty of Health Sciences, Department of Physiotherapy, Oslo, Norway, and 4FORMI, Clinic for Surgery and Neurology, Oslo University Hospital, Oslo, Norway

Abstract Background: Exercising is recommended for people with hand osteoarthritis (HOA), but there is no consensus regarding the design of exercise programmes. Objective: To describe the development and content of an evidence-based exercise programme for people with HOA. Methods: The development was based on research evidence, professional expertise, and client evidence and adhered to the new Medical Research Council framework for design and evaluation of complex interventions. The process included literature search and appraisal, discussions with clinicians and patient research partners, and piloting, followed by a revision of the programme based on feedback from pilot participants. Results: The programme contains three exercises to increase the strength and stability of the shoulder, arm and wrist muscles, and four exercises to maintain or increase range of motion, grip strength, and joint stability in the finger joints. It starts with a warm-up period, ends with a finger stretch exercise, and follows the American College of Sports Medicine’s recommendations regarding exercise intensity, session frequency, and length of exercise period. An exercise diary is included as part of the programme. Conclusions: An evidence-based exercise programme for people with HOA has been developed. The effect of the programme has recently been evaluated in a randomized controlled trial.

Key words: osteoarthritis, hand, exercises, evidence-based practice

Introduction Hand osteoarthritis (HOA) is one of the most common joint disorders, and may have large influences on an individual’s function, health-related quality of life, and participation in the society (1). Among important risk factors for developing HOA are female gender and higher age. As life expectancy is increasing, the number of people with HOA is expected to rise in the coming decades (1), and effective therapeutic strategies are needed to help patients to manage their condition. Occupational therapists and physical therapists are in a crucial position to provide support to this patient group for better self-management,

including providing interventions related to exercise and behavioural change (2,3). The manifestations of HOA are soft tissue swelling, inflammation, bony enlargements, and bone erosions, most frequently in the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints of the 2nd– 5th fingers and the carpometacarpal (CMC1) joint of the thumb (4). Common symptoms are pain and stiffness, while functional consequences are reduced mobility and grip force, and activity limitations and participation restrictions, which may lead to reduced work ability and increased dependency (5–7). Studies further indicate that the levels of pain and disability are significantly higher among people with OA in the

Correspondence: Ingvild Kjeken, National Advisory Unit on Rehabilitation in Rheumatology, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, PO Box 23, Vinderen, N-0319 Oslo, Norway. Tel: +47 22 45 48 45. Fax: +47 22 45 48 50. E-mail: [email protected] (Received 27 March 2014; accepted 1 July 2014) ISSN 1103-8128 print/ISSN 1651-2014 online 2014 Informa Healthcare DOI: 10.3109/11038128.2014.941394


2

I. Kjeken et al.

CMC1 joint compared with those without OA in this joint (8,9). CMC1 OA presents with a combination of structural changes that involve reduced cartilage thickness, increased ligament laxity with resultant instability, and subluxation of the base of the metacarpal on the trapezium, which in turn results in decreased thumb web space (10,11). There is currently no cure for HOA. The European League Against Rheumatism (EULAR) states in its treatment recommendations that the optimal management of HOA requires a combination of nonpharmacological and pharmacological treatments (12). The EULAR further recommends that all patients with HOA should receive an exercise regimen that involves both range of motion (ROM) and strengthening exercises, but underscores that direct evidence for the effect of exercise is lacking, and that robust randomized trials are needed. The core intervention in such trials should be an evidence-based exercise programme, but at the time we initiated our study there was no consensus regarding the design of such programmes for people with HOA. Furthermore, to be able to compare and replicate successful interventions in clinical practice, detailed descriptions of the interventions should be given. Unfortunately, these are often lacking in the reporting of rehabilitation interventions (13). Therefore, the aim of this study is twofold: to describe the development of an evidence-based exercise programme for people with HOA, and to provide a thorough description of the programme. Material and methods The development of an evidence-based exercise programme should be based on synthesized evidence from three key sources: research evidence, clinical expertise, and client evidence (14). Moreover, as such programmes contain many interacting elements, the development should also adhere to the framework for the design and evaluation of complex interventions as described by the new Medical Research Council (15). This study addresses the first two phases in this framework, (i) searching and appraising the evidence, identifying appropriate theory and literature, and (ii) designing and pilot testing a new exercise programme for people with HOA (Figure 1). The efficacy of the programme has recently been examined in a randomized controlled trial (ClinicalTrials.gov registration number: NCT01245842) (16). Phase 1 Identifying research evidence. At the time we initiated our study, the EULAR recommendations (12) and

three systematic reviews summing up the evidence for non-surgical interventions for HOA were available (17–19). In summary, they concluded that there is some evidence supporting that hand exercises may reduce pain and increase grip strength, ROM, and function. Nevertheless, none of the reviews contained any detailed description or evaluation of the exercise programmes in the included studies. We therefore performed a systematic literature search in the Cochrane Central Register of Controlled Trials, AMED, Medline, Embase, CINAHL, OT seeker, and PEDro up to May 2010, searching for primary studies evaluating the effect of exercise programmes in people with HOA. We included any study with a controlled design; that is, randomized controlled trials, controlled clinical trials, and interrupted time series. A detailed description of the search and an evaluation of included studies is provided in a review published in 2011 (20). Each identified exercise programme was described according to its content, and evaluated following the American College of Sports Medicine’s (ACSM) recommendations for developing muscular strength and flexibility in older frail adults, defined as people aged 50 years or older (21) (Table I). To obtain a basis for the exercise programme development, we also searched for other relevant literature, such as theories and recommendations addressing design and effect of hand exercises in rheumatic diseases. Professional expertise: input from clinicians in design of the new exercise programme. The new exercise programme was developed by clinicians and researchers at the National Advisory Unit on Rehabilitation in Rheumatology, based on current evidence and existing literature relevant to exercises for HOA. Three occupational therapists with lengthy experience in treating HOA patients, one of whom is also a researcher, and two physiotherapists affiliated with sports medicine, participated in discussions and gave input for the design of the programme. Phase 2 Client evidence: input from clients through pilot-testing and evaluating the new exercise programme. An effective exercise programme should be tolerable and yield positive changes in people with both normal and impaired hand function. As a consequence, we involved people both with and without HOA in the pilot testing of the programme, and recruited patient research partners, colleagues at the National Advisory Unit on Rehabilitation in Rheumatology, and their relatives (hereafter termed participants). In total, the pilot group consisted of one man and 10 women

