Researches into the Effectiveness of Physiotherapy in Rheumatoid Arthritis of the Hand

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CRITICAL REVIEW

Researches into the Effectiveness of Physiotherapy in Rheumatoid Arthritis of the Hand Me1 Stewart

Key Words Rheumatoid arthritis, hand, physiotherapy, research, exercise.

Summary People presenting with rheumatoid arthritis affecting the hands are often referred for physiotherapy. There is little research which shows that physiotherapy is effective in managing this condition. This paper reviews some of the modalities which have been investigated and the contribution they have made to the treatment of the hands of patients with rheumatoid arthritis. Some of the limitations and omissions in these researches are discussed. Suggestions are forwarded which take account of the need for a balance between the qualitative and quantitative methods employed in the investigation of physiotherapy, especially when exercises are administered in the management programme. It is suggested that research methods which take heed of the science as well as the art of physiotherapy may facilitate a more accu- rate evaluation of the effectiveness of physiotherapy in practice.

A Professional Perspective Literature which addresses the problems of physiotherapy in the management of rheumatoid arthritis (RA) is conspicuously lacking. Thus any attempt to assess the contribution of physiotherapy is immediately limited. This is in strong contrast to the literature which is available on the use of drugs. Drugs have been the mainstay in the management of RA for some time but their unac- ceptable toxicity and ineffectiveness in delaying the progress of the disease have recently been emphasised again (Schenkier and Golbus, 1992; Skeith and Davis, 1992; Guzman, 1993). This among other issues has heralded the need for urgent investigation into less hazardous methods of treatment and for ones which may ultimately help in the prevention of joint deformities.

RA is the most common of the rheumatic diseases with approximately 90% of patients who have the condition experiencing some wrist and hand problem (McKenna and Wright, 1985). Alongside other professions allied t o medicine, physiotherapy has been one of the main contributors in the management of patients with this condition for many years. I t is considered to be an essen- tial part of treatment for many patients but it is also thought t o be probably one of the least researched (Smith-Pigg, 1989). Its effects are unpublished or anecdotal. Fragmented information can often be found in the form of individual

medical case notes which, by their nature, rarely make overall objective analysis easy. Rush and Shore (1988) have recognised the infrequency of publications about the effects of physical modalities in the rheumatology journals. The apparent lack of scientific reasoning behind the various therapeutic interventions has not gone unnoticed (Trentham, 1993; Herbert, 1993). The challenge to demonstrate and investigate the contribution made by individual or combined therapies cannot be ignored, especially when they are all being considered in the economics of health care.

The aims of this article are first t o review the evidence in the literature of the contribution that physiotherapy has made to the treatment of RA of the hands; secondly to analyse from a quantitative and qualitative perspective some of the limitations of the research methodologies which have been employed to demonstrate physiotherapy outcomes; and thirdly to suggest possible strategies which may be employed to help further research. The documents included in the review were obtained from the following databases: CINAHL, MEDLINE Rehabilitation Index, Occu- pational Therapy Index, ASSIA, Physiotherapy Index, CSP research database and the CSP documents database.

Studies In the management of RA many of the following modalities have been used in physiotherapy: wax, hot packs, exercises, electrotherapy (pulsed electromagnetic energy, ultrasound, etc), splints, and advice on joint protection among many others. Some of these have received the attention of investigators.

Use of Wax, Ultrasound, and Exercise Hawkes et al (1986) compared three different physiotherapy modalities for RA of the hand for three groups of patients: group 1, exercise and wax; group 2, exercise and ultrasound; and group 3, exercise, ultrasound and faradic hand baths. Thirty patients were randomly allocated t o one of these three groups and treated for three weeks. The result for all three methods showed a significant improvement in all of the seven measures taken - grip strength, joint size, pain, articular

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index, range of movement, timed task and a checklist of activities. However it is not clear whether the exercises were considered to be a significant factor in bringing about some of the changes. Additionally, there were no controls. The evidence presented makes it difficult t o identify which of the modalities or combination of modalities was the most likely beneficial mode of treatment.

