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A review of the history of hand

exercises in rheumatoid arthritis
Anne Chadwick M Phil, MCSP, SRP
Keele University, Staffordshire

Abstract
The management of the hand in the patient with rheumatoid arthritis (RA) is a challenge
to all therapists and evidence for optimum management historically scarce. Given that it is
estimated that hands and wrists are affected in 8090% of RA patients (Maini and
Feldmann, 1998), it is apparent that this is an important area for both the patient and
practitioner. While acknowledging the importance of hand function to the patient with RA
(Jones et al., 1991), it should also be admitted that there is little research evidence relating
to the conservative management of hand function in this patient population. This paper
reviews the research that has been carried out in this area and explores possible areas for
further research.
Key words: hand, rheumatoid arthritis, exercises, history

Introduction
A literature search was undertaken by one reviewer of the following databases:
Medline, CINAHL, and AMED databases (19552003) in addition to the
Cochrane Collaboration Library (19592003). The search terms used (alone and in
combination) were: rheumatoid arthritis, RA, hand, finger, exercise, conservative
treatments, physiotherapy, physical therapy, hand therapy, randomized controlled
trials and RCT. Controlled studies were included where the primary intervention
had been exercise therapy and the full text was available. Studies were excluded if
they were not published in the English language.

Rheumatoid arthritis
RA affects approximately 0.81% of the adult population in the UK, where around
387,000 adults have been diagnosed with the condition (Symmons et al., 2002). It is a
disease with no cure and one that often affects people of working age. The prevalence
increases with age and may reach 5% above the age of 55 (Jones and Covert, 1996).

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RA is an autoimmune condition manifesting itself predominantly in a

symmetrical inflammatory polyarthritis with systemic manifestations (Lloyd, 1998).
Soft tissue structures, in particular the synovium of the joint, are affected before
articular structures. Proliferation of synovial tissue and an increase in production of
synovial fluid, leads to joint swelling. Erosions can occur at the junction between
synovial tissue, articular cartilage and bone. These arise where an increase in
vascular tissue (pannus) is laid down, invading the joint margins (Maini and
Feldmann, 1998). Local and systemic extra-articular manifestations may also be
present. The resultant chronic joint damage leads to disability, which slowly
increases over a 1020 year period (Scott et al., 2000). Typically small joints, such
as those of the fingers and toes, are affected more than larger weight-bearing joints,
especially in the early stages of the disease.
RA patients report hand function to be of utmost importance in their daily
lives (Jones et al., 1991). The therapist has several therapeutic aims, all of which
endeavour to maximize a patients function through treatment programmes and
education. A successful therapeutic outcome may be one where a patient is
discharged not only aware of how to manage the symptoms of his or her disease
independently, but also is knowledgeable about when to seek further advice from
members of the rheumatology multi-disciplinary team.
While increasing research is focusing on pharmacological management of this
autoimmune condition, comparatively little research has been undertaken to
identify optimum therapeutic management from either a physiotherapy or
occupational therapy perspective.

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Hand therapy
The treatment options available today for the rheumatological therapist are
extensive and may include manual therapy, electrotherapy, injection therapy as well
as increasing use of alternative medicine approaches (Ernst, 2000) such as
acupuncture (Casimiro et al., 2002; Hardware and Lacey, 2002) in addition to
traditional exercise therapy. However, as Stewart (1996) commented, the
effectiveness of these treatments, specifically used in RA, is often not clearly
demonstrated. While it has been acknowledged for some time that physiotherapy
may be one of the main contributors, and indeed an essential part of treatment in
the management of RA patients, it is probably one of the least researched treatments
(Smith-Pigg, 1989). A clear need still exists for evidence-based hand therapy in the
management of the patient with RA.
Rheumatological physical therapy aims to maximize hand function through
specific improvements in the many joint ranges of movement as well as targeting the
strength of key muscle groups via exercise. In tandem, the education of the patient