An evidence-based exercise programme for hand OA

3


Systematic literature search for controlled trials examining the effect of exercises in HOA Search for literature containing theories or recommendations relevant for the design of exercise programmes in HOA Phase 1: Development of an exercise programme and diary using the best available evidence and appropriate theory

Appraising the research evidence from controlled trials concerning design and effect of the identified HOA programmes, (n = 6, containing 7 different exercise programmes) Appraising relevant theories or recommendations addressing design and effect of hand exercise programmes in HOA

Development of the first version of a new exercise programme, including a diary to record adherence, by a group including three experienced occupational therapists, of which one is also a researcher, and two physiotherapists affiliated in sports medicine

Phase 2: Testing the exercise program me and diary in pilot studies

Pilot testing of the first version of the programme and diary by one man and 10 women, of whom six had HOA Interviews with participants regarding their experiences with the programme and diary

Research evidence

Professional expertise

Client evidence

Adjusting the programme and diary

Testing of the second version of the exercise programme and diary by two patient research partners, two researchers, and one occupational therapist working in specialist health care, and three health professionals working in primary health care

Client evidence and professional expertise

Evaluating the effect of the exercise programme and diary in a randomized controlled trial, ClinicalTrials.gov registration number: NCT01245842 Figure 1. Phases (left column), steps (middle column), and type of evidence (right column) informing the development of an exercise programme and diary for people with hand osteoarthritis (HOA).

Table I. American College of Sports Medicine’s (ACSM) recommendations for developing muscular strength and flexibility in people aged 50 years or older. Recommendation 1

An exercise programme should be performed 2–3 days per week

2

It should start with a warm-up period

3

It should include exercises to both increase and maintain ROM and to increase strength and endurance

4

Exercises to increase ROM should be performed with at least four repetitions per muscle group

5

Exercises to increase strength and endurance should be individualized and progressive

6

The programme should include one set of 10–15 repetitions that condition the major muscle groups

7

The minimum exercise bout should be at least 20 minutes in duration

8

A minimum recovery period of at least 48 hours between exercise sessions should be allowed

9

A minimum training period of at least 12–15 weeks is recommended to achieve an optimal effect


4

I. Kjeken et al.

(mean age 55.0; SD 9.7), six of whom had HOA. They tested the programme during a four-week period from May–June 2010. As part of the programme, participants recorded their exercises in an exercise diary, and measures of grip strength were performed both before and after each exercise period, using the Grippit electronic instrument (22). After the four-week period, the participants were interviewed regarding their experiences with the programme and the exercise diary. In the interview, the participants were asked to describe how they had experienced performing the programme, if there was anything they particularly liked or disliked about the programme, whether there was anything that made it easier or more difficult to perform the programme, and whether they had any suggestions for improvements in the programme design. In a last question, the participants were asked if there was anything else they would like to add. The programme was then adjusted according to feedback from the participants, and a second pilot testing was performed in a group consisting of two patient research partners, two researchers, and one occupational therapist who had participated in the first pilot testing, in addition to three health professionals working in primary health care. Results Phase 1 Appraising research evidence. A total of six studies were identified in the literature search (Table II), of which three assessed the effectiveness of exercises (23–25); one assessed the effectiveness of a combination of splints and exercises (26); and two evaluated the effect of joint protection, with the addition of home exercises (27) or splinting and exercises (28). One of the studies comprised two different programmes (26); therefore, a total of seven exercise programmes were reviewed. Design of the exercise programmes: The purpose of the exercise programmes was to increase ROM, grip and/ or pinch strength (23–25,28), and stability of the CMC1 joint (24,26,28) (see Table II). However, the number and types of exercises varied substantially among the seven programmes, ranging from only a single thumb exercise in one study (26) to nine exercises in two studies (25,28). Concerning the exercises to increase ROM, four programmes included exercises to increase finger flexion and opposition of the thumb (24,25,27,28). Regarding strength, three programmes included an exercise to increase grip strength (24,25,28), four contained an exercise to increase pinch strength (24–26,28), and one had exercises to increase key pinch (25). A device

or material was used to provide resistance during the strengthening exercises in four programmes (24–26,28). Moreover, two programmes included a thumb abduction and extension exercise (26,28), of which one was a resisted thumb abduction and extension exercise (28). The design of the programme was justified in only one study (26). None of the seven exercise programmes met all nine ACSM recommendations, although one programme met seven of the criteria (24) (see Table II). Of the described programmes, three included the recommended combination of exercises addressing strength and ROM (24,25,28), but only two of these also had the recommended number of repetitions (24,25). While most programmes probably had the potential to achieve the recommended duration of a minimum of 20 minutes, the participants were instructed to exercise every day in five of the programmes (25–28), whereas only one programme had the recommended two to three exercise days per week (24). There was a progression in the exercise programme through increasing the number of repetitions in three of the programmes (25,26), and through increasing isotonic resistance while reducing the number of repetitions in one programme (24). Only three programmes lasted for the recommended minimum of 12 weeks (25,27,28), and only one included a warm-up period (28). Adherence to the programme was recorded in two of the studies (25,27). Effect of the exercise programmes: Three of the studies examined a combination of exercises and other treatment modalities, thus making it impossible to single out the effect of hand exercises. Based on a summary of the three other studies (23–25), we concluded that there is a limited amount of evidence showing that hand exercises may reduce pain and increase ROM and strength in HOA. Furthermore, the appraisal of the evidence did not provide any indications regarding which of the seven programmes was the most effective (20).