Dellhag et al(1992) investigated the effectiveness of exercise and wax treatment for 52 patients with RA. The patients were randomised into four groups: group 1, exercise and wax; group 2, exercise only: group 3, wax only; and group 4, no treatment control group. Treatment was given three times a week for four weeks. Measurements included grip strength, grip function, pain, stiffness, and deficits in flexion and extension in the second to fifth digits. These were made before and after treatment. Wax and exercise were said t o result in significant improvements in the ranges of movement and grip function, while active hand exercise resulted in a reduction of stiffness and pain and increased range of motion. These findings are in line with the previous study by Hawkes et al(1986). The wax bath alone had no significant effect.

Exercise alone was not investigated as a separate entity in the study by Hawkes et al(1986). The implication of the study by Dellhag et al, if it can be compared to the study by Hawkes et al, is that exercise alone could have been a significant factor in bringing about some of the changes which occurred.

A fundamental principle of physiotherapy is the pursuit of normal movement, or ability to achieve maximum potential with regard to normal movement through ‘exercise’. Therefore many studies have incorporated exercises in their rehabilitation programmes.

Home Exercises Hoenig et al (1993) investigated the effects of different regimes of home hand exercises; on grip strength and the short-term effects on range of motion, pain, deformities, hand disease activity and dexterity in patients with RA. This randomised controlled trial was carried out over 12 weeks with the subjects performing the exercises 10-20 minutes daily. Details were not provided of the nature of the interventions, how subjects were allocated, if there was any attempt at the standardisation of the exercises, any variation in duration of exercise, when and what measurements were taken, or conditions for the controls. Therefore results need t o be treated cautiously. They indicated that the ranges of

movement and balanced resisted exercises were associated with increased left hand dexterity and that home hand exercises significantly increased left grip strength. Again, the implication was the positive contribution of exercise for RA.

Passive and Active Exercise, Wax, and Ultrasound Bromley et al (1994) investigated the changes in stiffness in RA following the short- and long-term application of standard physiotherapy techniques including exercise. They took the definition of stiffness used in relation t o the knee joint by Thompson (1978): ‘The resistance to passive motion at a joint throughout the normal range of motion in the usual functional plane.’

The study sought to investigate a previous claim by Helliwell et al (1987) and Yung et al (1984) that the stiffness levels in normal subjects were very similar t o those of patients with RA. A six-week period of physiotherapy was also implemented to address the criticism levelled at a previous study when conclusions were drawn from only one treatment.

A comparison of the stiffness levels of 12 normal subjects with a mean age of 22 years and 18 patients who were in hospital with active RA with a mean age of 57 was made. The metacarpophalangeal (MCP) joint of their right index finger was measured for stiffness at 06.00, 12.00 and 18.00 hours using an arthrograph developed by Unsworth et aZ(1982).

The short-term and long-term effects of physiotherapy were also tested after multiple applications of treatment. Ten patients received hot wax, 11 patients ultrasound, 13 patients hot wax followed by ultrasound, and six patients active and passive movements. Stiffness parameters were measured before and after each session of approximately 30 minutes. Additionally, a circadian variation was observed in a group of patients with RA but who were not receiving physiotherapy. Their MCP joint stiffness was measured twice in the same afternoonwith an interval of 30 minutes.

The authors concluded that none of the treatments considered caused a significant long-term change in the joint stiffness parameters. However, the torque range and energy dissipation were reduced highly significantly but only temporarily by a single application of wax plus ultrasound.

There appear to be many omissions and flaws in these studies regarding the standardisation of the subjects and the administration of the physiotherapy. It is well known that the stage of the disease, drug therapy, and intra-articular injec-

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tions are all factors which may alter an individual's response to any form of treatment, yet the measures taken t o standardise these were not clarified. Equally unclear were important parameters incorporated for some of the forms of treatment. For example for ultrasound, the power, the dosage and the area of application of the ultrasound were left unreported. Identification of an effective dose of ultrasound for a given patholog ical problem, and especially one with fluctuating course, is still open to question (Kitchen and Partridge, 1992). Therefore, given that part of the main thrust of this study was to investigate the effect of ultrasound on the stiffness of the MCP joint of the right index finger using standard physiotherapy techniques, the results leave many questions unanswered. The limitation of the application of physiotherapy treatment to one joint which may or may not have been affected directly by the disease process also requires some explanation.

