Rheumatol Int (2013) 33:2625–2630
DOI 10.1007/s00296-013-2787-z
ORIGINAL ARTICLE
Effects of isotonic and isometric hand exercises on pain,
hand functions, dexterity and quality of life in women
with rheumatoid arthritis
Beril Dogu • Hulya Sirzai • Figen Yilmaz •
Basak Polat • Banu Kuran
Received: 1 August 2012 / Accepted: 21 May 2013 / Published online: 6 June 2013
Ó Springer-Verlag Berlin Heidelberg 2013
Abstract The primary objective of our study was to eval-
uate the effect of 6-week-long isotonic and isometric hand
exercises on pain, hand functions, dexterity and quality of life
in women diagnosed as rheumatoid arthritis (RA). Our sec-
ondary objective was to assess the changes in handgrip
strength and disease activity. This randomized, parallel, sin-
gle-blinded 6-week intervention study enrolled 52 female
patients between 40 and 70 years of age, who were diagnosed
with RA according to American College of Rheumatology
criteria, had disease duration of at least 1 year and had a stage
1–3 disease according to Steinbrocker’s functional evaluation
scale. Patients were randomized into isotonics and isometrics
groups. Exercises were performed on sixth week. All patients
were applied wax therapy in the first 2 weeks. Their pain was
assessed with visual analog scale (VAS), their hand functions
with Duruöz Hand Index (DHI), dexterity with nine hole peg
test (NHPT) and quality of life with Rheumatoid Arthritis
Quality of Life questionnaire (RAQoL). Dominant and non-
dominant handgrip strengths (HS) were measured. Disease
activity was determined by disease activity score (DAS 28).
We evaluated the difference in the above parameters between
baseline and 6 weeks by Wilcoxon paired t test. The study
B. Dogu (&)
H. Sirzai
F. Yilmaz
B. Polat
B. Kuran
Department of Physical Medicine and Rehabilitation, Sisli Etfal
Education and Research Hospital, 34377 Istanbul, Turkey
e-mail: berildogu@hotmail.com
H. Sirzai
e-mail: hsirzai@gmail.com
F. Yilmaz
e-mail: figenyilmaz@yahoo.com
B. Polat
e-mail: basak_ial@msn.com
B. Kuran
e-mail: banukuran@gmail.com
was completed with 47 patients (isotonics n = 23; isometrics
n = 24). VAS, DHI, NHPT, and RAQoL scores significantly
improved in both groups by the end of 6th week compared to
the baseline scores of the study (for isotonics p = 0.036,
p = 0.002; p = 0.0001, p = 0.003; for isometrics
p = 0.021, p = 0.002, p = 0.005, p = 0.01, respectively).
DAS 28 scores decreased in both exercise groups (p = 0.002;
p = 0.0001, respectively), while isometrics showed a signif-
icant increase in dominant HS (p = 0.029), and isotonics
showed a significant increase in non-dominant HS
(p = 0.013). This study showed that isometric and isotonic
hand exercises decrease pain and disease activity and improve
hand functions, dexterity and quality of life as well as mildly
increasing muscle strength in patients diagnosed as RA.
Keywords Hand exercise
Pain
Hand function

Dexterity
Quality of life
Rheumatoid arthritis
Introduction
Rheumatoid arthritis (RA) is a systemic disease with a
chronic and progressive course [1, 2]. In the hand, it gen-
erally leads to erosions of the wrists, metacarpophalangeal
(MCP) joints and proximal interphalangeal joints. Fur-
thermore, the synovitis, capsular distension, ligament lax-
ity, loss of range of motion (ROM) that RA causes and the
functional loss in the hands due to muscular imbalance are
the major sources of disability in RA patients [1, 3].
Using the hand effectively requires anatomical integrity,
mobility, muscle strength, sensation, coordination and the
lack of pain. To ensure these in RA patients, we provide
advice for joint protection, we use assistive devices and
splints as well as electrotherapy and exercises comple-
menting medical methods [4, 5]. Especially during the last
123
2626
decade, exercise therapy became the most important
component of rehabilitation [6, 7].