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in ways to protect and optimize use of the hand in everyday life, minimizing stresses
on the small joints of the hand is also essential (Hammond and Lincoln, 1999).
Additional aims may be to reduce pain, stiffness and swelling, to minimize deformity
and guide the patient in maintaining a general level of physical fitness (Philips,
1989) as well as preventing general functional decline (Strenstrom, 1994a).
Dellhag and Burckhardt (1995) investigated the relationship between joint
range and both self-reported and actual hand function by studying 52 patients with
RA. They concluded that the strongest predictors of actual hand function, as
measured by the Sollerman grip function test (Sollerman, 1980), were flexion and
extension deficits in all of the fingers of the hand. The study measured range of
movement deficits in the dominant hand in millimetres, but details of the sample
and the level of ability were limited. Nonetheless, the implication that early
detection of loss of joint range of movement is significant. This important role may
often be undertaken by the therapist or nurse.
Typically physical therapists have included exercise in their rehabilitation
programmes (Stewart, 1996). Predominantly these exercises tend to be active or
auto-assisted in nature, but on occasions passive physiological or accessory
movements are also employed. Wherever possible, as with any chronic condition,
patients should be encouraged by the therapist to take responsibility for their own
management (Affleck et al., 1987) and empowered to do so by the therapist.
Having gained the knowledge to carry out exercises effectively and understood the
rationale for undertaking hand exercises, the patient is then encouraged to
continue a personalized exercise programme independently, although it is
generally accepted that group activities may also have a valuable role. Review
sessions are always advisable to check the accuracy of the patients performance of
exercises and to maximize adherence. The use of an exercise diary may be
beneficial (Francis, 1997) and may act as an aide memoire to promote precise
reproduction of any exercise.
The multiple benefits of exercise
Adopting some control over outcome through exercise programmes can play an
important part in a patients rehabilitation (Affleck et al., 1987). This may be
additional to any physiological gains. Exercise allows individuals to take more
responsibility for their own treatment and the therapist empowers the patient to do
just that. This view is supported by a more recent study (van Lankveld et al., 2000)
that analysed the effect of coping with pain in 80 randomly selected RA patients
over a three-year period. One conclusion reached was that decreasing activity levels
were related to an increase in self-reported psychological distress. Maximizing
functioning, therefore, in everyday life, by whatever means, but obviously which
may include exercise, might therefore lead to minimizing such distress. However,

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exercise in patients with inflamed joints has been controversial for many years. Some
of the arguments will be evaluated and explored further.
The historical controversy of exercise in inflammatory arthritis
Wozny and Long (1966) first suggested that hand exercises may hasten the process
of deformity in inflammatory arthritis. This stance was adopted following
biomechanical research into hand muscle activity during finger movements, in
particular focusing on the functional movement of finger and hand flexion. Finger
flexion exercises, they concluded, especially ball or sponge squeezing (i.e. against
some resistance) will lead to further metacarpophalangeal (MCP) joint subluxation
in the RA hand. This view was subsequently moderated however by encouraging the
use of passive finger exercises and stretches in the rheumatoid hand to prevent
tightening of soft tissue structures around a deformity. The seed of doubt was
nonetheless sown that active movements or specific active hand exercises could be
harmful. While this viewpoint is now over 40 years old, some still harbour concerns
about exercising any actively inflamed joints.
Some clinicians have reported that they believe that exercising an inflamed
joint induces intra-articular damage (Blake et al., 1989). This generally wellaccepted theory followed a series of studies undertaken with RA patients utilizing
isometric quadriceps contraction to replicate exercise for varying lengths of time
between 30 seconds and 2 minutes. The rationale given was that this activity would
help to establish the effect of exercise on intra-articular pressure and synovial
capillary blood flow in the knee joint. This was an experimental design; additionally
the duration of the muscle contraction was far from typical in everyday life for the
RA patient and may not be transferable to functioning in RA hands. The
conclusions drawn were negative; that exercising an inflamed joint induces hypoxic
re-perfusion injuries. However these conclusions may be limited by study design,
issues of recruitment, blinding and methods of randomization. Nonetheless, further
doubt was subsequently thrown on the belief that exercising any inflamed joint could
be beneficial.
Even recent correspondence (Edmonds et al., 2001) has challenged the
proposed explanations for the decrease in inflammatory markers found after
intensive exercise in an RA population (Van den Ende et al., 2000). It has been
suggested that, not only may joint inflammation be enhanced as a result of exercise
during active RA, but a;sp cartilage destruction may be accelerated, concluding that
exercise in active RA should be restricted to gentle assisted range of movement
exercises only (Semble, 1995; Scott and Wolman, 1992). However, randomized
controlled studies to evaluate the effectiveness of any active or passive exercises have
not been conducted to explore this hypothesis in RA hands.
More recent work however demonstrates positive evidence for the therapeutic

