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Patients with rheumatoid arthritis of the hand and wrist, and therapists treating these patients.


Developing online tools for patients and therapists to learn the 'Strengthening and Stretching for Rheumatoid Arthritis of the Hand' (SARAH) programme.

SARAH is a proven and effective exercise-based therapy used alongside drugs to treat rheumatoid arthritis (RA) of the hand. SARAH is currently delivered to patients face-to-face by specially trained therapists.


  • To develop online learning tools to deliver training in SARAH to both patients (mySARAH) and NHS therapists (i-SARAH)
  • To identify and overcome obstacles that may hinder the use of these online tools, based on the input of therapists, patients, and expert groups
  • To refine the learning tools through usability testing, and refine our assessment of how effectively these tools can be set-up and used
  • To assess the reach, satisfaction, experiences and outcomes for patients and therapists using these training tools

Why this is important

Rheumatoid arthritis (RA) is an autoimmune disease affecting about half a million people in the UK.

In this disorder, the body's immune system, which usually fends off infections, mistakenly attacks cells in the body's joints. This causes inflammation which over time damages joints, making them stiff, swollen and painful.

While RA can affect any joint, it is most common in the small joints of the hand. Here, it can be very disabling, affecting almost every function of life, from self-care to the ability to work.

Drug therapies are effective at reducing the clinical symptoms of RA, such as swelling and pain. However, they do not always result in improved function or strength of the hand, and, as a result, patient’s quality of life. The SARAH programme addresses this shortcoming.

Research has shown that SARAH is a low cost and effective addition to the treatment of RA. SARAH has been shown to improve hand function, reduce disability and improve quality of life for people with RA of the wrist and hand.

SARAH consists of seven stretches and four strengthening exercises. Currently, patients attend five exercise sessions over 12 weeks face-to-face with a trained therapist. Therapists monitor their progress, tailoring the exercises to each patient.

At the moment SARAH is only available in a handful of NHS organisation which helped to develop it. Making SARAH available across the entire NHS by means of traditional training approaches, such as face-to-face workshops, would be expensive and time-consuming.

By contrast, delivering effective online training in SARAH, to both patients and NHS therapists, would have four main advantages:

  1. Lower costs.
  2. Training would be more accessible throughout the NHS.
  3. Uptake across the NHS could be far faster.
  4. Patients would be able to learn the SARAH exercises at their own speed and convenience.

All of these would work together to bring the benefits of SARAH to more patients sooner.



So far we have surveyed 100 hand therapists who have previously downloaded the SARAH materials to find out about their views on using SARAH.

In this study we will also consult other groups interested in the development and use of SARAH. This will include NHS hand therapists, patients and NHS Choices, who will host the patient-focused website.

We will use the feedback to:

  • help develop the prototypes of both websites ('i-SARAH', for therapists, and mySARAH for patients);
  • develop and refine how we will assess the uptake, use and effectiveness of these sites (their implementation).

We will also use the knowledge gathered from development of a similar CLAHRC project (Back Skills Training) to help inform these.

A small number of therapists and patients will test both sites prior to the large-scale evaluation.


Evaluation of implementation

To evaluate i-SARAH, we aim to recruit a minimum of 250 hand therapists from across the UK.

The implementation of i-SARAH will be assessed by questionnaires and telephone interviews with therapists, carried out at the end of the study, and six months later.

The results will be used to assess:

  • the number of NHS departments using i-SARAH;
  • the number of therapists who register on i-SARAH and complete the training;
  • therapists’ experiences of using i-SARAH;
  • therapists’ intention to use, and their actual use of, SARAH in clinical practice.

300 patients treated by these therapists will be asked to complete a self-report questionnaire. This will be used to assess both the delivery of SARAH as well as patients’ perceived changes in RA symptoms, and their satisfaction with the treatment.

To assess mySARAH (for patients), a minimum of 300 patients will be recruited via the NHS Choices website.

The number of people who complete the training will be measured using Google analytics data.

Questionnaires will be used to measure patient-reported use of the programme four months after enrolling in my-SARAH. These will be used to measure how much of the programme they followed, their levels of satisfaction with the treatment and any perceived changes in their RA symptoms.

How this could benefit patients

This project aims to train more therapists, more quickly than is possible using conventional methods, in how to deliver SARAH to patients with RA of the hand. Bringing this treatment to patients rapidly across the NHS will improve their quality of life sooner.

This project also aims to develop an online and more convenient way for patients to access the SARAH training themselves, without the need to visit their therapists.

Additionally, the lessons learned in developing and rolling out the online SARAH programmes could also be applied to other types of healthcare programmes in the future. This could further broaden the reach and speed at which therapists and patients can access effective new developments in healthcare and reap their benefits.

What people have said about iSARAH

Just completed the iSARAH training for delivering an evidence based hand exercise programme for patients with RA. Excellent behavioural strategies to support exercise adherence for all patients with hand conditions. @BAHTHandtherapy

— Debbie Larson (@DebbieLarson22) 13 January 2018

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