Studies on hand exercises in RA have usually evaluated
the effects on pain, ROM, strength, function/dexterity and
stiffness. Published reviews have reported varied benefits
hand exercises in evaluation parameters. It has been sug-
gested that these differences are results of variability of
study designs, the interventions performed, varied study
populations and lack of blinded study designs. Further-
more, by stressing that it was not specified whether the
hand exercises performed in those studies were range of
motion or strengthening exercises, these reviews empha-
sized the need specification, the type and number of repeats
of exercises in patients with RA in future studies [3, 8].
Therefore, primary objective of our study was to evaluate
the effect of 6-week-long isotonic and isometric hand
exercises on pain, hand functions, dexterity and quality of
life in women diagnosed as RA. The secondary objective of
our work was to evaluate the effects of both exercise types
on handgrip strength and disease activity.
Methods
This study was designed as a randomized, parallel, single-
blinded 6-week intervention study. The patients were ran-
domized by a random number sequence to receive either
isotonics or isometrics group.
All the patients received the instructions for exercises as
printed material. In first 2 weeks of the study, the exercises
were performed under the guidance of a therapist 5 days a the
week. During this period, wax treatment was performed
30 min prior to the exercise treatment to ensure the arrival of
the patients to the hospital and to increase their compliance.
Both hands were dipped into a 45 °C wax bath twice, then
wrapped with a towel and were kept there for 15 min. During
the weekends of these 2 weeks and from third to sixth weeks,
the patients continued to perform the exercises at home. At
the beginning of each week, the patients were called, infor-
mation was obtained to see whether they performed the
exercises regularly or not and they were encouraged to per-
form them. All exercises were performed on a daily basis and
repeated 10 times at a session. For more detailed descriptions
of the exercises, see ‘‘Appendices 1 and 2’’.
Patients
We recruited female patients fulfilling American College of
Rheumatology criteria for RA [9]. They were followed-up by
our rheumatology outpatient clinic. Inclusion criteria were
disease duration of longer than 1 year, an age of 40–70 years
and Stage 1–3 patients based on Steinbrocker’s functional
evaluation scale. The patients with carpal tunnel and cubital
123
Rheumatol Int (2013) 33:2625–2630
tunnel syndromes, those with polyneuropathies, pregnant
patients, patients having undergone hand surgery, those with
active arthritis of the hand joints and those with problems of
cooperation were excluded from the study.
The dominant and non-dominant hand deformities, the
medical treatments received during the duration of the study
and the comorbid diseases the patients had were all recorded.
Outcome assessments
Pain
Hand pain was measured on a VAS ranging from 0 to 10
(0 = no pain, 10 = highest pain tolerance limit).
Hand function
Duruöz Hand Index (DHI) was developed in 1996 as a self-
reported questionnaire consisting of 18 questions aiming at
evaluating the limitations in hand functions of RA patients.
All questions are scored from 0 (not difficult) to 5
(impossible to perform). Higher scores represent more
severe restriction of activities [10, 11].
Dexterity
Dexterity was measured by nine hole peg test (NHPT). The
tool consists of a square board with nine holes, nine round
pegs for these holes and a storage box. The patients are
asked to quickly get the pegs from the storage box, place
them in the holes and put them back in the storage box.
Meanwhile, the time required to complete this task is
measured with a chronometer [12, 13].
Quality of life
Rheumatoid Arthritis Quality of Life (RAQoL) is a self-
reported disease-specific scale consisting of 30 questions.
The questions are replied as yes or no. Higher scores
indicate worsening of the quality of life [14, 15].
Handgrip strengths
The handgrip strenghts (HS) of dominant and non-domi-
nant hands were measured by a handheld dynamometer
(JAMAR dinamometer) and expressed in kilograms. The
maximal HS of dominant and non-dominant hands were
measured three times each, and the means were calculated.
Disease activity
Disease activity was determined by disease activity score
(DAS 28).
2626
decade, exercise therapy became the most important
component of rehabilitation [6, 7].