Relief, it gained, may be brought about as a result of treatments directed at achieving the more common aims of relieving pain, reducing the loss of range, the education of the individual on joint protection, etc. Therefore the outcome of the investigation raises serious questions about the reliability and validity of the investigation where only one joint was assessed using techniques which were not standardised.

Long-term and Short-term Effects of Simple Exercise In a controlled study which investigated the long-term effects of an exercise programme on rheumatoid hands, Brighton et al (1993) found that a simple exercise programme carried out regularly at home improved grip for a rheumatoid hand. However, the range of movement in the MCP and proximal interphalangeal joints (PIP) deteriorated over the four-year period. There was a significant loss of extension at the MCP joint in both the control and the experimental groups with the experimental group having a lesser but still statistically significant loss of extension. A significant loss of extension at the PIP was recorded for the control but not for the experimental group. This is one of the few studies which took a long- term view (48 months) of the measurement of therapy outcomes in rheumatoid hands using exercises, where a list of the exercises given were reported, and where the compliance of the subjects was addressed. However, the reliability and validity of the measuring instruments were not confirmed.

Therapy for patients with RA has used orthoses to limit joint deformity. This area of practice has crossed professional boundaries, including those

of physiotherapy and occupational therapy. Where splints have been applied to minimise joint contracture in RA, some authors have reported findings which have been consistent while the conclusions of others have been mixed. Overall it is suggested that, in addition to the benefits indicated previously, splinting helps to protect joints and reduce pain and swelling (McKenna and Wright, 1985; Flatt, 1989; Fess and Phillips, 1987). Their use appears valuable but limited.

Much of the information on therapeutic interventions in RA by the professions allied to medicine appears speculative and subjective but has become almost traditional in its recommendations (Bishop et al, 1991).

Philips (1989), an occupational therapist, outlined the therapists' role in the evaluation and treatment of patients at various stages of RA with particular emphasis on patients with hand involvement. Although she highlighted many methods of assessment and treatment there is little indication of how effective these strategies are likely to be except from a personal point of view. In her summing up she suggested that the main goal of management is to help the patients to live more comfortable and productive lives within the limitations of their disease.

Summary of the Literature Analysis The literature records various physiotherapeutic interventions in treatment of hands. Exercise, wax and ultrasound are thought to have a beneficial effect, but the overall improvement appears marginal. It includes increase in grip strength, ranges of movement and the reduction of pain, swelling and, perhaps, stiffness. With the excep- tion of exercise, few researchers have addressed the individual and specific effects of the interventions and little is known about their long-term outcomes. Investigations have shown a lack of consistency in approach even when the same types of intervention have been employed; thus it is difficult to draw any definitive comparisons or conclusions. The reliability of some of the measurers and measuring instruments is doubtful, and so is the validity of some of these studies where many of the confounding variables do not appear to have been considered.

Omissions in the Research Literature The preventive strategies which could be employed in physiotherapy in the early management process, as well as in the later stages of the disease, remain unexplored (Rush and Shore, 1988). Eberhardt and Fex (1995) highlighted the alarming increase in the radiographic changes of

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the hands and feet in a group of 63 patients with definite RA which occurred during the first two years of a five-year study. Half of the patients had impaired hand function when the study began. In another study Eberhardt et aZ(1991) studied 100 patients with RA and found that after two years 31 patients had developed one or more deformities of the hand. Dellhag and Burkhardt (1995) studied 52 patients with RA and found that the strongest predictors of hand function were flexion and extension deficits in the index, middle, ring and little fingers. If prevention of joint deformity is considered to be the key to the maintenance of function (Flatt, 1989) and physiotherapy employs methods which could address this problem, then further investigations are needed. Physiotherapy should be considered not only when functional capacity has become impaired but also earlier, when predisposing factors have been identified. It is well known that some individuals who experience severe joint deformities can and do retain much of their gross functional capacity (Phillips, 1989), yet little has been reported on how this has been achieved and the compensations that the individuals have made. In the past, emphasis has been placed on the use of drugs o r corrective surgery when joint subluxation or d.islocation has developed. These should be now considered in conjunction with physiotherapy at an early stage.