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benefits of exercise in patients with arthritis. Hurley (1999) proposes that

rehabilitation exercise therapy may delay or even prevent onset in osteoarthritis
(OA). While acknowledging that predominantly indirect evidence was used, Hurley
suggests that motor and sensory dysfunction of muscle may be important factors in
the pathogenesis of articular damage in OA. Work undertaken the previous year
(Hurley and Scott, 1998) with 60 OA knee subjects demonstrated that an
association exists between specific quadriceps sensorimotor dysfunction and
disability in this patient group. Additionally, and very encouragingly, improvements
were seen in strength, sensorimotor function and disability at six months following a
pragmatic exercise regime. The relevance of this to patients with inflammatory
arthritis is not fully known, but contemporary work (Bearne et al., 2002) has
concluded that rehabilitation exercises can not only improve the quadriceps
sensorimotor dysfunction associated in RA, but also do so without exacerbating
disease activity as measured by serological inflammatory markers.
Exacerbating disease activity has long been a concern for clinicians. A
systematic review in the late 1990s from The Netherlands informed and reassured
therapists that dynamic exercise need not exacerbate inflammatory conditions. The
review, undertaken by two blinded reviewers, included six controlled trials (Van
den Ende et al., 1998). Inclusion criteria necessitated studies which cited exercising
at more than 60% maximum heart rate for at least 20 minutes more than twice a
week, over a minimum of a six week period. The authors concluded that dynamic
exercise therapy is effective in increasing aerobic capacity and muscle strength. In
addition, no detrimental effects on either disease activity or pain were observed.
Such reviews lend weight and encouragement to therapists who argue the
importance of seeking to improve RA patients exercise tolerance, but who are
anxious not to flare up their joints.
It should be noted however, that none of these studies focuses specifically on
the hand in inflammatory arthritis. How generalizable studies relating predominantly
to the knee, a large weight-bearing synovial joint are and whether such studies could
be relevant to the smaller joints of the hand and fingers, which are predominantly
concerned with mobility, may be questioned and no doubt debated.
Muscle strength in inflammatory arthritis
Van den Ende et al.s review (1998) gave weight to the results of an earlier controlled
study undertaken by Hakkinen et al. (1995). Lower limb and upper limb muscle
strength was evaluated in patients diagnosed with inflammatory arthritis. Following
a six-month progressive strengthening regime, the inflammatory arthritis group
significantly increased (p < 0.001) the dynamic strength of both their knee extensors
and grip strength. The authors concluded that the neuromuscular performance
capacity of this patient population could safely be improved without detrimental