Studies on hand exercises in RA have usually evaluated
the effects on pain, ROM, strength, function/dexterity and
stiffness. Published reviews have reported varied benefits
hand exercises in evaluation parameters. It has been sug-
gested that these differences are results of variability of
study designs, the interventions performed, varied study
populations and lack of blinded study designs. Further-
more, by stressing that it was not specified whether the
hand exercises performed in those studies were range of
motion or strengthening exercises, these reviews empha-
sized the need specification, the type and number of repeats
of exercises in patients with RA in future studies [3, 8].
Therefore, primary objective of our study was to evaluate
the effect of 6-week-long isotonic and isometric hand
exercises on pain, hand functions, dexterity and quality of
life in women diagnosed as RA. The secondary objective of
our work was to evaluate the effects of both exercise types
on handgrip strength and disease activity.
Methods
This study was designed as a randomized, parallel, single-
blinded 6-week intervention study. The patients were ran-
domized by a random number sequence to receive either
isotonics or isometrics group.
All the patients received the instructions for exercises as
printed material. In first 2 weeks of the study, the exercises
were performed under the guidance of a therapist 5 days a the
week. During this period, wax treatment was performed
30 min prior to the exercise treatment to ensure the arrival of
the patients to the hospital and to increase their compliance.
Both hands were dipped into a 45 °C wax bath twice, then
wrapped with a towel and were kept there for 15 min. During
the weekends of these 2 weeks and from third to sixth weeks,
the patients continued to perform the exercises at home. At
the beginning of each week, the patients were called, infor-
mation was obtained to see whether they performed the
exercises regularly or not and they were encouraged to per-
form them. All exercises were performed on a daily basis and
repeated 10 times at a session. For more detailed descriptions
of the exercises, see ‘‘Appendices 1 and 2’’.
Patients
We recruited female patients fulfilling American College of
Rheumatology criteria for RA [9]. They were followed-up by
our rheumatology outpatient clinic. Inclusion criteria were
disease duration of longer than 1 year, an age of 40–70 years
and Stage 1–3 patients based on Steinbrocker’s functional
evaluation scale. The patients with carpal tunnel and cubital
123
Rheumatol Int (2013) 33:2625–2630
tunnel syndromes, those with polyneuropathies, pregnant
patients, patients having undergone hand surgery, those with
active arthritis of the hand joints and those with problems of
cooperation were excluded from the study.
The dominant and non-dominant hand deformities, the
medical treatments received during the duration of the study
and the comorbid diseases the patients had were all recorded.
Outcome assessments
Pain
Hand pain was measured on a VAS ranging from 0 to 10
(0 = no pain, 10 = highest pain tolerance limit).
Hand function
Duruöz Hand Index (DHI) was developed in 1996 as a self-
reported questionnaire consisting of 18 questions aiming at
evaluating the limitations in hand functions of RA patients.
All questions are scored from 0 (not difficult) to 5
(impossible to perform). Higher scores represent more
severe restriction of activities [10, 11].
Dexterity
Dexterity was measured by nine hole peg test (NHPT). The
tool consists of a square board with nine holes, nine round
pegs for these holes and a storage box. The patients are
asked to quickly get the pegs from the storage box, place
them in the holes and put them back in the storage box.
Meanwhile, the time required to complete this task is
measured with a chronometer [12, 13].
Quality of life
Rheumatoid Arthritis Quality of Life (RAQoL) is a self-
reported disease-specific scale consisting of 30 questions.
The questions are replied as yes or no. Higher scores
indicate worsening of the quality of life [14, 15].
Handgrip strengths
The handgrip strenghts (HS) of dominant and non-domi-
nant hands were measured by a handheld dynamometer
(JAMAR dinamometer) and expressed in kilograms. The
maximal HS of dominant and non-dominant hands were
measured three times each, and the means were calculated.
Disease activity
Disease activity was determined by disease activity score
(DAS 28).
Rheumatol Int (2013) 33:2625–2630 2627

All the evaluations were performed by another physician Table 1 Patient characteristics
blinded to the type of the exercise both at the beginning of Isotonics Isometrics
the exercise period and at the end of 6 weeks.
