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The presence of central sensitization leads to overestimation of pain sensitivity and disease activity in rheumatoid arthritis (RA) patients. Central sensitization should not be overlooked in RA patients to avoid over-treatment for inflammation and to determine the need for treatment of nociplastic pain. While literature contains no studies comparing alternative programs with the standard hand rehabilitation program in the presence of central sensitization in rheumatoid arthritis patients, the objective of this study is to investigate whether desensitization exercises provide additional benefit in this patient group.
The study is designed prospectively and will be conducted between August 22, 2025, and June 22, 2026. Patients who are regularly followed in the Physical Medicine and Rehabilitation rheumatology outpatient clinic of Haydarpasa Numune Training and Research Hospital and who meet the inclusion and exclusion criteria will be included. Demographic data such as age, height, weight, waist circumference, and diet type of participants will be recorded. At baseline, the Central Sensitization Scale, Rheumatoid Arthritis Quality of Life Scale, RA Articular Damage Score, Health Assessment Questionnaire, and Duruöz Hand Index questionnaires will be administered. DAS28 and ACR50 responses will be noted. Sedimentation and CRP values from routine follow-up files, as well as hand dynamometry and pinchmeter (lateral, palmar, and fingertip) grip strengths, will be recorded.
The study consists of one group of rheumatoid arthritis patients and two groups of rheumatoid arthritis patients with accompanying central sensitization. Group 1 (Rheumatoid Arthritis Patients) and Group 2 (Rheumatoid Arthritis Patients with Central Sensitization) will be taught determined strengthening and mobility exercises under the supervision of a physiotherapist to ensure correct home application. The investigator will also provide recorded exercise videos and handouts for patients. Group 3 (RA Patients with Central Sensitization) will additionally perform desensitization exercises 7 days a week for 3 months, in addition to the strengthening and mobility exercises. Randomization will be conducted using the sealed envelope method. Patient compliance with the exercise program will be monitored by the investigator via telephone contact on specific days of the week.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Rheumatoid Arthritis Patients | Experimental | SARAH Exercise |
|
| Rheumatoid Arthritis Patients with Central Sensitization1 | Experimental | SARAH Exercise |
|
| Rheumatoid Arthritis Patients with Central Sensitization2 | Experimental | SARAH Exercise + Desensitization Exercises |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Exercise1 | Other | Participants will be asked to practice home exercises every day of the week for 12 weeks. The SARAH exercise program consists of 7 mobility and 4 strengthening exercises. Progress will be made by increasing the repetitions and duration of the exercises every week. |
| Measure | Description | Time Frame |
|---|---|---|
| VAS | The Visual Analog Scale (VAS) is used to assess pain intensity. Scores range from 0 to 10, where 0 represents "no pain" and 10 represents "the worst possible pain." Lower scores indicate a better clinical outcome. | Assessments will be conducted at baseline, at the end of the 3-month exercise program, and at the 6-month follow-up. |
| CENTRAL DESENSÄ°TÄ°ZATÄ°ON SCALE | Participants were categorized based on their Central Sensitization Inventory (CSI) scores, which range from 0 (no symptoms) to 100 (extreme symptoms). A clinical threshold was set at 40; participants scoring 40 or higher were identified as meeting the criteria for central sensitization | Assessments will be conducted at baseline, at the end of the 3-month exercise program, and at the 6-month follow-up. |
| DURUOZ HAND INDEX | Participants achieved a functional response based on the Duruöz Hand Index (DHI), which ranges from 0 (best outcome) to 90 (worst outcome). A response was defined as a significant reduction in the total score from baseline, where lower scores indicate improved hand function and independence in daily activities. | Assessments will be conducted at baseline, at the end of the 3-month exercise program, and at the 6-month follow-up. |
| Dynamometer-measured hand grip strength measurements (kg) | Hand grip strength was measured using a calibrated dynamometer to assess isometric muscle strength. Results are reported in kilograms (kg). On this scale, higher values indicate greater muscle strength and better physical performance (best outcome), while lower values indicate reduced grip strength (worst outcome). | Assessments will be conducted at baseline, at the end of the 3-month exercise program, and at the 6-month follow-up. |
| Pinchmeter-measured finger strength measurements (kg) (Tip, Lateral, Palmar) |
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Inclusion *Rheumatoid Arthritis Group Without Central Sensitization (Group 1):