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effects of disease activity. This has subsequently been confirmed by Bearne et al.s
study (2002). An additional earlier study also found other encouraging evidence no
long-term differences were seen in the rate of radiological progression between RA
patients who exercised twice a week or more compared with those exercising only
once a week or less (Strenstrom, 1994b).
Once again there are no comparable studies focusing solely on strengthening
exercises in the rheumatoid hand. It is therefore left up to therapists to draw their
own conclusions.
Association between exercising in RA and functional activity levels
Patients anecdotally are rarely bothered about changes in the minutiae of
impairment measures (such as joint range of movement or grip strength) that
practitioners assess. They are however very motivated by improvements in their
functional ability. The relationship between the two in the RA hand has been
investigated (Chadwick et al., 2002). The authors found moderate correlations
between impairment and activity limitation outcome measures. A moderate negative
correlation (r = 0.507, p < 0.0005), was found between key grip and the hand and
finger function subscale of the Arthritis Impact Measurement Scales (AIMS2;
Meenan et al., 1992), and similarly a moderate relationship (r = 0.45, p = 0.001)
was found between dominant hand gross grip and AIMS2 upper limb function. This
translated meant the stronger the key grip and power grip, the better the selfreported hand and finger or upper limb function. While small to moderate
associations were also found, weakness of grip strength and reduced joint range of
movement were associated with greater limitation in performance of activities of
daily living, but these relationships were not strong. Conclusions were therefore
drawn that separate measurement of both impairment and activity limitation in the
assessment of the hands in RA should be recommended.
One broader study with a 24-week follow-up investigated muscle strength and
functional ability with 64 in-patients with active RA whose mean disease duration
was 8 years (Van den Ende et al., 2000). Subjects were randomized to either an
intensive exercise group or a conservative exercise programme incorporating only
range of motion and isometric strengthening exercises. The intensive exercise group
undertook dynamic and isometric shoulder and knee exercises against resistance five
times per week, as well as conditioning bicycle training three times per week. Results
showed that muscle strength, as measured by an isokinetic dynamometer, was
statistically significantly improved compared with the conservative exercising group
and remained so over the six-month period. Functional ability, measured using the
Dutch validated version of the Health Assessment Questionnaire (HAQ; Fries et al.,
1982), was also significantly improved for patients in the same intensive exercising
group. Subjects in the intensive exercise group undertook their programme in

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addition to the conservative programme and thus were performing considerably more
exercise each day during the study. Nevertheless the outcome remains consistently
in favour of the intensive exercising subjects with no deleterious effects observed on
disease activity.
Hand treatments and stiffness in RA
Joint stiffness, especially early in the morning, is frequently reported by RA patients
and is notably one of the diagnostic criteria for RA (Arnett et al., 1988). Changes in
joint stiffness have only been specifically evaluated following various therapy
interventions in RA in one small study with 18 patients (Bromley et al., 1994).
Outcome was evaluated after one treatment and at six weeks follow up in a four-arm
study where patients received either pulsed ultrasound therapy, wax baths,
ultrasound, or hand exercises alone. Passive and active finger flexion and extension
exercises were performed. The electrotherapy modalities employed, the specific
exercises performed and the regularity or number of repetitions were not described in
detail, making it difficult to draw meaningful conclusions from this study. However,
no long-term statistically significant differences in stiffness were found between any
of the groups. The authors concluded therefore that only short-term symptomatic
relief was found, the benefit of which was lost by six weeks.
Types of exercise
There are many types of exercise available for the hand therapist to choose. Some
early researchers have supported a very pragmatic approach to exercising with RA
(Flatt, 1963). A combination of both mobility and resistive exercises were promoted
to be beneficial, if undertaken three times a day. A very functional approach to
exercising was adopted using clothes washing tasks, tasks involving clothesline rope
with broom handles with weights attached, using elastic bands for resistive exercise,
as well as using everyday writing activities for exercise therapy. No evidence was
offered specifically for the use of these novel exercises, but it is suspected such a
logical approach would be accessible to the majority and minimize costs.
Fifteen years later both active and passive exercises were proposed and
encouraged for patients experiencing any hand stiffness (Curtis, 1978). The main
aim was to improve joint range of movement, but was also tempered by the need to
avoid an increase in joint swelling and pain. This advice however was not supported
by evidence.
Various other theories have been proposed relating to the type of exercise that
should be used in RA, but on most occasions the evidence is not substantiated.
Some believe that dynamic isotonic exercise requiring muscle work during joint
motion (as opposed to static isometric exercise) is superior for RA patients
(Strenstrom, 1994a). In order to come to this conclusion 11 internationally

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published studies were reviewed, each evaluating exercise programmes with an

aerobic and dynamic approach for patients with RA. Great variability was found
between these studies; frequency of exercising (ranging from once to seven times per
week), duration of each exercise session (ranging between 15 and 60 minutes) and
length of follow-up (ranging between 8 weeks and 2 years) making any comparisons
between the studies difficult.