Questions persist regarding the both the long- term and short-term effects of any physiotherapy intervention of the in the management of RA. There is a clear need to rectify this (Hoenig et aZ, 1993; Rush and Shore, 1988).

The aesthetic appearance of the hands can also change considerably during the progress of the disease. The effects of this alteration appear rela- tively unexplored in the literature. Additionally they are often omitted in the analysis of clinical findings and in psychosocial assessments.

Considerations for Future Research Physiotherapy as Art and a Science It is extremely difficult to quantify and analyse the qualitative nature of physiotherapy in treatment programmes. Rehabilitation involving hands epitomises these difficulties. The complex integration of the anatomical and neurophysio- logical mechanisms of hands is highlighted by the dominance of their representation in the sensory and motor cortex. They are tools which combine strength and speed with sensibility (American Society for Surgery of the Hand, 1990) and contribute to the reflection of personality and expression. There is a clear need to evaluate these aspects of hand function in research, given the potential benefit for both patients and the study

of the art and science of physiotherapy. The use of the hands is basic to physiotherapy (Williams, 1986). Bear-Lehman and Abreu (1989) are among many who recognise the artistry involved in hand therapy and the need to take account of more than just physical properties.

Compliance, the level of performance of patients, and the success of management programmes may be influenced by many factors including the inter- personal skills of physiotherapists, environment, placebo effect, the amount of attention given and the experience of clinicians. Researchers in behav- ioural science suggest these influences could have profound effects on treatment outcomes (Tepestra et al , 1992). The continuous patient-therapist interaction needs to be addressed in terms of verbal and non-verbal communication and touch. Thus the measurement and analysis of the inputs and outcomes of physiotherapy in management of RA will need to be diverse in order to reflect these factors. Indeed, it might be appropriate to offer a written analysis of the less tangible charact- eristics of this patient-therapist interaction to enable readers to make a more meaningful evaluation of the research findings for themselves. Researchers need to satisfy readers’ curiosity about the nature of the input of the art of physiotherapy.

Special attention needs to be given to the reporting of the use of exercise in rehabilitation. It is a t the core of physiotherapy practice (Williams, 1986) and yet on the whole the research outlined above gives little clear evidence of the nature of its use within those programmes, eg the type of exercise (passive, active and/or active-assisted), the number and rate of repeti- tions, the actions of the physiotherapist during active-assisted exercises, the amount of help given, and the nature of any verbal encourage- ment. Any adverse effects during or following exercise should also be reported and measured against any deterioration which could be expected as a result of the disease itself.

If the views of patients are sought regarding their expectations, their role in the rehabilitation process, and their commitment to pursue regular exercise, then these may contribute to psychoso- cia1 assessment. This may give meaningful insight into the dynamics of rehabilitation and empowering patients in the rehabilitation process. This latter objective falls in line with the government directives in the Patient’s Charter and The Health of the Nation documents (DOH, 1991a, b).

If these are to be serious considerations for future research, then research based solely on positivism will be unsatisfactory.


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Positivism and Phenomenology These two philosophical standpoints provide a basis from which research in physiotherapy may be viewed. Positivism (mainly qualitative) and phenomenology (mainly qualitative) make different assumptions about the world (Shepard et al, 1993) Physiotherapy research has tended to concentrate on the former (Robertson, 1995b). Jensen (1989) and Shepard et a1 (1993) offer useful comparisons on the philosophical stance of these two approaches. In the main, quantitative research demands that researchers apply rigorous control to experiments, distance themselves from them in order to maintain objectivity, and provide factual data that are usually generalisable to larger groups. Typical examples of this approach are randomised controlled trials, but the findings of some of these and their application to the work- place have been criticised by many, including Pope and Hayes (1995).

