SARAH: Implementing an evidence-based hand exercise programme into NHS practice
9 February 2017
Rheumatoid arthritis (RA) is a long-term autoimmune disease that causes swelling, stiffness and pain in the joints – mainly the hands, wrists and feet, but it can also affect other parts of the body, such as the kidneys.
The severity and level of disability RA causes can vary from person to person and time to time (due periods of worsened symptoms called ‘flare-ups’). The joint damage, pain and stiffness it causes can have a significant effect on an individual’s day-to-day life, work, or recreational activities.
Finger joint deformities, hand muscle weakness and loss of the full range of finger and wrist movements can make something as simple as turning on a tap a painful, time-consuming ordeal.
At the moment, sadly, RA is incurable. But that doesn’t mean there’s nothing we can do to help manage symptoms or slow down the damage. For example, there is a range of drugs available that can be used to help manage the symptoms or control the progression of RA such as anti-inflammatories, pain killers and disease modifying anti-rheumatic drugs.
But there is also a range of effective non-drug based treatments available which can be used alongside drug-based therapies, including joint protection advice, splints, physical therapy and exercise-based treatments.
The Strengthening and Stretching for the Rheumatoid Arthritis of the Hand programme, or ‘SARAH’ for short, falls into the latter category. The SARAH programme includes a total of 11 flexibility and strength exercises, supplemented with simple behavioural change support strategies recommended by health professionals to help patients adhere with their SARAH exercises and make hand exercising a daily habit.
The SARAH programme is designed so it can be tailored to an individual patient’s needs and it uses minimal equipment – nothing you wouldn’t find in a typical hand therapy clinic.
SARAH was tested in a clinical trial of 490 people with RA across 17 NHS trusts. Compared to the people who received usual treatment, SARAH group had improved hand function, reduced disability and improved quality of life. Improvements in hand function after 4 and 12 months were seen more than double in the SARAH group compared to the usual treatment group. SARAH was also well-received by patients, safe to use and cost-effective.
The SARAH programme was recommended in the 2015 update of the National Institute for Clinical Excellence (NICE) guidelines (section 18.104.22.168) for the management of people who have hand and wrist function problems due to RA and not under RA drugs or have been on a stable drug regime for a minimum of 3 months.
So, SARAH improves patient outcomes, and is recommended by NICE, but how can we best translate this knowledge into standard clinical practice across the NHS? How can we cheaply and quickly train physiotherapists and occupational therapists who work with people with RA deliver the SARAH programme to those in need at a potentially national scale ?
Our answer to these questions is ‘iSARAH’.
Our team of clinical trial and implementation researchers, clinicians, and information technology experts have developed a simple online training course (iSARAH) to train NHS physiotherapists and occupational therapists to deliver the SARAH programme to their patients with RA.
We are providing iSARAH completely free of charge. All that’s required to register is an active NHS email address and internet access.
The iSARAH training itself is made up of four simple instructional modules with exercise videos and illustrations, a section on frequently asked questions, and a self-assessment at the end of the training. In total iSARAH takes about 3-4 hours to complete. So, not long at all.
On completion of i-SARAH training, we will evaluate the usefulness of i-SARAH through brief online questionnaires. We would also invite therapists to participate in phone-based interviews and share the experiences they had in implementing SARAH programme in their clinical practice
A course certificate can be downloaded on successful completion of the course.
Currently, to get as many people enrolled as possible, we are promoting iSARAH via websites and social media pages of national level physiotherapy, occupational therapy and hand therapy organisations.
But we don’t intend to stop there.
We also intend to develop and evaluate a home-based SARAH programme that patients with RA themselves can follow: mySARAH.
mySARAH will be a website where patients with RA themselves can directly register and access the SARAH programme at their convenience. The site will guide them through each exercise session of the 12 week programme, alongside regular monitoring for symptoms of pain and hand function over a period of one year through simple online forms.
mySARAH will include simple exercise training and review sessions, online forms, exercise videos demonstrated by patient volunteers, illustrations, an exercise diary and exercise planner, technical and therapist support, and visual reports of their progress made.
You can register for iSARAH, or find out more, at isarah.octru.ox.ac.uk or contact us via email (firstname.lastname@example.org) or call (01865) 737907.