The present study was approved by the local ethics n % n %
committee. All patients signed an informed consent form Profession
before participating in the study. Housewife 22 95.7 23 95.8
Secretary 1 4.3 1 4.2
Statistical analysis Dominant hand
Left 2 8.7 2 8.3
In this study, the statistical analyses were performed with Right 21 91.3 22 91.7
NCSS (Number Cruncher Statistical System) 2007 Statis- Dominant hand deformity
tical Software (Utah, USA) package program. In the No deformity 17 73.9 14 58.3
evaluation of the data, in addition to descriptive statistical Swan neck 2 8.7 4 16.7
methods (mean, standard deviation, median, interquartile
Boutonniere 2 8.7 4 16.7
range), Wilcoxon test was used for the measurements
Z deformity 1 4.3 1 4.2
before and after the treatment. Mann–Whitney U test was
Swan neck ? Boutonniere 1 4.3 1 4.2
used for the comparisons of pairs, and Chi-square test was ? Z Deformity
used for the comparison of qualitative data. The results Non-dominant hand deformity
were evaluated at a significance level of p \ 0.05. No deformity 15 65.2 11 45.8
Swan neck 2 8.7 5 20.8
Boutonniere 3 13.0 5 20.8
Results Z deformity 1 4.3 1 4.2
Ulnar Deviation 1 4.3 0 0.0
The study initially included 52 eligible female patients.
Swan neck ? Boutonniere 1 4.3 1 4.2
During the study period, 3 patients were excluded since
Swan neck ? Boutonniere 0 0.0 1 4.2
they exercised irregularly; one patient was excluded due to ? Z Deformity
a distal forearm fracture, and 1 other patient due to a Medication
metatarsal fracture. So, the study was completed with 47 Anti-TNF therapy 0 0.0 1 4.2
female patients, and 47 female patients were analyzed DMARDs 23 100.0 23 95.8
(isotonics n = 23; isometrics n = 24). Comorbid diseases
Mean age and disease duration for isotonics were Yes 7 30.4 13 54.2
54.91 ± 9.27 years and 10.65 ± 7.64 years, and for iso- No 16 69.6 11 45.8
metrics, these results were 50.38 ± 9.32 years and
Steinbrocker’s stage
8.17 ± 6.51 years, respectively. There were no significant
Stage I 19 82.6 21 87.5
differences between the groups (for age p = 0.101, for
Stage II 2 8.7 3 12.5
disease duration p = 0.235). The characteristics of the
Stage III 2 8.7 0 0.0
patients are shown on Table 1.
At the end of 6th week, isometrics showed a significant DMARDs disease-modifying antirheumatic drugs, Anti-TNF therapy
anti-tumor necrosis factor drugs
increase in dominant HS, and isotonics showed a signifi-
cant increase in non-dominant HS as compared to baseline.
Other evaluation parameters significantly improved in both Pain is a condition that is associated with physical dis-
groups (Table 2). ability. In the study by Covic et al., pain was shown to be
When the differences in improvements were compared, correlated with physical disability, passive coping, depres-
we found no statistical differences between groups in any sion and helplessness [16]. A decreased pain especially
of the parameters evaluated (Table 3). during movements favorably affects individual’s physical
well-being. Several activities of daily living (ADL)
including leisure and work tasks require the frequent
Discussion movement of the hands. Performing these activities neces-
sitate the ROM and muscular strength of the fingers. When
This study demonstrated that 6-week-long isotonic and compared to healthy individuals, RA patients have 75 %
isometric hand exercises decreased pain and disease decrease in ROM and muscular strength [4, 17]. The exer-
activity while increasing hand functions, dexterity, quality cises aim at reducing the pain and increasing the muscular
of life and HS in RA patients. strength for performing these activities comfortably.

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Table 2 Pain, hand function, dexterity and quality of life, handgrip differences between the two groups regarding joint
strength and disease activity changes in isotonics and isometrics mobility and functional ability, and intensive exercise
before and after 6 weeks of hand exercise
program was found to be well tolerated and more effective
Isotonics (n = 23) Isometrics (n = 24) p [19].