Qualitative research allows researchers to search for meanings (Taylor and Bogdan, 1984) or as outlined by Pope and Hayes (19951, it seeks to develop concepts ‘which help us to understand social phenomena in natural (rather than experimental) settings, giving due emphasis t o the meanings, experiences, and views of all the part- icipants’. In order to investigate physiotherapy practice the two approaches of positivism and phenomenology should be viewed as complemen- tary to each other and not as completely separate and alternative strategies. Parry (1991) supports this view and suggests the use of multiple approaches or triangulation to help to generate new theory in physiotherapy.

In the context of physiotherapy research and hands, if quantitative research is to be the method of choice, then due consideration needs to be given to some of the pervading problems, criticisms and omissions outlined above. However, if the wish is explore the deficits which indicate that this method may be inappropriate or even invalid at times, then research based on a phenomenological philosophy may contribute.

Approaches to Qualitative Research These are wide-ranging and hence only a brief outline of some approaches to qualitative research can be offered here. The model of the ‘practitioner scientist’ which is grounded in clinical practice is advocated by Robertson (1995a) for investigation of practice and to help in future development of the profession. This model recognises the implicit practice-based knowledge of the profession but also the difficulties of the informal nature of the model and the problems of effective scrutiny. It would necessitate a change in focus from the

‘scientist-practitioner’ model to that of ‘practitioner-scientist’, thereby facilitating active reconsideration of research methods. This model places initial emphasis on generation of articles by clinicians based on practice and material already published that could provide further relevant information for clinicians. Robertson suggests that the absence of materials with more than anecdotal support on a number of central topics would raise questions which many physiotherapists would want to address. Therefore the accumulation of reliable practice-oriented or craft knowledge alongside the development of cohesive research programs should be given some consideration. The use of single subject experimental designs provides another alternative for investigation. This method is often confused with the investigation of single cases which are not experimental and do not investigate the outcomes of controlled applications and withdrawals of interventions (Robertson and Lee, 1994). However, both their methods provide detailed accounts of individual responses in particular contexts, For both methods there are advocates (Riddoch and Lennon, 1991; Robertson, 1994) and critics (Bithell, 1994). Case reports and case studies have also been put forward but as means of investigation (Rothstein, 1993). They focus on one or a limited number of settings and are generally used to explore con- temporary issues. The data may be exploratory, explanatory, descriptive or a combination of these (Pope and Hayes, 1995). It is suggested that case reports and case studies provide excel- lent tools to begin to understand the practical knowledge, theory and wisdom embedded in clinical practice.

Many other common approaches including obser- vation and in-depth interviews have been promoted by several authors. It seems that the balance of methodologies appropriate to investigation of physiotherapy practice is yet to be achieved. The application of the traditional scientific approach when this is inappropriate for the patient-therapist environment should be a cause for concern.

Conclusion Many authors including Smith-Pigg (1989) and Borenstein et al (1993), have highlighted the important contribution physiotherapy appears to play in the management of patients with RA. The extent to which it or exercise might benefit the patient (Yetterberg et al, 1994) is still not clear. Substantiating evidence is minimal, though in the main positive. The interactions between patients

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and physiotherapists during treatment are critical influences on the rehabilitation process and these must be taken into account alongside both the physical and the less tangible aspects of hand function when research is being considered. Lincoln and Guba (1985) suggest that so far as possible the world should be studied in its ‘natural’ state undisturbed by researchers. Qual- itative research as ‘naturalistic inquiry’ provides an approach from which this could be developed.

The possible benefits of physiotherapy to patients with RA, the increasing numbers of people in the UK affected by the condition, and the increasing financial constraints of the present health care system, demand that physiotherapy and its effectiveness in the treatment of hands is appropriately investigated with some urgency.

Acknowledgment My thanks are due to Dr Anne Parry, scientific editor of Physio- therapy, for her helpful comments on this paper.

Author and Address for Correspondence Me/ Stewart MEd MCSP DipTP is a lecturer in the Department of Physiotherapy at the University of Birmingham, Morris House, Edgbaston, Birmingham B15 2TT.

This article was received on August 8, 1995, and accepted on August 15,1996.

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Researches into the Effectiveness of Physiotherapy in Rheumatoid Arthritis of the Hand