OARSI Clinical Trials Recommendations: Design and conduct of clinical trials for hand osteoarthritis

Impact of thumb osteoarthritis on pain, function, and quality of life: a comparative study between erosive and non-erosive hand osteoarthritis

OBJECTIVE

The study was aimed to compare the impact of thumb base osteoarthritis (TBOA) on pain, function, and quality of life in patients with erosive or non-erosive hand osteoarthritis (HOA).

METHODS

This observational retrospective study included 232 patients: 64 with erosive HOA (EHOA) and concomitant TBOA, 36 with isolated EHOA, 97 with non-erosive HOA (non-EHOA) and TBOA, and 35 with isolated non-EHOA. Hand pain by a visual analogue scale (VAS), Functional Index for Hand Osteoarthritis (FIHOA) score, Health Assessment Questionnaire (HAQ), the Medical Outcomes Study 36-Item Short Form (SF-36), and the possible correlations between VAS and FIHOA with radiological score were assessed.

RESULTS

No differences were found between EHOA with TBOA and isolated EHOA in VAS and FIHOA scores; opposite, there was a significant difference in VAS (p < 0.01) and FIHOA (p < 0.001) between subjects with non-EHOA and TBOA and patients with only non-EHOA. VAS and FIHOA values resulted slightly higher in patients with EHOA and TBOA vs non-EHOA and TBOA; they were significantly more elevated in EHOA and TBOA group compared to isolated non-EHOA (p ≤ 0.001) and in isolated EHOA vs isolated non-EHOA (p < 0.01 and p < 0.001, respectively). HAQ, SF-36 resulted significantly better in isolated non-EHOA patients compared to the other groups. Finally, we observed a significant correlation between FIHOA and all the Kallman scales in EHOA patients with TBOA and between FIHOA and Kallman's thumb score in non-EHOA-TBOA group.

CONCLUSIONS

EHOA has a more severe clinical burden than non-EHOA; the presence of TBOA appeared an important determinant of pain and disability in non-EHOA.Key Points• Each subset of HOA can have a different impact on pain and functionality, with EHOA determining more severe effects on hand symptoms and disability than non-EHOA.• The presence of TBOA appeared an important determinant of pain and disability in non-EHOA, but not in EHOA.• Our findings support the need for an individualized therapy for each phenotype of hand osteoarthritis.

Treating hand and foot osteoarthritis using a patient's own blood: A systematic review and meta-analysis of platelet-rich plasma

Background

This study summarizes all literature investigating platelet-rich plasma (PRP) in the treatment of osteoarthritis of the hands and feet.

Materials & methods

This is a PRISMA compliant systematic review of 7 databases and includes a meta-analysis of randomized controlled trial (RCT) data on pain and function.

Results

Nine articles were included in the review. Meta-analysis of 4 RCTs shows PRP significantly improves pain and function versus control. More results are significant at longer duration follow-up.

Conclusions

PRP improves pain and function of osteoarthritis. Heterogeneity and risk-of-bias limit current data, requiring more RCTs to determine any regenerative potential of PRP.

Prospero Systematic Review Registration Number

136582.

A periodized training attenuates thigh intermuscular fat and improves muscle quality in patients with knee osteoarthritis: results from a randomized controlled trial

OBJECTIVE

To analyze the influence of a 14-week periodized circuit training (CT) protocol on thigh intermuscular fat and muscle quality (force per unit area of lean tissue) in patients with knee osteoarthritis (KOA).

DESIGN

Randomized controlled trial METHODS: Sixty-one selected participants with KOA grades 2 and 3, 40-65 years old, and BMI < 30 kg/m² were randomized into three groups: CT, conventional strength training (ST), and educational protocol (EP). The CT and ST protocols consisted of 14-week training protocols conducted 3 times a week. The CT group performed exercises stratified as light, moderate, and intense, arranged progressively in a circuit model. The ST group performed conventional strength exercises, and the EP group participated in lectures twice a month about healthy lifestyles. Baseline and follow-up (week 0 and week 14) evaluations were conducted for thigh intermuscular fat (computed tomography), knee extension maximal isometric voluntary contraction (MIVC), and muscle quality (knee extension MIVC/muscle mass cross-sectional area).

