Full Length Article| Volume 35, ISSUE 3, P468-476, July 2022

The online version of an evidence-based hand exercise program for people with rheumatoid arthritis: A mixed-method, proof-of-concept study

Published:October 25, 2020DOI:


      • An online version of the National Institute for Health and Care Excellence recommended SARAH (Strengthening And stretching for Rheumatoid Arthritis of the Hand) program was developed (mySARAH) that could be accessed directly by people with rheumatoid arthritis.
      • The study purpose was to evaluate the feasibility, acceptability, and clinical impact of mySARAH.
      • Of 11 enrolled, 6 participants completed all mySARAH sessions; 3 partially completed; two discontinued the program.
      • Participants improved in grip strength and hand function with no increase in pain. The majority reported improvement.
      • Most participants had positive experiences of mySARAH. Ways to maximize patient engagement with mySARAH such as support from health professionals were suggested.



      The Strengthening And stretching for Rheumatoid Arthritis of the Hand (SARAH) program is a tailored, 12-week hand and arm exercise program recommended in the National Institute for Health and Care Excellence guidelines. It includes seven mobility exercises and four strength exercises against resistance. An online version of the SARAH program (mySARAH) has been developed to allow direct access for people with rheumatoid arthritis.


      The purpose of this study was to assess the feasibility, acceptability, and clinical impact of mySARAH in people with rheumatoid arthritis.

      Study Design

      This is a mixed-method, proof-of-concept study.


      mySARAH is a self-guided, online version of the SARAH program with six exercise training and review sessions. Participants were observed as they worked through four of the six online sessions. They were also asked to demonstrate the SARAH exercises. Participants undertook two sessions independently at home.
      At the baseline and 12 weeks, hand pain, hand function, and grip strength were measured. At 12 weeks, feedback on mySARAH, and perceived recovery were also collected. Approximately one month later, a telephone follow-up was conducted to explore participants' experiences with mySARAH. Pain, hand function, and perceived recovery were also assessed.


      Eleven participants (males/females: 3/8) with a median (interquartile range) age of 63 (17) years took part. Six participants completed all mySARAH sessions. About 512 exercise and load-setting demonstrations were observed and 491 (96%) were performed correctly. Improvements in grip strength and hand function were observed with no increase in pain. Most of the participants reported improvement and provided positive feedback. All participants perceived mySARAH as a useful resource. Features to improve the online exercise diary such as recording and tracking exercise dose and face-to-face or remote support by phone or Skype from health professionals were suggested to optimize user engagement.


      Initial evaluation of mySARAH indicates that mySARAH was feasible, acceptable, and beneficial to participants. Further iteration and evaluation are needed before large-scale implementation.