Being between 18-75 years of age
Not having had upper extremity surgery within the last 1 year
Patients without active arthritis
No change in medical treatment in the last 3 months
Having mild-moderate disease activity according to DAS28
*Rheumatoid Arthritis Group with Central Sensitization (Group 2):
Being between 18-75 years of age
Not having had upper extremity surgery within the last 1 year
Patients without active arthritis
No change in medical treatment in the last 3 months
Having mild-moderate disease activity according to DAS28
*Rheumatoid Arthritis Group with Central Sensitization (Group 3):
Being between 18-75 years of age
Not having had upper extremity surgery within the last 1 year
Patients without active arthritis
No change in medical treatment in the last 3 months
Having mild-moderate disease activity according to DAS28
Criteria:
-
Exclusion Criteria:
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| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Haydarpaşa Numune Eğitim Ve Araştirma Hastanesi Validebağ Ek Hizmet Binasi | Istanbul | ÜSKÜDAR | 34674 | Turkey (Türkiye) |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 38757102 | Background | Mesci N, Mesci E, Kandemir EU, Kulcu DG, Celik T. Impact of central sensitization on clinical parameters in patients with rheumatoid arthritis. North Clin Istanb. 2024 Apr 22;11(2):140-146. doi: 10.14744/nci.2023.81231. eCollection 2024. | |
| 30063798 | Background | Williams MA, Srikesavan C, Heine PJ, Bruce J, Brosseau L, Hoxey-Thomas N, Lamb SE. Exercise for rheumatoid arthritis of the hand. Cochrane Database Syst Rev. 2018 Jul 31;7(7):CD003832. doi: 10.1002/14651858.CD003832.pub3. |
| Label | URL |
|---|---|
| Related Info | View source |
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| ID | Term |
|---|---|
| D001172 | Arthritis, Rheumatoid |
| ID | Term |
|---|---|
| D001168 | Arthritis |
| D007592 | Joint Diseases |
| D009140 | Musculoskeletal Diseases |
| D012216 | Rheumatic Diseases |
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Central sensitization is a state of increased neuronal sensitivity and synaptic plasticity in central pain pathways following painful stimulation. Central sensitization causes increased sensitivity of the central nervous system to painful and non-painful stimuli. Central sensitization has been reported in 15-40% of patients with inflammatory rheumatic diseases.
The presence of central sensitization leads to overestimation of pain sensitivity and disease activity in rheumatoid arthritis patients.
Central sensitization should not be overlooked in RA patients to avoid over-treatment for inflammation and to determine the need for treatment of nociplastic pain.
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|
| Exercise2 | Other | Participants will be asked to practice home exercises every day of the week for 12 weeks. The SARAH exercise program consists of 7 mobility and 4 strengthening exercises. Progress will be made by increasing the repetitions and duration of the exercises every week. |
|
| Exercise3 | Other | Participants will be asked to practice home exercises every day of the week for 12 weeks. The SARAH exercise program consists of 7 mobility and 4 strengthening exercises. In addition to the strengthening and mobility exercises, participants will also perform desensitization exercises 7 days a week for 3 months. Progress will be made by increasing the repetitions and duration of the exercises every week. |
|
Finger pinch strength was measured using a calibrated pinchmeter to evaluate fine motor strength in three positions: Tip pinch (thumb to index finger), Lateral pinch (thumb to the radial side of the index finger), and Palmar pinch (thumb to index and middle fingers). Measurements are recorded in kilograms (kg). Higher values indicate greater functional strength and better hand performance (best outcome), whereas lower values indicate reduced pinch force (worst outcome). |
| Assessments will be conducted at baseline, at the end of the 3-month exercise program, and at the 6-month follow-up. |
| 37227116 | Background | England BR, Smith BJ, Baker NA, Barton JL, Oatis CA, Guyatt G, Anandarajah A, Carandang K, Chan KK, Constien D, Davidson E, Dodge CV, Bemis-Dougherty A, Everett S, Fisher N, Fraenkel L, Goodman SM, Lewis J, Menzies V, Moreland LW, Navarro-Millan I, Patterson S, Phillips LR, Shah N, Singh N, White D, AlHeresh R, Barbour KE, Bye T, Guglielmo D, Haberman R, Johnson T, Kleiner A, Lane CY, Li LC, Master H, Pinto D, Poole JL, Steinbarger K, Sztubinski D, Thoma L, Tsaltskan V, Turgunbaev M, Wells C, Turner AS, Treadwell JR. 2022 American College of Rheumatology Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis. Arthritis Care Res (Hoboken). 2023 Aug;75(8):1603-1615. doi: 10.1002/acr.25117. Epub 2023 May 25. |
| Related Info | View source |
| Related Info | View source |
| D003240 |
| Connective Tissue Diseases |
| D017437 | Skin and Connective Tissue Diseases |
| D001327 | Autoimmune Diseases |
| D007154 | Immune System Diseases |