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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

A programme of exercises for people with rheumatoid arthritis improves hand strength and function. The Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH) programme is recommended by NICE following positive results in a large clinical trial.

Therapists were initially trained face-to-face to deliver the SARAH programme. To speed up its routine use in practice, the researchers who developed SARAH went on to design online training called iSARAH. This study set out to evaluate its success.

Therapists who completed iSARAH training felt confident to deliver the SARAH programme, and most went on to do so. Their patients showed improvements in hand function and grip strength that mirrored the outcomes of the original clinical trial.

The effectiveness, ease of access, and potential reach of iSARAH training should accelerate the roll-out of the SARAH programme into routine care for people with rheumatoid arthritis.

What’s the issue?

Rheumatoid arthritis is an inflammatory joint disease, frequently affecting the hands and wrists. It affects 1.4% of women and 0.7% of men in the UK, causing joint pain, stiffness, swelling, and muscle weakness. Medication can ease symptoms, but patients may still have difficulty with everyday tasks such as carrying bags, doing up buttons, or opening doors. Over time, lack of use leads to muscle wasting and reduced hand function that medication cannot reverse.

Several years ago, researchers developed an exercise programme for people with rheumatoid arthritis. The SARAH programme includes 11 hand and arm exercises alongside self-monitoring, action planning and goal setting strategies to help patients make progress at home.

In a large clinical trial, the SARAH programme improved hand function and was safe and cost-effective. NICE guidelines were updated to recommend its use.

In the trial, therapists received face-to-face training. But this approach was too time-consuming to rapidly increase the use of the SARAH programme in routine NHS care. To speed up implementation, the research team developed freely available, online training to train therapists (iSARAH) in 2017. iSARAH is a self-paced course that takes two to three hours to complete.

This study explored whether iSARAH training could successfully train therapists to deliver the SARAH programme to their patients. It evaluated iSARAH’s ability to provide therapists with the knowledge and skills to deliver the SARAH programme. It also compared patients’ outcomes to those seen in the earlier clinical trial.

What’s new?

Of 790 therapists who enrolled on the SARAH training, 448 provided feedback on finishing the training and again six months later. They reported on their experiences, attitudes, and likely use of the SARAH programme in their practice. Therapists were also invited to take part in a service evaluation to measure their patients’ clinical outcomes.

The iSARAH online training successfully trained therapists to deliver a tailored hand exercise programme. Most therapists (99%) who completed the first survey felt confident and capable of delivering the programme. And most (85%) said they intended to use the programme.

Six months after completing the training, of 116 therapists who responded to a second survey, two in three (66%) were using the programme with their patients.

Researchers gathered complete data from 97 patients. They looked for changes in patients’ hand function and pain between their first and final sessions with their therapist and again four months later. Hand function was improved and pain was not worse at both time points. These improvements were in line with the outcomes of the clinical trial. At the final session with their therapist, grip strength increased by 24.5% (left) and 31% (right). Most patients (85%) rated themselves as improved.

Four months later, fewer but still most (74%), rated themselves as improved. Most patients (90%) were continuing to exercise, but only one in three (33%) were doing exercises daily. This compares with 44% who were still doing daily exercises at four months in the clinical trial.

Why is this important?

Feedback shows that the iSARAH online training is a satisfactory and effective way of training therapists to help people with rheumatoid arthritis. Patients showed similar improvements to those in the clinical trial.

iSARAH is now freely available to all healthcare professionals and students across the world. To date, there are 3351 users from 82 countries and 1629 have completed the training. Therapists commonly reported lack of time and equipment as barriers to delivering the SARAH programme. The researchers suggest that one solution could be therapists delivering sessions to small groups of patients rather than one-on-one, or delivering some of the sessions online, by video call or over the phone.

What’s next?

The funding for the study has now finished, and in 2021, the iSARAH online training will move to the FutureLearn platform so that therapists can continue to access it. This will also allow the team to improve the training, based on the study findings.

This study found that therapists used the self-monitoring, action planning and goal setting strategies less than the exercises. These behaviour-change techniques help motivate patients to continue exercising at home over the long-term. The revised training will emphasise the importance of these techniques.

The researchers have also developed an online version of the programme for patients so that in future, more people benefit from the SARAH programme.

You may be interested to read

The full paper: Williamson E, and others. Translating the Strengthening and Stretching for Rheumatoid Arthritis of the Hand Programme from clinical trial to clinical practice: An effectiveness–implementation study. Hand Therapy. 2020;25:87-97

The iSARAH training is available to all health professionals who treat patients with RA

The development of SARAH online training for health professionals, by the same research group: Srikesavan C, and others. A Web-Based Training Resource for Therapists to Deliver an Evidence-Based Exercise Program for Rheumatoid Arthritis of the Hand (iSARAH): Design, Development, and Usability Testing. J Med Internet Res. 2017;19:e411

Proof of concept study into patient-facing version of mySARAH, by the same research group: Srikesavan C, and others. The online version of an evidence-based hand exercise program for people with rheumatoid arthritis: A mixed-method, proof-of-concept study. J Hand Ther. 2020. doi: 10.1016/j.jht.2020.10.011

The paper evaluating the SARAH programme in a large clinical trial, by the same research group: Lamb SE, and others. Exercises to improve function of the rheumatoid hand (SARAH): a randomised controlled trial. Lancet. 2015;385:421-429

NICE guidance: Rheumatoid arthritis in adults: management [NG100] (2018, last updated 2020)


Funding: This research was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Oxford.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

NIHR Evidence is covered by the creative commons, CC-BY licence. Written content and infographics may be freely reproduced provided that suitable acknowledgement is made. Note, this license excludes comments and images made by third parties, audiovisual content, and linked content on other websites.

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