RESULTS

Only the CT group presented significant reductions in thigh intermuscular fat (p = 0.003) and significantly lower values in week 14 compared with the EP (p = 0.032). Both trained groups presented significant increases in muscle mass area (p=0.002 for CT and p=0.008 for ST) and increments in knee extension MIVC (p=0,033 for CT nd p=0.019 for ST) in week 14 compared with the EP and increases in muscle quality (p = 0.004 and 0.042).

CONCLUSION

It can be concluded that a 14-week periodized CT protocol attenuates thigh intermuscular fat and improves muscle quality in patients with KOA.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02761590; https://clinicaltrials.gov/ct2/show/NCT02761590Key Points•Fourteen weeks of periodized circuit training attenuates thigh intermuscular fat in patients with knee osteoarthritis.•Circuit training is as effective as strength training for improving muscle mass, strength, and quality.

Impact of Thumb Carpometacarpal Joint Osteoarthritis: A Pragmatic Qualitative Study

OBJECTIVE

First carpometacarpal (CMC1) joint osteoarthritis (OA) is typically understood as part of the disease entity of hand OA. However, CMC1 joint OA often occurs in isolation or is a primary source of symptoms. The aim of the current study was to explore the experiences of New Zealanders with CMC1 joint OA to better understand the unique impact of this condition, ascertain outcomes of importance, and identify treatment targets.

METHODS

In this pragmatic qualitative study, patients who either reported a history suggestive of CMC1 joint OA or had been diagnosed by a physician were recruited from health and community settings in 2 centers on the South Island of New Zealand. Thirty participants (11 men and 19 women, mean ± SD age 65.4 ± 11.36 years) took part in individual face-to-face interviews and kept diaries. The interviews were audio recorded, and along with the diaries, transcribed. Data were analyzed by thematic analysis using a primarily inductive approach. The Health Impact Model was employed to help with interpretation of the results.

RESULTS

Five interrelated levels of health impact were identified: symptom status, functional limitations, restrictions in social activities and roles, negative thoughts and feelings, and an altered sense of self. Constant pain and pain at night were key symptoms that were associated with impact at the other levels.

CONCLUSION

Constant pain, pain at night, functional capacity, medication burden, emotional impact, and sense of self are important outcomes and treatment targets in people with CMC1 joint OA.

Clinical Assessments of Hand Function in First Carpometacarpal Osteoarthritis Do Not Appear to Correlate with Radiographic Findings

BACKGROUND

Thumb carpometacarpal (first CMC) osteoarthritis (OA), a degenerative process affecting hand use, is typically assessed by clinical examination and radiographs. This assessment determines treatment, but it may not reflect functional limitations.

QUESTIONS/PURPOSES

We aimed to explore the relationship between measures of hand function and radiographs in individuals with and without first CMC OA.

METHODS

We designed a cross-sectional, observational pilot study, enrolling five patients with first CMC OA (nine thumbs with modified Eaton-Littler grades ranging from 1 to 4, using retrospective radiographic data) and nine healthy controls. They underwent evaluation of hand function using four patient-reported outcome measures (PROMs)-the Patient-Specific Functional Scale (PSFS); the Patient-Rated Wrist/Hand Evaluation (PRWHE); the Disabilities of the Arm, Shoulder, and Hand (DASH); and the Modified Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (M-SACRAH)-and one performance measure, the Arthritis Hand Function Test (AHFT). Spearman's ρ with 95% subject clustered bootstrapped confidence intervals was calculated to assess for correlations between radiographic findings and measures of hand function.

RESULTS

Only the DASH work score showed strong positive correlation with radiographic OA grade, with PSFS, PRWHE, M-SACRAH, and AHFT scores demonstrating low to moderate correlations. Notable differences were found between patients and control subjects in median scores of the DASH, PSFS, PRWHE, and M-SACRAH, as well as in the grip, pinch, and button scores of the AHFT.

CONCLUSION

While only the DASH work score strongly correlated with radiographic grade of first CMC OA, several measures detected considerable differences in functional hand use between patients and control subjects. The findings of this pilot study suggest that hand function scores be considered in addition to radiographs when determining severity of first CMC OA. The findings can also inform the design of a larger, powered study.

Injection therapy for base of thumb osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of injection-based therapy in base of thumb osteoarthritis.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE and EMBASE via OVID, CINAHL and SPORTDiscus via EBSCO were searched from inception to 22 May 2018.