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        • Wasserman A.M.
        Diagnosis and management of rheumatoid arthritis.
        Am Fam Physician. 2011; 84: 1245-1252
        • Symmons D.
        • Turner G.
        • Webb R.
        • et al.
        The prevalence of rheumatoid arthritis in the United Kingdom: new estimates for a new century.
        Rheumatol Oxf. 2002; 41: 793-800
        • Horsten N.C.
        • Ursum J.
        • Roorda L.D.
        • van Schaardenburg D.
        • Dekker J.
        • Hoeksma A.F.
        Prevalence of hand symptoms, impairments and activity limitations in rheumatoid arthritis in relation to disease duration.
        J Rehabil Med. 2010; 42: 916-921
        • Rydholm M.
        • Book C.
        • Wikström I.
        • Jacobsson L.
        • Turesson C.
        Course of grip force impairment in patients with early rheumatoid arthritis over the first five years after diagnosis.
        Arthritis Care Res. 2018; 70: 491-498
        • Kennedy T.
        • McCabe C.
        • Struthers G.
        • et al.
        BSR guidelineson standards of care for persons with rheumatoid arthritis.
        Rheumatology. 2005; 44: 553-556
        • Scottish Intercollegiate Guidelines Network (SIGN)
        Management of early rheumatoid arthritis. A National Clinical Guideline. SIGN Publication Number 48.
        (Available at:)
        Date: 2000
        Date accessed: March 31, 2009
        • National Institute for Health and Clinical Excellence (NICE)
        Rheumatoid Arthritis: The Management of Rheumatoid Arthritis in Adults.
        NICE, London2009
        • Wessel J.
        The effectiveness of hand exercises for persons with rheumatoid arthritis: a systematic review.
        J Hand Ther. 2004; 17: 174-180
        • Williams M.A.
        • Williamson E.M.
        • Heine P.J.
        • Nichols V.
        • Glover M.J.
        • Dritsaki M.
        • Adams J.
        • Dosanjh S.
        • Underwood M.
        • Rahman A.
        • McConkey C.
        Strengthening and Stretching for Rheumatoid Arthritis of the Hand (SARAH)..
        A Randomised Controlled Trial and Economic Evaluation. 2015;
        • Heine P.J.
        • Williams M.A.
        • Williamson E.
        • et al.
        Development and delivery of an exercise intervention for rheumatoid arthritis: strengthening and stretching for rheumatoid arthritis of the hand (SARAH) trial.
        Physiotherapy. 2012; 98: 121-130
        • Lamb S.E.
        • Williamson E.M.
        • Heine P.J.
        • et al.
        Exercises to improve function of the rheumatoid hand (SARAH): a randomised controlled trial.
        Lancet. 2015; 385: 421-429
      1. Rheumatoid Arthritis in Adults: Management NICE Guideline [NG100]. 2018 (Available at:)
        Date accessed: February 7, 2020
        • Srikesavan C.S.
        • Williamson E.
        • Eldridge L.
        • et al.
        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
        • Srikesavan C.
        • Williamson E.
        • Cranston T.
        • Hunter J.
        • Adams J.
        • Lamb S.E.
        An online hand exercise intervention for adults with rheumatoid arthritis (mySARAH): design, development, and usability testing.
        J Med Internet Res. 2018; 20: e10457
        • O’Connor R.J.
        • Jackson A.
        • Makower S.G.
        • et al.
        Feedback-controlled robotics-assisted treadmill exercise to assess and influence aerobic capacity early after stroke: a proof-of-concept study.
        Disabil Rehabil Assist Technol. 2014; 9: 271-278
        • Stoller O.
        • de Bruin E.D.
        • Schindelholz M.
        • Schuster C.
        • de Bie R.A.
        • Hunt K.J.
        Evaluation of exercise capacity after severe stroke using robotics-assisted treadmill exercise: a proof-of-concept study.
        Technol Health Care. 2013; 21: 157-166
        • Kemper K.J.
        • Yun J.
        Group online mindfulness training: proof of concept.
        J Evid Based Complementary Altern Med. 2015; 20: 73-75
      2. Research Registry UIN.
        (Available at:)
        Date accessed: February 7, 2020
        • Haefeli M.
        • Elfering A.
        Pain assessment.
        Eur Spine J. 2006; 15: S17-S24
        • Durmus D.
        • Uzuner B.
        • Durmaz Y.
        • Bilgici A.
        • Kuru O.
        Michigan Hand Outcomes Questionnaire in rheumatoid arthritis patients: relationship with disease activity, quality of life, and handgrip strength.
        J Back Musculoskelet Rehabil. 2013; 26: 467-473
        • Roberts H.C.
        • Denison H.J.
        • Martin H.J.
        • et al.
        A review of the measurement of grip strength in clinical and epidemiological studies: towards a standardised approach.
        Age Ageing. 2011; 40: 423-429
        • Nazari G.
        • Bobos P.
        • Lu Z.
        • MacDermid J.C.
        Measurement Properties of the Hand Grip Strength Assessment: A Systematic Review With Meta-analysis..
        Arch Phys Med Rehabil. 2020; 101: 553-565
      3. IBM SPSS Statistics for Windows, Version 22.0. IBM Corp, Armonk, NY2013 (Available at:)
      4. NVivo Qualitative Data Analysis Software. QSR International Pty Ltd. Version 12, 2018 (Available at:)
        Date accessed: February 7, 2020
        • Braun V.
        • Clarke V.
        Using thematic analysis in psychology.
        Qual Res Psychol. 2006; 3: 77-101
        • Wangberg S.C.
        • Bergmo T.S.
        • Johnsen J.A.
        Adherence in internet-based interventions.
        Patient Preference Adherence. 2008; 2: 57
        • Bossen D.
        • Buskermolen M.
        • Veenhof C.
        • de Bakker D.
        • Dekker J.
        Adherence to a web-based physical activity intervention for patients with knee and/or hip osteoarthritis: a mixed method study.
        J Med Internet Res. 2013; 15: e223
        • van Middelaar T.
        • Beishuizen C.R.L.
        • Guillemont J.
        • et al.
        Engaging older people in an internet platform for cardiovascular risk self-management: a qualitative study among Dutch HATICE participants.
        BMJ Open. 2018; 8: e019683
        • Schubart J.R.
        • Stuckey H.L.
        • Ganeshamoorthy M.A.
        • Sciamanna C.N.
        Chronic health conditions and internet behavioral interventions: a review of factors to enhance user engagement.
        Comput Inform Nurs Cin. 2011; 29: 81
        • Nichols V.P.
        • Williamson E.
        • Toye F.
        • Lamb S.E.
        A longitudinal, qualitative study exploring sustained adherence to a hand exercise programme for rheumatoid arthritis evaluated in the SARAH trial.
        Disabil Rehabil. 2017; 39: 1856-1863

      JHT Read for Credit

      Quiz: # 872

      Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to There is only one best answer for each question.
      • # 1.
        The SARAH is endorsed by the NIH and is composed of
        • a.
          12 exercises
        • b.
          15 exercises
        • c.
          4 strengthening and 7 mobility exercises
        • d.
          5 ROM and 5 grip exercises
      • # 2.
        mySARAH is composed of _______ sessions
        • a.
          6 online
        • b.
          10 online
        • c.
          8 at home
        • d.
          4 in clinic
      • # 3.
        Outcome measures included
        • a.
          grip strength
        • b.
        • c.
        • d.
          all of the above
      • # 4.
        Data were
        • a.
          all quantitative
        • b.
          all qualitative
        • c.
          a combination of qualitative and quantitative
        • d.
          none of the above
      • # 5.
        mySARAH was shown to be acceptable for universal application
        • a.
        • b.
      When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.