Summary of other literature relevant for designing exercise programmes in HOA. According to the literature, exercises in HOA are aimed at maximizing a stable and pain-free functional ROM of the finger joints, increasing functional strength, maintaining joint stability, and preventing or delaying the development of fixed deformities (29–34). Several studies have demonstrated significant correlations between poor grip strength and activity limitations (1,6,35,36), and reduced hand strength is described by people with HOA as an important functional consequence (5). Exercises aimed at improving functional grip strength should therefore

3

9

Improve joint stability, strength and possibly decrease OA pain

Improve joint flexibility (6 exercises) and strengthen grip and pinch strength (3 exercises)

Lefler et al., 2004 (24)

Rogers et al., 2009 (25)

ND

Increase ROM, grip strength and hand function Decrease swelling, pain and tenderness

Garfink et al., 1994 (23)

No. of exercises

Purpose

Study

Table II. Design of exercise programmes in hand osteoarthritis.

All ROM exercises started from the neutral position, and the hand was returned to a neutral position between each repetition. Tabletop: Flex at the second to fifth MCP joints only. Small fist: Flex at the second to fifth PIP and DIP only Large fist: Flex all joints to form a fist. Okay signs: Flex to form an “O” with the tip of the thumb to the tip of each finger, return to neutral after each.

Rice grabs (Gripping): Participants dug their hands into a bucket of rice, making a fist while squeezing the rice, and then opening their hand in the rice Pinch grip lifting: Subjects lifted a large bag filled with bags of sand, using all five fingers to hold the bag Wrist rolls: A bag filled with sandbags (each weighing 250 g) was attached to a rope, which again was attached to a piece of pipe insulation tube. “Dynamic exercises were performed through a full range of motion at a low pain level”

Classical yoga poses (asanas) under supervision. The programme included “stretching and strengthening exercises emphasising extension and alignment”. “For example, they raised and straightened their arms above their heads, intertwined their fingers, and then turned the palms upward and lifted the scapulae (parvatasana). A particular emphasis was to call the subjects’ attention to respiration and upper body alignment”

Type of exercises

Sixteen weeks

3, 4, 5, 6, and 9

1, 3, 4, 5, 6, 7, and 8

Six weeks

The programme was performed three times a week. Isometric resistance training was performed by doing 1–10 repetitions of the muscle groups of the hand and forearm, holding for six seconds, and at 40–60% of MVC. Isotonic resistance training began at 40% of 1RM for 10–15 repetitions, and progressed to 60% 1RM for 6–8 repetitions. Intensity was also adjusted by increasing the number of repetitions to 15 repetitions, and thereafter by adding one more bag of sand. If the subject’s joints were inflamed, only the isometric contractions were performed The programme was performed daily for approximately 10 to 15 minutes For the last three exercises, a nonlatex polymer ball (available in two sizes with different degrees of resistance) was used to give resistance. Starting resistance was determined by the participants’ baseline grip and pinch strength, and the participants could be

7 and 8

Ten weeks (with eight weeks of exercising)

One weekly one-hour session. No description of intensity or progression

Meeting ACMS’s rec no.

Study period

Intensity and progression


An evidence-based exercise programme for hand OA 5

ND

7

1

Programme 2: ND

Stamm, 2002 (27)

1

Programme 1: Provide reinforcement of the palmar leak ligament

Wajon et al., 2005 (26)

No. of exercises

Purpose

Study

Table II. (Continued).

Participants were instructed to perform three sessions per day, increasing from 5 to 10 repetitions per session, as pain and endurance permitted Patients were instructed to do every exercise with both hands 10 times daily. No description of intensity or progression

Participants were provided with an extra soft Foam Block and instructed to perform a fingertip pinch against resistance Making a fist, making a small fist (flexing the PIP and DIP joints only), flexing the MCP joints while keeping the PIP and DIP joints stretched, touching the tip of each finger with the tip of the thumb while keeping each finger flexed, spreading the finger as far as possible with the hand lying flat on the table, pushing each finger in the direction of the thumb with the hand lying flat on a table and touching the fifth MCP joint with the tip of the thumb

Participants were instructed to perform three sessions per day, increasing from 5 to 10 repetitions per session, as pain and endurance permitted

assigned to use more than one ball, i.e. a soft ball for pinching exercises and a firmer ball for gripping. Participants began with 10 repetitions the first four weeks, then progressed to 12, then 15 and finally 20, if able, during the last four weeks An exception was made for the fingertip pinch, in which repetitions were halved so as not to over stress the thumb

Finger spread: Hand is placed on flat table top and fingers are spread apart as wide as possible. Thumb reach: Reach across the palm of the hand and touch the tip of the thumb to the fifth MCP. Gripping: Hold the Thera-Band Hand Exerciser ball in the palm of the hand and squeeze until the ball is 50% depressed. Key pinch: Hold the TheraBand Hand Exerciser ball between the side of the thumb and the side of the index finger and squeeze until the ball is approximately 50% depressed. Fingertip pinch: Hold the Thera-Band Hand Exerciser ball between the side of the thumb and the tip of the index finger and squeeze until the ball is approximately 50% depressed; this is repeated for digits three to five Perform palmar abduction (thumb extension) against gravity in a smooth, controlled motion, avoiding any aggravation of pain