STUDY SELECTION

Randomised controlled trials (RCTs) and non-RCTs of adults with base of thumb osteoarthritis investigating an injection-based intervention with any comparator/s.

DATA EXTRACTION AND ANALYSIS

Data were extracted and checked for accuracy and completeness by pairs of reviewers. Primary outcomes were pain and function. Comparative treatment effects were analysed by random-effects model for short-term and medium-term follow-up.

RESULTS

In total, 9 RCTs involving 504 patients were identified for inclusion. All compared different injection-based therapies with each other, no studies compared an injection-based therapy with a non-injection-based intervention. Twenty injection-based intervention groups were present within these nine trials, consisting of hyaluronic acid (n=9), corticosteroid (n=7), saline placebo (n=3) and dextrose (n=1). Limited meta-analysis was possible due to the heterogeneity in the injections and outcomes used, as well as incomplete outcome data. Meta-analysis of two RCTs (92 patients) demonstrated reduced Visual Analogue Scale pain on activity with corticosteroid versus hyaluronic acid (mean difference (MD) -1.32, 95% CI -2.23 to -0.41) in the medium term, but no differences in other measures of pain or function in the short term and medium term. Overall, the available evidence does not suggest that any of the commonly used injection therapies are superior to placebo, one another or a non-injection-based comparator.

CONCLUSION

Current evidence is equivocal regarding the use of injection therapy in base of thumb osteoarthritis, both in terms of which injection-based therapy is the most effective and in terms of whether any injection-based therapy is more effective than other non-injection-based interventions. Given limited understanding of both the short-term and long-term effects, there is a need for a large, methodologically robust RCT investigating the commonly used injection therapies and comparing them with other therapeutic options and placebo.

PROSPERO REGISTRATION NUMBER

CRD42018095384.

Hand osteoarthritis: clinical phenotypes, molecular mechanisms and disease management

Osteoarthritis (OA) is a highly prevalent condition, and the hand is the most commonly affected site. Patients with hand OA frequently report symptoms of pain, functional limitations and frustration in undertaking everyday activities. The condition presents clinically with changes to the bone, ligaments, cartilage and synovial tissue, which can be observed using radiography, ultrasonography or MRI. Hand OA is a heterogeneous disorder and is considered to be multifactorial in aetiology. This Review provides an overview of the epidemiology, presentation and burden of hand OA, including an update on hand OA imaging (including the development of novel techniques), disease mechanisms and management. In particular, areas for which new evidence has substantially changed the way we understand, consider and treat hand OA are highlighted. For example, genetic studies, clinical trials and careful prospective imaging studies from the past 5 years are beginning to provide insights into the pathogenesis of hand OA that might uncover new therapeutic targets in the disease.

Musculoskeletal ultrasound in symptomatic thumb-base osteoarthritis: clinical, functional, radiological and muscle strength associations

Background

Thumb-base osteoarthritis (OA) is a common cause of pain and disability This study aimed to investigate the associations of musculoskeletal ultrasound OA pathologies with the extent of pain, function, radiographic scores, and muscle strength in symptomatic thumb-base osteoarthritis.

Methods

This is a cross-sectional study of an ongoing clinical trial with eligibility criteria including thumb-base pain on Visual Analogue Scale (VAS) ≥40 (0 to 100 mm), Functional Index for Hand OA (FIHOA) ≥ 6 (0 to 30) and Kellgren Lawrence (KL) grade ≥ 2. The most symptomatic side was scanned to measure synovitis and osteophyte severity using a 0–3 semi-quantitative score, power Doppler and erosion in binary score. A linear regression model was used for associations of ultrasound findings with VAS pain, FIHOA and hand grip and pinch strength tests after adjusting for age, gender, body mass index, disease duration and KL grade as appropriate. For correlation of ultrasound features with KL grade, OARSI ((Osteoarthritis Research Society International) osteophyte and JSN scores, Eaton grades, Spearman coefficients were calculated, and a significant test defined as a p-value less than 0.05.

Results

The study included 93 participants (mean age of 67.04 years, 78.5% females). Presence of power Doppler has a significant association with VAS pain [adjusted β coefficient = 11.29, P = 0.02] while other ultrasound pathologies revealed no significant associations with all clinical outcomes.