During the exercises that are performed, two types of
VAS
muscular activities take place: static and dynamic. While
Before treatment 5 (0–8) 3.5 (2–6.75) 0.636
static or isometric activity takes place, muscle tension is
At 6 weeks 3 (0–5) 4 (0–4.75) 0.931
created without a change in the muscle’s length. Isometric
p 0.036 0.021
activities are not only used for therapeutic exercises but
DHI
they are also elements of many daily activities and sports
Before treatment 15 (5–40) 16.5 (5.25–30.5) 0.823
participation. As the muscle length decreases and increases
At 6 weeks 11 (3–33) 12 (3.5–25.25) 0.814
during isotonic activity, this is a dynamic activity. Isotonic
p 0.002 0.002
ROM exercises are used during the initial stages of
NHPT
strengthening programs [20–22].
Before treatment 30 (25–45) 30 (20–38.75) 0.158 In this study, we also evaluated the effects of isotonic
At 6 weeks 28 (20–40) 23.5 (20–30) 0.276 and isometric hand exercises composed of ROM exercises
p 0.0001 0.005 since these exercises very simple and feasible may be
RAQoL completed in any setting, and do not require any ancillary
Before treatment 19 (15–24) 18 (11.5–22.75) 0.572 equipment. Changes in pain and functional status,
At 6 weeks 15 (14–21) 14.32 (7.25–21) 0.502 improvement of hand abilities and reflection of the effects
p 0.003 0.001 of hand exercises to daily practice were evaluated as pri-
DHS mary outcomes. With both types of exercises, we witnessed
Before treatment 10 (6–18) 10.5 (8–13.75) 0.991 reductions in pain, increases in hand function and abilities
At 6 weeks 11 (8–20) 14 (8.5–18) 0.572 and positive reflections of such differences on quality of
p 0.372 0.029 life.
NHDS Another outcome that we followed-up in our study was
Before treatment 9 (4–16) 10.5 (6–17) 0.363 HS. When we analyzed the literature, we see that different
At 6 weeks 10 (6–18) 10 (6.5–17.5) 0.616 exercise protocols were used for different durations; so the
p 0.013 0.138 effects of hand exercises performed by RA patients on the
DAS 28 increases of HS varied. In the study by Cima et al., with
Before treatment 3.99 (3.49–4.81) 4.06 (2.77–5.08) 0.632 strengthening exercises performed in RA patients having
At 6 weeks 3.2 (2.5–4.02) 3.03 (2.27–3.56) 0.425 hand deformities, there were improvements in handgrip
p 0.002 0.0001 and pinch strengths [17]. In another study evaluating iso-
metric hand exercises, isometric exercises for 8-week
The cells in the table depict median and interquantile range values
duration decreased the pain during movement and
Bold values indicate statistical significance p \ 0.05
increased the handgrip strength; however, these did not
VAS visual analog scale, DHI Duruöz Hand Index, NHPT nine hole
peg test, RAQoL Rheumatoid Arthritis Quality of Life, DHS dominant reach the level of statistical significance [23].
handgrip strength, NDHS non-dominant handgrip strength, DAS 28 In both exercise groups, we observed increases of hand
disease activity score 28 HS in both dominant and non-dominant hands; isometric
exercises resulted in statistically significant increases of
Very few studies have specifically investigated the dominant hand HS, and isotonic exercises resulted in
effects of hand exercises for the rheumatoid arthritis. In increases in non-dominant hand HS. This is related to the
such studies, the effects of the exercises on pain reduction, fact that our exercise program was milder in terms of
increasing functionality and muscle strengthening were duration and number of repetitions and that it did not
evaluated as outcomes. With a 3-week-long physical consist of intensive resistive exercises.
therapy and exercise program, Buljina et al. reported Our study also clarified the issue of whether these
decreases in pain and tenderness and increases in ROM, exercises had any deleterious effects on disease activity, we
ADL and hand strength [18]. Ronningen et al. compared concluded that the hand exercises performed by these
conservative exercise program with intensive exercise patients did not increase disease activity and even resulted
program in their study. At the end of 14 weeks, decreased in decreases in the measured disease activity by DAS 28.
pain increased non-dominant hand grip strength in the This result is consistent with the results of the previous
intensive exercise program group, but increased pain in studies, suggesting that intensive general body exercises
conservative exercise group; there were significant and hand exercises do not impair disease activity [23–26].