Type of exercises


4, 7, and 9

5 and 6

Six weeks

Three months

4 and 5


Six weeks

Study period

6 I. Kjeken et al.

Increase the ROM of all joints of the hand and to strengthen the structure around the CMC1 joint to help maintain its stability

Boustedet al.,* 2009 (28)

Type of exercises

Gripping: Squeeze the dough with all five fingers Roll the dough back and forth from the underarm and down to the PIP joints of the fingers. Stretch your fingers and elbows Large fist: First flex all joints to form a fist, thereafter extend all fingers. Use maximal force Stretching: Put your fingers in the dough with extended MCP joints, and thereafter “plow a furrow” in the dough by stretching your fingers Thumb reach: While resting the hand at the table in a neutral position, push your thumb through the dough until it reaches the base of the little finger Okay signs: Flex around the dough to form an “O” with the tip of the thumb to the tip of each finger, returning to neutral after each repetition Thumb extension: Flex your thumb and put the dough over your thumb. Thereafter, extend your thumb through the dough Thumb abduction: Put your hand on the table palm down. Put the dough at the radial side of your thumb. Push the thumb against the dough Thumb abduction: Put your hand on the table palm down. Put the dough between the thumb and the index finger, and push the thumb against the index finger

No. of exercises 9

Study period

The study period lasted for one year, with assessments also after the first six weeks


All participants had two sessions a week for five weeks. Each session included a paraffin wax treatment and hand exercises with paraffin dough, focusing on ROM and pain-free moderate strength of the hand intrinsic and the thumb extrinsic muscles. Each exercise was repeated three times, except for the first exercise, which was also repeated three times at the end of the programme. All but one exercise was performed with dough Participants in the experimental group were instructed to carry out the same exercises with paraffin dough once a day during the study period

2, 3, 7, 8, and 9


Notes: ACMS’s rec no. = American College of Sports Medicine’s recommendation number; ROM = range of motion (mobility); ND = not described; PIP joints = proximal interphalangeal joints; DIP joints = distal interphalangeal joints; MCP joints = metacarpophalangeal joints; CMC1-joint = the carpometacarpal joint of the thumb; MVC = maximum voluntary contraction; isometric resistance training = an exercise in which the joint angle and muscle length do not change during contraction’ 1RM = one repetition maximum (the maximum amount of weight one can lift in a single repetition for a given exercise). *Additional information given on request to the first or corresponding author.

Purpose

Study

Table II. (Continued).


An evidence-based exercise programme for hand OA 7


8

I. Kjeken et al.

be included in a HOA exercise programme. As it is well known that hand injuries or diseases may lead to muscle atrophy and restriction of movement in the elbow and shoulder (37), exercises for the shoulder girdle and upper arm may also be an important part of an exercise programme for HOA. It is suggested that the deforming force of the CMC1 joint is the strong pull from the adductor pollicis muscle combined with an increasing weakness of the opposing thenar intrinsic musculature (30–34). Hence, in order to maintain the first web space, avoid adduction deformity, and improve thumb stability, it is recommended to strengthen the thumb extensors and abductors as well as the wrist extensor muscles. Many authors further claim that excessive exercises to improve pinch or key grip strength should be avoided, as these, especially in later phases of CMC1 OA, may result in increased subluxation and pain in instable joints (31–34). Concern is also expressed regarding exercises aimed at reaching full flexion and opposition of the thumb, since the motion gained by this exercise may be of no functional benefit to the patient if the increased ROM results in a painful motion (34). It is often stated that exercises for people with HOA should be of low intensity, be performed in periods with little pain and inflammation, and not cause pain that persists for more than two hours after the activity (30,31,34). Nonetheless, it has been argued that for people with OA, a pain score of 5 on a scale from 0 to 10 (0 = no pain) is acceptable immediately after training and that the pain should be back to a basic level after 24 hours (38). There is also a considerable amount of research demonstrating that intensive exercise is well tolerated and has a positive effect on pain alleviation and function in knee OA (39,40). With regard to disease activity and radiological damage of the hands and feet, studies have shown that intensive programmes are well tolerated and safe for patients with rheumatoid arthritis (41). Furthermore, these programmes have also proved to be more effective than low-intensity programmes in improving general muscle strength, joint mobility, and functional ability (42,43). It is stated in evidence-based recommendations for exercise in the management of OA of the hip or knee that adherence is the principal predictor of long-term outcome from exercising. Strategies to improve and maintain adherence, such as self-monitoring by means of an exercise diary, should therefore be adopted (44). Phase 2 The first version of the exercise programme and exercise diary. The aims of the new programme were: (i) to maintain or increase strength and stability of the

CMC1 joint, (ii) to increase or maintain thumb web space, grip strength and ROM in the 2nd–5th digits and to maintain the joint mobility of the thumb, and (iii) to maintain or increase strength and stability of the shoulder girdle, upper arm, and wrist. Based on the literature summary, there was consensus in the group not to include any exercise to increase maximum opposition of the thumb or strengthen the pinch or key grip. Furthermore, an exercise diary was developed to enhance programme adherence. The first version of the programme contained three exercises to increase the strength and stability of the shoulder girdle, upper arm, and wrist muscles. Following these exercises, two more were designed to maintain or increase the thumb web space and flexibility of the MCP, PIP, and DIP joints: one exercise to increase the stability of the CMC1 joint by strengthening the thumb extensors and abductors, and one exercise to increase grip strength by strengthening the finger flexors. The programme started with a warm-up period consisting of a few minutes of rubbing the hands together and doing arm swings, and ended with a finger stretch exercise. An exercise band was used in the first three shoulder and upper arm exercises, and the participants were instructed to apply moderate to vigorous intensity in the strengthening exercises and to gradually progress over time by adjusting the resistance (e.g. by shortening the length of the exercise band or changing to a band with more resistance). Pipe insulation tubes were used to give resistance to the grip-strengthening exercise, and were also used in the exercise to strengthen the thumb extensors and abductors by instructing the participant to place the pipe parallel to the first metacarpal and push the thumb against the pipe while keeping the MCP and IP joints slightly flexed. Participants were instructed to perform the programme three times per week. Exercises 1–7 were performed in one set with 10 repetitions for the first two weeks and 15 repetitions for the following weeks, while the stretch exercise was performed four times at the end of every session. As part of the programme, participants also kept an exercise diary. A first version of the diary was designed for the pilot-testing comprising 13 sections, each containing an 11-point numeric rating scale by which the participants reported their pain immediately after exercising (0 = no pain, 10 = maximum pain), as well as the date, place, and length of each exercise session and comments related to the exercises (Figure 2).