In comparison to radiograph, ultrasonographic osteophyte score was significantly associated with KL grade [r_s = 0.44 (P < 0.001)], OARSI osteophyte grade [r_s = 0.35 (P = 0.001)], OARSI JSN grade [r_s = 0.43 (P < 0.001)] and Eaton grade [r_s = 0.30 (P < 0.01)]. Ultrasonographic erosion was significantly related with radiographic erosion [r_s = − 0.49 (P = 0.001)].

Conclusion

From a clinical perspective the significant relationship of power Doppler with pain severity in thumb base OA suggests this might be a useful tool in understanding pain aetiology. It is important to recognise that power Doppler activity was only detected in 14% of the study so this might be an important subgroup of persons to monitor more closely.

Trial registration

Registered at Australian New Zealand Clinical Trials Registry (ANZCTR), http://www.anzctr.org.au/, ACTRN12616000353493.

Association of Comorbid Interphalangeal Joint Pain and Erosive Osteoarthritis With Worse Hand Function in Individuals With Symptomatic Thumb Base Osteoarthritis

OBJECTIVE

Hand osteoarthritis (OA) trials often target exclusively the thumb base joint, although concomitant widespread interphalangeal (IP) joint involvement is frequent. We aimed to compare hand strength and function between individuals with isolated thumb base OA and those with coexistent IP joint pain and erosive OA.

METHODS

Baseline data from a thumb base OA trial were analyzed (n = 204). Participants were age ≥40 years with symptomatic and radiographic thumb base OA. Only the index hand was included. Self-reported IP joint pain (in any proximal, distal, or thumb IP joint), hand function score (Functional Index for Hand Osteoarthritis questionnaire [range 0-30]), and hand grip and tip-pinch strength test results were obtained at baseline. Radiographs were scored for OA severity at each joint (Kellgren/Lawrence grade) and for the presence of erosive OA at the thumb base or IP joints. Multiple linear regression was used adjusting for age, sex, body mass index, and radiographic thumb base OA severity.

RESULTS

Compared to individuals with isolated thumb base OA (62%), those with concomitant IP joint pain (17%) and erosive OA (21%) had significantly worse hand function (β = 1.82 [95% confidence interval (95% CI) 0.36, 3.28] and β = 1.47 [95% CI 0.74, 2.88], respectively). In addition, coexistence of erosive OA was independently associated with lower grip and tip-pinch strength (β = -5.14 [95% CI -7.58, -2.70] and β = -0.61 [95% CI -1.05, -0.17], respectively).

CONCLUSION

Concomitant IP joint pain and erosive OA are associated with worse hand function in individuals with thumb base OA. Patient stratification based on these characteristics may improve the design of future thumb base OA trials.

Effectiveness of splinting for pain and function in people with thumb carpometacarpal osteoarthritis: a systematic review with meta-analysis

OBJECTIVE

To examine the effectiveness of splinting for reducing pain and improving function and health-related quality of life (HR-QoL) in people with thumb carpometacarpal osteoarthritis (CMC OA).

DESIGN

The Cochrane Library, MEDLINE, Embase, CINAHL, ISI Web of Science, Scopus and Google Scholar, 3 trial registries and 4 conference proceedings were systematically searched for randomised and non-randomised controlled trials up to March 17th, 2018. Two reviewers independently applied the inclusion criteria to select potential studies and assess risk of methodologic bias using the Cochrane Collaboration's Risk of Bias Tool. Studies were pooled using the inverse variance method to calculate standardised mean difference (SMD). Sensitivity analyses were conducted and the quality of evidence for each outcome was judged following the Grades of Recommendation Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Twelve studies were retrieved (n = 1353), 4 comparing a splint to control and 8 to another splint. In the medium-term (3-12 months), low quality evidence showed that splints cause a moderate to large reduction in pain (SMD 0.7 [95% confidence interval (CI) 1.04, 0.35], P < 0.0001) and small to moderate improvement in function (SMD 0.42 [95% CI 0.77, 0.08], P = 0.02). No significant effect was found at short-term or for different types of splints. No studies reported HR-QoL.

CONCLUSIONS

Splinting demonstrated a moderate to large effect for pain and small to moderate effect for function in the medium-term but not in the short term. Quality of the evidence is low. Major challenges are the lack of diagnostic criteria and of a gold-standard outcome measure for thumb CMC OA.

