The Role of the Physiotherapist in the Management Systemic Sclerosis

At SRUK's Regional Conference in Glasgow, physiotherapist Will Gregory articulated the pivotal role of physiotherapy in alleviating some of the symptoms of scleroderma over the whole body, and how relevant healthcare professionals can encourage and support individuals to gain as much as possible from this manner of treatment. Previously funded by SRUK to investigate the effectiveness of wax-bath therapy in addition to hand exercises for people with scleroderma, we were very excited to listen to Will discuss the latest research within this field as well as his recommendations for helpful exercises that could be performed. Below is a summary of the points he raised.

It is thought that 90% of people affected by scleroderma will experience some form of musculoskeletal problems at some stage of their medical journey, and so referral to physiotherapy is not uncommon. The importance of physiotherapy is emphasized by the implementation of guidelines by the British Society of Rheumatology (BSR) in 2016 and European League Against Rheumatism (EULAR) in 2017 incorporating the efficacy of non-pharmacological treatments in scleroderma, such as physiotherapy, as well as research evaluating the benefits of various physiotherapy treatments. Over the last decade, there has been invested efforts in looking into the effects of mouth stretches, lymph drainage and hydrotherapy, to name a few.

Leading from evidence of its benefits in relieving some of the symptoms of rheumatoid arthritis, there have been three studies examining the potential of wax bath as a treatment for scleroderma. Wax baths have been used to diminish the symptoms of a range of conditions within rheumatology since the early 1900s. It involves using paraffin wax that is soft and melts at temperatures lower than normal, therefore not causing any burns or blisters. More information about wax baths can be found here. Proposed benefits include an increase of pain threshold, reduction in joint stiffness and swelling, and improvements in mobilisation. One study conducted in Sweden by Sanqvist et al. observed significant clinical improvement in Hand Mobility in Scleroderma (HAMIS), as well as greater finger flexion and increased grip strength. Building upon these findings, Sanqvist and his team went on to adapt hand exercises according to each individual's needs, alongside a set of exercises such as isolated finger flexion, finger extension and finger abduction; again, there were significant improvements in hand range of motion and grip strength.

To further explore the potential of wax baths and hand exercises, Will Gregory launched a study to compare the effects of daily hand exercises with or without daily home wax bath hand treatment in people with scleroderma. This was a single centre study, where 36 participants with hand skin tightening caused by scleroderma were randomised into a group either receiving or not receiving the wax bath intervention. Both groups continued to perform regular hand exercises as part of their treatment. Outcome measures such as the HAMIS test, the grip and pinch test, and the Scleroderma Health Assessment Questionnaire (SHAQ) were used in assessment. Although the group comparisons did not demonstrate any statistically significant evidence of effectiveness of the wax bath treatment, most participants did show some form of improvement over the study period. Therefore, the findings should not exclude the possibility that individuals may still benefit from this treatment approach.

Below are some exemplar exercises that Will talked through with the audience at the conference. Please remember that these are only examples and may not be suitable for everyone – if carrying them out, it is important to be aware of your body's limitations. Breathing deeply throughout each exercise will help.

Opening the thumb joint:

• Starting with your hand flat on the table, pull your thumb away from your index finger using your other hand. Hold it as far as possible for 20 seconds. 5 repetitions should be done on each hand.
• Starting with your thumb on the table, lower your other fingers towards the floor. 5 repetitions should be done on each hand.
• Spread your thumb as far as possible from your index finger. Place a round object(e.g. a glass) in the gap to hold the fingers as far apart as possible. This position should be held for 5 minutes and repeated twice on each hand.

Position for extending the wrists:

• Starting with your hands flat on the table, position your shoulders over your hands, with your elbows stretched. Keep them stretched as much as possible for 20 seconds. This should be repeated 5 times and palms should not be lifted from the table.
• Standing, grip the edge of the table with your hands. Then position your shoulders above your hands with your elbows stretched. Hold this position for 20 seconds and repeat this 5 times.

Mobilizing the elbows:

• In extension: Starting seated and facing a table, rest your arms on a bolster with your hands a broom handle and your palms upwards. Stretch out your elbows and hold this stretched position for 20 seconds. This should be repeated 5 times.
• In rotation: Starting seated, place your forearm on the table and hold a bottle of water in your hand. Tip the bottle from one side to another, emphasizing the palm-upwards from side to side movement especially. Hold the stretched position for 20 seconds and do 5 repetitions with each hand.

Watch Will's full presentation below:

To learn more about research into physiotherapy, as well as more examples of exercises, please watch the full presentation Will gave at our Glasgow Conference for further detail.

If you are interested in helping SRUK to fund work that will help to improve the quality of life of our community, then please donate today. We rely on the generosity of the community to continue to support groundbreaking research in both scleroderma and Raynaud's.

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Information and advice for managing scleroderma can be found here: 6 tips for self-management.