Pilot testing and adjustment of the exercise programme and exercise diary. The results showed that five participants (three of whom had HOA) performed six or fewer exercise sessions, while the other six participants

An evidence-based exercise programme for hand OA Day

Date

Time used

____day

9

Comments

____ min

Pain immediately after exercising: 0 No pain

1

2

3

4

5

6

7

8

9 10 Unbearable pain


Figure 2. Illustration of one exercise session recording in the exercise diary.

completed all 12 sessions. The maximum grip strength increased from baseline to four weeks in both hands, for participants both with and without HOA. The median pain (min, max) in participants with and without HOA at baseline 2 (0, 6), and 0 (0, 1), respectively, while median pain after four weeks was 1 (0, 3) and 0 (0, 0). In the interviews, participants reported that they found the exercises easy to perform, but some said the programme was time-consuming, and some found it somewhat boring. Many said it was positive that the programme could be performed almost everywhere because the equipment was easy to bring along. Regarding specific exercises, several commented on the exercise to strengthen the thumb extensors and abductors, which they found difficult to understand and perform, whereas one suggested using a rubber band instead of the pipe to give resistance. A common statement was also that having the equipment visible and easily available made it easier to remember to exercise, whereas holidays and busy schedules made it more difficult to remember to exercise. Suggestions for improvements were to help participants to make an exercise plan, to exercise in a group, and follow-up in terms of repeated measures of grip strength, to encourage participants to continue to adhere to the programme and to provide guidance in adjustments if necessary. It was also suggested that the exercise diary should include basic information about HOA, and explain the rationale for why exercising is important. Adjusting the exercise programme and exercise diary. As a result of the participants’ feedback, the programme was adjusted as follows: The exercise to strengthen the thumb extensors and abductors (exercise 6) was modified by using a rubber band around the metacarpals, instead of the insulation tubes, to help add resistance. Brief information about HOA and the importance of exercising was also included in the exercise diary, as well as a page where participants were encouraged to write down a plan for when and where to exercise.

The second version of the programme and exercise diary was then piloted in one session in a group consisting of two patient research partners, two researchers, and one occupational therapist who had participated in the first pilot testing, in addition to three health professionals working in primary health care. The participants first tested the adjusted programme, and thereafter gave feedback in a group discussion. This testing did not result in any additional changes. The final exercise programme and exercise diary. The final exercise programme is outlined in Figure 3, and the content of the exercise diary is outlined in Table III. In the randomized controlled trial examining the effect of the programme, four weekly group sessions (weeks 1, 2, 3, and 8) led by an occupational therapist, and weekly telephone follow-up in the eight weeks with no group session were included to further enhance programme adherence (16). Discussion This study reports on the development and pilot testing of an evidence-based exercise programme for people with HOA and provides a thorough description of the exercise programme, including an exercise diary that may be used to monitor programme adherence and pain following each exercise session. The development was based on relevant literature identified through literature searches, input from clinicians with experience from sports medicine and the treatment of HOA, and client evidence collected through pilot testing and interviews with study participants, including two patient research partners (14). The study adheres to the framework for the design and evaluation of complex interventions described by the new Medical Research Council (15), and the design of the programme also followed the ACSM’s recommendations for developing muscular strength and flexibility in older frail adults (21). As such, it represents an important step in the process

10

I. Kjeken et al.


No.

Exercise illustration

Instructionsa

1.

Shoulder extension: Sit on an armless chair, knees slightly flexed and heels on the floor. Start position: hands partly pronated (thumbs up), close to the knees. Pull the exercise band back, as the hands follow the thigh to the iliac crest.

2.

Biceps curl: Stand with the feet shoulder width apart, arms hanging down. Hands are supinated (thumbs laterally). Bend both elbows, pulling the exercise band towards the shoulders.

3.

Shoulder flexion: Stand with the feet shoulder width apart, arms hanging down. Hands are pronated (thumbs medially). Keep the elbows extended and lift the arms to face level.

Figure 3. The exercise programme. a The participants were instructed to perform the programme three times per week, with one set of ten repetitions of exercises 1 to 7 during the first two weeks, increasing to 15 over the next ten weeks. The strengthening exercises should be applied with a moderate to vigorous intensity, and to help maintain the intensity level, the exercise band resistance should be gradually increased over time (e.g., by shortening the length of the exercise band or changing to a band with more resistance).

of building evidence and improving the treatment for this patient group. The functional association between the hand and the rest of the upper limb is emphasized in rehabilitation literature (37). In contrast to most other HOA exercise programmes, our programme therefore included exercises for the shoulder girdle and upper arm. After we developed our programme, recommendations for HOA exercises (45), two studies of

multi-professional and multi-dimensional HOA intervention programmes (46,47), and an exercise programme for CMC1 OA have been published (48). The selection of hand exercises in our programme is very much in line with the recommendations by Kjeken et al. (45), while the exercises for CMC1 OA follow the suggestions made by Colditz in a debate on the programme for CMC1 OA (49).


An evidence-based exercise programme for hand OA 4.