Report from the Hand Osteoarthritis Working Group at OMERACT 2018: Update on Core Instrument Set Development

Objective.

To evaluate hand osteoarthritis tools for core instrument set development.

Methods.

For OMERACT 2018, a systematic literature review and advances in instrument validation were presented.

Results.

Visual analog and numerical rating scales were considered valuable for pain and patient’s global assessment, despite heterogeneous phrasing and missing psychometric evidence for some aspects. The Modified Intermittent and Constant Osteoarthritis Pain scale was lacking evidence. The Michigan Hand Outcomes Questionnaire had advantages above other pain/function questionnaires. The Hand Mobility in Scleroderma scale was valid, although responsiveness was questioned. Potential joint activity instruments were evaluated.

Conclusion.

The development of the core instrument set is progressing, and a research agenda was also developed.

Influence of a periodized circuit training protocol on intermuscular adipose tissue of patients with knee osteoarthritis: protocol for a randomized controlled trial

BACKGROUND

The objective of this study is to analyze the influence of a 14-week periodized circuit training protocol on patients with knee osteoarthritis (OA), in randomized intervention groups, on thigh intermuscular adipose tissue (interMAT), body composition, systemic inflammation, cartilage degradation, and its repercussion on pain, functional performance and quality of life.

METHODS

This study presents a protocol for a randomized controlled trial. Sixty selected participants diagnosed with knee OA grades II and III, 40-65 years old and BMI < 30 kg/m2, will be randomly divided into three groups:periodized circuit training, strength training, and educational protocol. The circuit training and strength training protocols consist of 14-week training protocols conducted 3 times a week. The circuit training group will perform selected exercises previously stratified as light, moderate, and intense, arranged progressively in a circuit model, the strength group will perform regular strength exercises, and the educational protocol group will participate in a 14-week protocol with lectures twice a month about healthy lifestyles. Baseline and follow-up evaluations will be conducted for thigh interMAT (computed tomography), body composition (DXA), inflammation (IL-1β, IL-6, IL-10, TNF-α, leptin, and adiponectin), and joint degradation biomarkers (uCTX-II and sCOMP), performance-based tests (30s Chair Stand Test, 40 m Fast-paced Walk Test and Stair Climb Test), quadriceps and hamstring maximal isometric voluntary contraction (MIVC), and questionnaires (WOMAC and pain catastrophizing scale). Repeated measures ANOVA will be used to compare differences between groups (circuit training X strength training X educational protocol) at the different times of assessment (baseline x follow-up or baseline x during protocol x follow-up) for each of the dependent variables. When significant main effects were found, the pots hoc Bonferroni test will be used to identify statistical differences. A significance level of 5% (p < 0.05) will be adopted.

DISCUSSION

This will be the first randomized controlled trial to assess the effects of a circuit training protocol on patients with knee OA on thigh intermuscular adipose tissue (interMAT). Given the prevalence and impact of OA and the widespread availability of this intervention, assessing the efficacy of a low-cost, non-pharmacological, and non-invasive treatment for knee OA patients has the potential for immediate and high clinical impact.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02761590 , registered in May 4, 2016.

Functional consultation and exercises improve grip strength in osteoarthritis of the hand - a randomised controlled trial

BACKGROUND

Evidence for non-pharmacological interventions in hand osteoarthritis is promising but still scarce. Combined interventions are most likely to best cover the clinical needs of patients with hand osteoarthritis (OA). The aim of this study was to evaluate the effect of a combined, interdisciplinary intervention feasible in both primary and specialist care compared to routine care plus placebo in patients with hand OA.

METHODS

This was a randomised, controlled 2-month trial with a blinded assessor. In the combined-intervention group, rheumatology-trained health professionals from different disciplines delivered a one-session individual intervention with detailed information on functioning, activities of daily living, physical activity, nutrition, assistive devices, instructions on pain management and exercises. Telephone follow up was performed after 4 weeks. The primary outcome was grip strength after 8 weeks. Secondary outcomes were self-reported pain, satisfaction with treatment, health status, two of the Jebsen-Taylor Hand Function subtests and the total score of the Australian/Canadian Hand Osteoarthritis Index (AUSCAN). Statistical significance was calculated by Student's t test or the Mann-Whitney U test depending on data distribution. Binominal logistic regression models were fitted, with the primary outcome being the dependent and the group allocation being the independent variable.