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Timing and frequency of hand exercises

Very little guidance has been found relating to duration and frequency of exercising
for the patient with RA. Most studies failed to provide any detail relating to these
important areas. Boscheinen-Morrin et al. (1985) did however recommend that
hand therapists promote short gentle exercise periods for RA patients to begin as
soon as inflammation has subsided (Boscheinen-Morrin et al., 1985). The definition
of short was not provided. Similarly the reader is not clear how inflammation
subsiding is defined. However it is suggested that sessions should be undertaken
several times per day and include passive, active-assisted and active movements,
dependant upon the patients tolerance. Whether the tolerance refers to discomfort
or levels of fatigue is also left to individual interpretation.
More specific advice was offered in the 1980s when tendon gliding exercises,
designed to allow maximum excursion of the flexor and extensor tendons of the
fingers were proposed (Wehbe, 1987). The frequency of exercising, it is suggested,
should be tailored to the individual with an average programme including 10
repetitions of an exercise, twice daily. While therapists welcomed this specific advice
and guidance regarding hand exercise in arthritis, no studies have been found to
corroborate this prescriptive approach.
Specific hand exercises in RA
Hand exercises can incorporate exercising all the small joints of the fingers: the
metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal
interphalangeal (DIP) joints. Due to the nature of these joints being so small and
instability in RA being secondary to repeated episodes of active synovitis, it seems
logical that hand exercises should be designed to avoid over-straining of these small
joints and historically that has meant that they have rarely involved weight bearing.
The importance of taking into consideration the biomechanics of the small
joints of the hand when prescribing exercise has also been stressed (Smith et al.,
1966). The authors suggest that strengthening exercises focusing on the flexor
digitorum superficialis and profundus muscles should be avoided for fear of
exacerbating any pre-existing damage at the MCP joints. Wehbe (1987) however,
believed that arthritis should not be a contra-indication to performing flexion
exercises. Not only can these exercises be used prophylactically to prevent adhesions

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forming, Wehbe maintained that specific tendon-gliding exercises can allow each
joint in each digit to go through its maximum available range, thus improving
cartilage nutrition and joint motion. Moreover, Wehbe also stated that any
adhesions already formed secondary to the chronic synovitis of RA could also be
minimized using these exercises.

Conclusion
It would appear that no published study yet exists that clearly demonstrates the
effectiveness of specific hand exercises in inflammatory arthritis and particularly in
RA. Various methodological issues have left therapists lacking in conviction about
the optimum use of such exercises in the management of their patients. Further work
addressing all conservative treatments leading to improved hand function is urgently
needed. A randomized controlled trial investigating the effectiveness of conservative
hand therapy treatments in RA has been undertaken and preliminary results
reported (Chadwick et al., 2001).
Establishing an evidence-based rationale for the prescription of specific hand
exercises is a priority for patients with differing rheumatology pathologies. Large
multi-centred randomized controlled studies are needed. Several other important
research questions still remain. The optimum frequency of undertaking hand
exercises; twice daily, daily, twice weekly or any other combination has yet to be
established. Similarly, the optimum numbers of repetitions a patient should
undertake to complete an exercise or the optimum number of hand exercises to carry
out in a treatment package is still unknown. Finally, further clarification is needed in
larger studies to establish how the anticipated improvements in hand impairment in
a given individual impacts on hand function and activity limitation. While
provisional findings in a pilot study appear encouraging (Chadwick et al., 2002) this
has yet to be demonstrated in a larger cohort of patients with RA. The therapists
challenge continues.

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