Make an “O sign”: Keep the thumb IP and MCP joints slightly flexed throughout. First, open the hand as if grabbing a bottle. Bring the index finger tip to the thumb tip, keeping the MCP, PIP and DIP joints flexed. Open the hand again (“grab the bottle”). Repeat with the 3rd, 4th and 5th fingers.

5.

Roll into a fist: First, flex the 2nd to 5th DIPs and PIPs only (keep the MCPs extended). Then flex the MCPs. Hold for five seconds. Reverse: Extend the MCPs only, then the PIPs and DIPs.

6.

Thumb abduction/extension: Put one or more small elastic band(s) around the 1st to 5th proximal phalanges. Rest the loose fist, pronated, on a flat surface. Keep the thumb MCP and IP joints flexed and abduct/extend the thumb. Hold for five seconds.

7.

Grip strength: Squeeze a pipe insulation tube as hard as possible (isometric hold) for 10 seconds.

8.

Finger stretch: Lay the right hand on a flat surface. Use the left hand to apply firm pressure for 30 seconds, stretching the 2nd to 5th PIP and DIP joints. Repeat two times for each hand. If the finger joints are painful, stretch one finger at a time; place the 2nd to 4th finger tips (opposite hand) between the finger joints of the 2nd finger; press for 30 seconds.

11

Figure 3. (Continued).

In a paper from 2007, Kloppenburg states that there is an urgent need for improvement in the treatment and rehabilitation of people with HOA (2). Hand exercising was a frequently cited strategy in a recent study of self-management strategies among persons with HOA (50). However, participants in a qualitative study appeared to be unsure as to whether exercising their hands and fingers might aggravate their HOA (51). In order to be able to provide safe and effective treatment for people with HOA, it is

therefore important to develop, describe, and test the efficacy of exercise programmes in this patient group. Results from studies in people with rheumatoid arthritis (52) and HOA (53) indicate a beneficial effect of hot paraffin baths. However, as participants in the pilot testing underlined the importance of a programme being easily applicable in a variety of settings, we decided to use simple active warm-up strategies that do not require advanced remedies or equipment.

12

I. Kjeken et al.

Table III. The exercise diary.


Pages

Content

1–2

Information on OA in general, about HOA, and a rationale for why exercising is important

2

Information on the exercise programme, comprising some general advice regarding how to design an exercise plan, the importance of sitting comfortably, remembering to breathe and keep the shoulders low while performing the hand exercises, and instructions for the warm-up period. Thereafter followed information regarding the weekly frequency, number of repetitions and intensity of each exercise, and how to adjust the programme in the exercise period

3

Exercise plan, in which participants were encouraged to write down when (day and time) they would exercise

4–6

The exercise programme

5–9

Four pages (one for each week) which each contain three sections with an 11-point Numeric Rating Scale in which the participants reported their pain immediately after exercising (0 = no pain and 10 = maximum pain), date, and length of exercise session, and gave comments (see Figure 2)

10

A text stating that “you have now finished 1/3 of the programme”, together with a cartoon and an exercise plan which the participant may use if she/he needs to revise her/his original plan

11–14

Four more pages (one for each week) for recording of pain immediately after exercising, date and length of exercise session, and comments (see Figure 2)

15

A text stating that “you have now finished 2/3 of the programme”, together with a cartoon and an exercise plan which the participant may use if she/he needs to revise her/his original plan

16–19

Four more pages (one for each week) for recording of pain immediately after exercising, date and length of exercise session, and comments (see Figure 2)

In an article addressing the ways to improve patients’ adherence to hand therapy, it is emphasized that patients who are given clear and consistent education are more likely to follow their exercise programme (54). Information about HOA and why it is important to exercise was also requested by the participants in our pilot study, and was therefore included in the exercise diary. Some of the participants in the piloting of the exercise programme indicated that it would be easier to adhere to the programme if they could participate in group sessions and receive follow-up in terms of encouragement to continue pursuing the programme. Peer support groups are also a suggested strategy to increase adherence to hand therapy (54) as well as to exercising for hip and knee OA (44). Hence, participation in exercise groups and follow-up calls or consultations may be important means for improving adherence to the exercise programme, and this is included in the randomized controlled trial that evaluated the effect of the programme (16). Occupational therapists and physical therapists play an important role in enhancing self-management in people with HOA (3). A major strength related to this study is therefore that therapists with different clinical and academic backgrounds, and who represent both specialist and primary health care, were involved in developing and testing the programme. Together with the involvement of patient research partners and people with HOA, this ensured that the programme is acceptable and feasible in a variety of settings. A weakness of the study may be the pragmatic approach used when designing the pilot testing, as

number of participants and length of exercise period were primarily based on a clinical judgement. Further, an inclusion of male participants with HOA too may have provided important information for the design of the exercise programme and the exercise diary. In conclusion, an evidence-based exercise programme for people with HOA has been developed, while further research has been conducted to investigate the effectiveness of this programme.

Acknowledgments The authors would like to thank the patient research partners Øyvor Andreassen and Anne Teigland, the primary care health professionals Therese Ingebrigtsen, Liv Yttersian, and Aud Lise Rognhaug, the occupational therapists Merete Herman and Tove Nilsen, and the physiotherapists Silje Halvorsen and Camilla Fongen for their participation in the development of the exercise programme. They would also like to thank all the participants in the pilot study. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References 1. Zhang Y, Niu J, Kelly-Hayes M, Chaisson CE, Aliabadi P, Felson DT. Prevalence of symptomatic hand osteoarthritis and its impact on functional status among the elderly: The Framingham Study. Am J Epidemiol 2002;156:1021–7.