RESULTS

There were 151 participating patients (74 in the combined-intervention and 77 in the routine-care-plus-placebo group) with 2-month follow-up attendance of 84% (n = 128). Grip strength significantly increased in the combined-intervention group and decreased in the routine-care group (dominant hand, mean 0.03 bar (SD 0.11) versus - 0.03 (SD 0.13), p value = 0.001, baseline corrected values) after 8 weeks.

CONCLUSION

The combined one-session individual intervention significantly improved grip strength and self-reported satisfaction with treatment in patients with hand OA. It can be delivered by different rheumatology-trained health professionals and is thus also feasible in primary care.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN62513257 . Registered on 17 May 2012.

Cross-cultural adaptation and validation of the Korean Version of the Functional Index for Hand Osteoarthritis (FIHOA)

AIM

This study aimed to translate the Functional Index for Hand Osteoarthritis (FIHOA) into Korean, and establish its reliability and validity in Korean patients with hand osteoarthritis (OA).

METHOD

The FIHOA was translated into Korean (K-FIHOA) following cross-cultural adaptation guidelines. The K-FIHOA was pretested on 40 patients with hand OA. The adapted K-FIHOA was then administered to 100 consecutive hand OA patients together with the modified Health Assessment Questionnaire (mHAQ) and visual analog scale (VAS) for hand pain. The test-retest reliability of each item and total scores were assessed using Spearman's correlation coefficient and intraclass correlation coefficient (ICC). The internal consistency reliability was evaluated as Cronbach's alpha. The external construct validity was assessed using the correlation between K-FIHOA, mHAQ and hand pain VAS.

RESULTS

The test-retest reliability for the total score was strong (r = 0.87 and ICC = 0.83). Cronbach's alpha was also high (0.88), which suggests that there is strong internal coherence in the test items. We identified significant correlations between K-FIHOA and mHAQ (r = 0.52, P < 0.01), mHAQ hand function score, (r = 0.57, P < 0.01) and hand pain VAS (r = 0.53, P < 0.01).

CONCLUSION

The K-FIHOA is a reliable and valid instrument for evaluating functional disability in Korean hand OA patients.

Lack of beneficial effects of low-dose radiation therapy on hand osteoarthritis symptoms and inflammation: a randomised, blinded, sham-controlled trial

OBJECTIVES

Low-dose radiation therapy (LDRT) is widely used as treatment for osteoarthritis (OA) in some countries, while relatively unknown in others. Systematic literature review displayed a lack of high-level evidence for beneficial effects in clinical practice. The aim was to assess the efficacy of LDRT on symptoms and inflammation in hand OA patients in a randomised, blinded, sham-controlled trial, using validated outcome measures.

DESIGN

Hand OA patients, ≥50 years, with pain ≥5 (scale 0-10) and non-responding to conservative therapy were included and randomised 1:1 to receive LDRT (6 × 1 Gy in 2 weeks) or sham (6 × 0 Gy in 2 weeks). Primary outcome was the proportion of OMERACT-OARSI responders, 3 months post-intervention. Secondary outcomes were pain and functioning (Australian/Canadian Hand Osteoarthritis Index; AUSCAN), quality of life (Short Form Health Survey; SF36) and inflammatory outcomes: erythrocyte sedimentation rate and C-reactive protein serum levels, effusion, synovial thickening and power Doppler signal on ultrasound (range 0-3).

RESULTS

Fifty-six patients were included. After 3 months, no significant difference in responders was observed between groups (LDRT: 8 (29%); sham: 10 (36%); difference -7% (95%CI -31-17%)). Also, differences in clinical and inflammatory outcomes between groups were small and not significant.

CONCLUSIONS

We were unable to demonstrate a substantial beneficial effect of LDRT on symptoms and inflammation in patients with hand OA, compared to sham treatment. Although a small effect can not be excluded, a treatment effect exceeding 20% is very unlikely, given the confidence interval. Therefore, in the absence of other high-level evidence, we advise against the use LDRT as treatment for patients with hand OA.

CLINICAL TRIAL REGISTRATION NUMBER

NTR4574 (Dutch Trial Register).