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Rheumatol Int (2013) 33:2625–2630 2629

Table 3 The comparisons of differences in improvements after treatment in isotonics and isometrics
Isotonics (n = 23) Isometrics (n = 24) Differences p
between groups

VAS
Mean ± SD 1.26 ± 2.68 1.04 ± 2.13 0.22 0.711
Median (IQR) 1 (0–3) 0 (0–2.75)
DHI
Mean ± SD 2.83 ± 3.71 3.06 ± 3.60 0.23 0.847
Median (IQR) 2 (0–7) 2 (0.25–6)
NHPT
Mean ± SD 5.17 ± 5.19 4.12 ± 6.92 -1.05 0.123
Median (IQR) 5 (2–5) 2 (0–8.75)
RAQoL
Mean ± SD 4.09 ± 5.14 6.04 ± 8.76 1.95 0.748
Median (IQR) 3 (0–9) 2 (0–13.75)
DHS
Mean ± SD 0.56 ± 2.62 2.04 ± 4.28 1.48 0.136
Median (IQR) 0 (-1 to 2) 2 (-0.75 to 4)
NDHS
Mean ± SD 1.30 ± 3.39 1.00 ± 2.84 -0.30 0.327
Median (IQR) 2 (0–2) 0 (-1 to 2)
DAS 28
Mean ± SD 0.70 ± 1.08 0.78 ± 0.80 0.08 0.856
Median (IQR) 0.7 (0.2–1.24) 0.68 (0.21–1.27)
Statistically significant (p \ 0.05)
VAS visual analog scale, DHI Duruöz Hand Index, NHPT nine hole peg test, RAQoL Rheumatoid Arthritis Quality of Life, DHS dominant
handgrip strength, NDHS non-dominant handgrip strength, DAS 28 disease activity score 28

This suggests that DAS 28 score may have decreased as a
result of a decline in VAS score with exercise and a
favorable change in patient global assessment, one of the
parameters used in DAS 28 calculation, as a result of a
6-week close, direct interaction between the physician and
the patient.
The limitations of our study were the shortness of the
duration of the hand exercise program. We evaluated the
effects of the program at the end of 6 weeks and did not
have a long-term follow-up. As RA is a chronic disease
with a possibly progressive course, exercise programs
should be of long duration and programs should also
include resistive strengthening exercises. The studies to be
performed should also include data about radiological
progression. However, ensuring patient compliance is very
difficult in long-term exercise programs. Even shorter
exercise programs of 6 weeks that do not require additional
equipment and can be performed at home could create
compliance problems. Two patients had to quit the study
because of fractures. Three Out of the remaining 50
patients dropped out because of non-compliance. In addi-
tion, as any exercise can produce an effect, lack of a
control group was a limitation of our study.
To the best of our knowledge, our study is the first study
investigating effects of isometric and isotonic hand exer-
cises in RA patients. This study even though it was
underpowered provided data supporting that both isometric
and isotonic hand exercises decrease pain and disease
activity, improve hand functions, dexterity and quality of
life well as mildly increasing muscle strength. As a con-
clusion, we suggest that both exercise types can be used in
patients with RA.
Conflict of interest The authors declare that they have no conflict
of interests.
Appendix 1
1. Flexion and extension of the wrist
2. Supination and pronation of the hand and the forearm
3. The fingers would be made flexed to form a fist and
extended back
4. To touch the tips of other fingers with the thumb.
5. Flexion of the IP joint of the thumb
6. Abduction and adductions of the fingers.

123
2630
All the movements were performed once a day with 10
repetitions.
Appendix 2
1. To push the hands by facing the palms towards each
other
2. Ulnar deviation against pressure while the fingers are
in flexion
3. Pushing the lid of the perfume bottle while the IP joint
of the thumb is in flexion
4. Abduction and adduction by placing the hands of the
physician in between the fingers
5. While the fingers are at 90° flexion at the MCP joint,
flexion and extension of the fingers against pressure
6. Gripping the water glass placed into the palm.
All the movements are to be performed once a day with 10
repetitions. The movement is to last for 5 s with 15 s
pauses in between the movements.
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