An evidence-based exercise programme for hand OA 2. Kloppenburg M. Hand osteoarthritis: An increasing need for treatment and rehabilitation. Curr Opin Rheumatol 2007;19: 179–83. 3. Dziedzic KS, Hill JC, Porcheret M, Croft PR. New models for primary care are needed for osteoarthritis. Phys Ther 2009;89: 1371–8. 4. Botha-Scheepers S, Riyazi N, Watt I, Rosendaal FR, Slagboom E, Bellamy N, et al. Progression of hand osteoarthritis over 2 years: A clinical and radiological follow-up study. Ann Rheum Dis 2009;68:1260–4. 5. Stamm TA, Van der GF, Thorstensson CA, Steen E, Birrell F, Bauernfeind B, et al. Patient perspective of hand osteoarthritis in relation to concepts covered by instruments measuring functioning: A qualitative European multi-centre study. Ann Rheum Dis 2009;68:1453–60. 6. Kjeken I, Dagfinrud H, Slatkowsky-Christensen B, Mowinckel P, Uhlig T, Kvien TK, et al. Activity limitations and participation restrictions in women with hand osteoarthritis: Patients’ descriptions and associations between dimensions of functioning. Ann Rheum Dis 2005;64:1633–8. 7. Hill S, Dziedzic KS, Ong BN. The functional and psychological impact of hand osteoarthritis. Chronic Illn 2010;6:101–10. 8. Bijsterbosch J, Visser W, Kroon HM, Stamm T, Meulenbelt I, Huizinga TW, et al. Thumb base involvement in symptomatic hand osteoarthritis is associated with more pain and functional disability. Ann Rheum Dis 2010; 69:585–7. 9. Haara MM, Heliovaara M, Kroger H, Arokoski JP, Manninen P, Karkkainen A, et al. Osteoarthritis in the carpometacarpal joint of the thumb: Prevalence and associations with disability and mortality. J Bone Joint Surg Am 2004;86-A: 1452–7. 10. Colditz JC. The biomechanics of a thumb carpometacarpal immobilization splint: Design and fitting. J Hand Ther 2000; 13:228–35. 11. Neumann DA, Bielefeld T. The carpometacarpal joint of the thumb: Stability, deformity, and therapeutic intervention. J Orthop Sports Phys Ther 2003;33:386–99. 12. Zhang W, Doherty M, Leeb BF, Alekseeva L, Arden NK, Bijlsma JW, et al. EULAR evidence based recommendations for the management of hand osteoarthritis: Report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2007;66:377–88. 13. Glasziou P, Meats E, Heneghan C, Shepperd S. What is missing from descriptions of treatment in trials and reviews? Br Med J 2008;336:1472–4. 14. Rappolt S. The role of professional expertise in evidencebased occupational therapy. Am J Occup Ther 2003;57: 589–93. 15. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: The new Medical Research Council guidance. Br Med J 2008;337:a1655. 16. Osteras N, Hagen KB, Grotle M, Sand-Svartrud AL, Mowinckel P, Kjeken I. Limited effects of exercises in people with hand osteoarthritis: results from a randomized controlled trial. Osteoarthritis Cartilage 2014; Epub ahead of print. 17. Towheed TE. Systematic review of therapies for osteoarthritis of the hand. Osteoarthritis Cartilage 2005;13:455–62. 18. Mahendira D, Towheed TE. Systematic review of nonsurgical therapies for osteoarthritis of the hand: An update. Osteoarthritis Cartilage 2009;17:1263–8. 19. Valdes K, Marik T. A systematic review of conservative interventions for osteoarthritis of the hand. J Hand Ther 2010;23:334–50.

13

20. Kjeken I, Smedslund G, Moe RH, Slatkowsky-Christensen B, Uhlig T, Hagen KB. Systematic review of design and effects of splints and exercise programs in hand osteoarthritis. Arthritis Care Res (Hoboken) 2011;63:834–48. 21. American College of Sports Medicine Position Stand. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998;30: 975–91. 22. 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;22:14–19. 23. Garfinkel MS, Schumacher HR Jr, Husain A, Levy M, Reshetar RA. Evaluation of a yoga based regimen for treatment of osteoarthritis of the hands. J Rheumatol 1994; 21:2341–3. 24. Lefler C, Armstrong J. Exercise in the treatment of osteoarthritis in the hands of the elderly. Clin Kinesiol 2004;58:13–17. 25. Rogers MW, Wilder FV. Exercise and hand osteoarthritis symptomatology: A controlled crossover trial. J Hand Therapy 2009;22:10–18. 26. Wajon A, Ada L. No difference between two splint and exercise regimens for people with osteoarthritis of the thumb: A randomised controlled trial. Aust J Physiother 2005;51:245–9. 27. Stamm TA, Machold KP, Smolen JS, Fischer S, Redlich K, Graninger W, et al. Joint protection and home hand exercises improve hand function in patients with hand osteoarthritis: A randomized controlled trial. Arthritis Rheum 2002;47:44–9. 28. Boustedt C, Nordenskiold U, Lundgren NA. Effects of a handjoint protection programme with an addition of splinting and exercise: One year follow-up. Clin Rheumatol 2009;28:793–9. 29. Kurtz PE. Concervative management of arthritis. In Burke SL, Higgins JP, McClinton MA, Suanders RJ, Valdata L, editors. Hand and upper extremity rehabilitation. 3rd ed. St Louis: Elsevier; 2006. p 649–58. 30. Poole JU, Pellegrini VD Jr. Arthritis of the thumb basal joint complex. J Hand Ther 2000;13:91–107. 31. Neumann DA, Bielefeld T. The carpometacarpal joint of the thumb: Stability, deformity, and therapeutic intervention. J Orthop Sports Phys Ther 2003;33:386–99. 32. Moran ME. Osteoarthritis and occupational therapy intervention. Phys Med Rehabil 2001;15:65–81. 33. Taylor J. Restoration of dynamic stability in early osteoarthritis of the carpometacarpal joint of the thumb. Br J Hand Ther 2000;5:37–41. 34. Lockard MA. Exercise for the patient with upper quadrant osteoarthritis. J Hand Ther 2000;13:175–83. 35. Allen KD, Jordan JM, Renner JB, Kraus VB. Relationship of global assessment of change to AUSCAN and pinch and grip strength among individuals with hand osteoarthritis. Osteoarthritis Cartilage 2006;14:1281–7. 36. Jones G, Cooley HM, Bellamy N. A cross-sectional study of the association between Heberden’s nodes, radiographic osteoarthritis of the hands, grip strength, disability and pain. Osteoarthritis Cartilage 2001;9:606–11. 37. Neumann DA. Hand. In Neumann DA, editor. Kinesiology of the musculoskeletal system: Foundations for rehabilitation. 2nd ed. St Louis: Mosby Elsevier; 2010. p 244–88. 38. Roos E. [Physical activity can influence the course of early arthritis. Both strength training and aerobic exercise provide pain relief and functional improvement]. Lakartidningen 2002;99:4484–9. 39. Fransen M, McConnell S. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev 2008:CD004376.