The Ottawa Panel guidelines on programmes involving therapeutic exercise for the management of hand osteoarthritis

OBJECTIVE:

To identify programmes involving therapeutic exercise that are effective for the management of hand osteoarthritis and to provide stakeholders with updated, moderate to high-quality recommendations supporting exercises for hand osteoarthritis.

METHODS:

A systematic search and adapted selection criteria included comparable trials with exercise programmes for managing hand osteoarthritis. Based on the evaluated evidence, a panel of experts reached consensus through a Delphi approach endorsing the recommendations. A hierarchical alphabetical grading system (A, B, C+, C, C-, D-, D, D+, E, F) was based on clinical importance (≥15%) and statistical significance ( P < 0.05).

RESULTS:

Ten moderate- to high-quality studies were included. Eight studies with programmes involving therapeutic exercise (e.g. range of motion (ROM) + isotonic + isometric + functional exercise) seemed to be effective. Forty-six positive grade recommendations (i.e. A, B, C+) were obtained during short-term (<12 weeks) trials for pain, stiffness, physical function, grip strength, pinch strength, range of motion, global assessment, pressure pain threshold, fatigue and abductor pollicis longus moment and during long-term (>12 weeks) trials for physical function and pinch strength.

CONCLUSION:

Despite that many programmes involving exercise with positive recommendations for clinical outcomes are available to healthcare professionals and hand osteoarthritis patients that aid in the management of hand osteoarthritis, there is a need for further research to isolate the specific effect of exercise components.

Class IV laser therapy for trapeziometacarpal joint osteoarthritis: Study protocol for a randomized placebo-controlled trial

OBJECTIVE

Osteoarthritis (OA) is a chronic and prevalent joint disorder with great impact on quality of life and high economic burden. Although a number of conservative therapies have proven to be effective for the management of hand OA, only modest treatment effects were reported for most individual interventions. The aim of the proposed study is to assess the effect of Class IV laser therapy (LT) on pain and pinch strength in patients with thumb carpometacarpal (TCMC) OA.

METHODS

A randomized, controlled, single-centre, double-blind, clinical trial, with 1:1 allocation ratio, will be carried out involving patients presenting TCMC-OA Grades 1-2 (aged >18 years). Both assessor and statistician will remain blinded. Patients with TCMC-OA will be randomly assigned to the experimental group (will receive LT) and control group (will receive a placebo treatment). Outcome measures will be pain scores at the base of the thumb measured with visual analogue scale (0-10: 0, no pain and 10, worst pain) and changes in pinch strength, both collected at baseline, 4, and 12 weeks. Statistical analyses will be based on an intention-to-treat analysis using the last value forward method. A two-tailed independent Student's t test for the continuous variable of age and baseline scores will be used for comparison of baseline characteristics and outcome variables. Paired Student's t tests will be used to determine the level of significance of the differences between the pretreatment and posttreatment measurements of the individual groups. Repeated measures analysis of variance will be used to determine the differences in time as the within-subjects factor and group as the between-subjects factor.

DISCUSSION

To our knowledge, the results of this study will provide the first double-blinded evidence for Class IV LT in patients with TCMC-OA.

Validity, reliability, responsiveness and feasibility of four hand mobility measures in hand osteoarthritis

Objectives

To investigate metric properties of four hand mobility tests in hand OA patients, using the OMERACT filter.

Methods

Trained assessors examined the Hand Mobility in Scleroderma test (HAMIS), fingertip-to-palm distance (FPD), modified Kapandji index (MKI) and number of hand joints with limited mobility in participants from two cohorts [Genetics ARthrosis and Progression (n = 207) and Hand OSTeoArthritis in Secondary care (n = 174)]. Validity was appraised by assessment of correlations with other outcome measures, and ability to measure thumb vs finger mobility specifically, using cumulative probability plots. The proportion of participants changing in hand mobility based on the smallest detectable difference was calculated for responsiveness. Intraclass correlation coefficients (ICCs) for intra- and interobserver reliability, and feasibility (time to perform tests) were studied in a random sample (n = 20).