14

I. Kjeken et al.

40. Zhang W, Nuki G, Moskowitz RW, Abramson S, Altman RD, Arden NK, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage 2010;18:476–99. 41. De Jong Z, Vlieland TP. Safety of exercise in patients with rheumatoid arthritis. Curr Opin Rheumatol 2005;17:177–82. 42. Rønningen A, Kjeken I. Effect of an intensive hand exercise programme in patients with rheumatoid arthritis. Scand J Occup Ther 2008;15:173–83. 43. 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;59:615–21. 44. Roddy E, Zhang W, Doherty M, Arden NK, Barlow J, Birrell F, et al. Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee: The MOVE consensus. Rheumatology (Oxford) 2005;44:67–73. 45. Kjeken I. Occupational therapy based and evidence supported recommendations for assessment and exercises in hand osteoarthritis. Scand J Occup Ther 2011;18:265–81. 46. Stukstette M, Hoogeboom T, de RR, Koelmans P, Veerman E, den BA, et al. A multidisciplinary and multidimensional intervention for patients with hand osteoarthritis. Clin Rehabil 2012;26:99–110.

47. Dziedzic K, Nicholls E, Hill S, Hammond A, Handy J, Thomas E, et al. Self-management approaches for osteoarthritis in the hand: A 2x2 factorial randomised trial. Ann Rheum Dis 2013; Epub ahead of print. 48. Valdes K, von der HR. An exercise program for carpometacarpal osteoarthritis based on biomechanical principles. J Hand Ther 2012;25:251–63. 49. Colditz JC. An exercise program for carpometacarpal osteoarthritis based on biomechanical principles. J Hand Ther 2013;26:81–2. 50. Kjeken I, Darre S, Slatkowsky-Cristensen B, Hermann M, Nilsen T, Eriksen CS, et al. Self-management strategies to support performance of daily activities in hand osteoarthritis. Scand J Occup Ther 2013;20:29–36. 51. Hill S, Dziedzic KS, Nio OB. Patients’ perceptions of the treatment and management of hand osteoarthritis: A focus group enquiry. Disabil Rehabil 2011;33:1866–72. 52. Dellhag B, Wollersjo I, Bjelle A. Effect of active hand exercise and wax bath treatment in rheumatoid arthritis patients. Arthritis Care Res 1992;5:87–92. 53. Dilek B, Gözüm M, Sahin E, Baydar M, Ergör G, Özlem E, et al. Efficacy of paraffin bath therapy in hand osteoarthritis: A single-blinded randomized controlled trial. Arch Phys Med Rehabil 2013;94:642–9. 54. O’Brien L. The evidence on ways to improve patients’ adherence in hand therapy. J Hand Ther 2012;25:247–50.

Exercise programme with telephone follow-up for people with hand osteoarthritis - protocol for a randomised controlled trial.

Effects of an exercise programme with people living with HIV: research in a disadvantaged setting.

Better Management of Patients with Osteoarthritis: Development and Nationwide Implementation of an Evidence-Based Supported Osteoarthritis Self-Management Programme.

Review: Exercise interventions improve pain and function in people with knee osteoarthritis compared with no exercise.

Perceptions of Participants in a Group, Community, Exercise Programme for People with Multiple Sclerosis.

Effects of physical exercise programme on happiness among older people.

Exercise for people with hip or knee osteoarthritis: a comparison of land-based and aquatic interventions.

Development of comorbidity-adapted exercise protocols for patients with knee osteoarthritis.

Hand and heart, hand in hand: is radiological hand osteoarthritis associated with atherosclerosis?

Exercise programs for people with dementia.

More hurdles: exercise for people with disabilities.

Joint protection and hand exercises for hand osteoarthritis: an economic evaluation comparing methods for the analysis of factorial trials.

Changes in success rates of smoking cessation treatment associated with take up of a national evidencebased training programme.

Group exercise for subjects with osteoarthritis of the knee.

Chronic disease management: improving care for people with osteoarthritis.

Exercise for osteoarthritis of the knee.

Exercise for osteoarthritis of the hip.

Quadriceps rate of force development affects gait and function in people with knee osteoarthritis.

Effects of a 12-week community exercise programme on older people.

The development and pilot randomised controlled trial of a group education programme for promoting walking in people with intermittent claudication.

Delirium in older people in hospital: an education programme.

Development Mobilities: Identity and Authority in an Angolan Development Programme.

Does pain relate with activation of quadriceps and hamstrings muscles during strengthening exercise in people with knee osteoarthritis?

Effects of two physiotherapy booster sessions on outcomes with home exercise in people with knee osteoarthritis: a randomized controlled trial.