Results

Participants displayed large variation in mobility scores. Strongest correlations were observed with structural damage (rs = 0.43-0.52) and bony swelling (rs = 0.46-0.58); correlation patterns were similar among tests. HAMIS, FPD and MKI could all measure finger mobility specifically, but only HAMIS measured thumb mobility particularly. Interobserver reliability was best for HAMIS, ICC 0.90 (95% CI: 0.76, 0.96); intraobserver reliability was excellent for all (ICCs 0.94-0.97). In 2 years, little change was observed; HAMIS was the most sensitive-to-change (smallest detectable difference 3.7% of maximum score). The mean performance time ranged from 0.7 (s.d. 0.5, for FPD) to 5.7 (s.d. 1.3, for HAMIS) min.

Conclusion

HAMIS, FPD, MKI and number of joints with limited mobility are all valid, reliable and feasible measures for assessing hand mobility in hand OA, although HAMIS had slightly more favourable properties. Studies assessing sensitivity-to-change in a clinical trial setting are warranted.

The knitting community-based trial for older women with osteoarthritis of the hands: design and rationale of a randomized controlled trial

BACKGROUND

The prevalence of hand osteoarthritis (HOA) has been reported to be higher amongst women over 50 years old (66%) compared to men of the same age (34%). Although exercise therapy has been shown effective in reducing symptoms and disability associated with HOA, adherence to treatment programs remains low. The primary objective of this RCT is to examine the effectiveness of a 12-week knitting program for morning stiffness (primary outcome) and pain relief (secondary outcome) 2 h post-wakening in females (aged 50 to 85 years old) with mild to moderate hand osteoarthritis (HOA).

METHODS/DESIGN

A single-blind, two-arm randomized controlled trial (RCT) with a parallel group design will be used to reach this objective and compare results to a control group receiving an educational pamphlet on osteoarththritis (OA) designed by the Arthritis Society. The premise behind the knitting program is to use a meaningful occupation as the main component of an exercise program. The knitting program will include two components: 1) bi-weekly 20-min knitting sessions at a senior's club and 2) 20-min home daily knitting sessions for the five remaining weekdays. Participants assigned to the control group will be encouraged to read the educational pamphlet and continue with usual routine. Pain, morning stiffness, hand function, self-efficacy and quality of life will be measured at baseline, six weeks, 12 weeks (end of program) with standardized tools. We hypothesize that participants in the knitting program will have significant improvements in all clinical outcomes compared to the control group. A published case study as well as the preliminary results of a feasibility study as examined through a 6-week pre-post study (n = 5 women with HOA) involving 20-min daily knitting morning sessions led to this proposed randomized controlled trial research protocol. This article describes the intervention, the empirical evidence to support it.

DISCUSSION

This knitting RCT has the potential to enhance our understanding of the daily HOA symptoms control and exercise adherence, refine functional exercise recommendations in this prevalent disease, and reduce the burden of disability in older women.

TRIAL REGISTRATION

(ACTRN12617000843358) registered on 7/06/2017.

Guidelines for the conduct of pharmacological clinical trials in hand osteoarthritis: Consensus of a Working Group of the European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)

OBJECTIVES

To gather expert opinion on the conduct of clinical trials that will facilitate regulatory review and approval of appropriate efficacious pharmacological treatments for hand osteoarthritis (OA), an area of high unmet clinical need.

METHODS

The European Society on Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal diseases (ESCEO) organized a working group under the auspices of the International Osteoporosis Foundation (IOF) and the World Health Organization (WHO).

RESULTS

This consensus guideline is intended to provide a reference tool for practice, and should allow for better standardization of the conduct of clinical trials in hand OA. Hand OA is a heterogeneous disease affecting different, and often multiple, joints of the thumb and fingers. It was recognized that the various phenotypes and limitations of diagnostic criteria may make the results of hand OA trials difficult to interpret. Nonetheless, practical recommendations for the conduct of clinical trials of both symptom and structure modifying drugs are outlined in this consensus statement, including guidance on study design, execution, and analysis.

CONCLUSIONS

While the working group acknowledges that the methodology for performing clinical trials in hand OA will evolve as knowledge of the disease increases, it is hoped that this guidance will support the development of new pharmacological treatments targeting hand OA.

The effect of pregabalin or duloxetine on arthritis pain: a clinical and mechanistic study in people with hand osteoarthritis

Osteoarthritis (OA) is the most prevalent arthritis worldwide and is characterized by chronic pain and impaired physical function. We hypothesized that heightened pain in hand OA could be reduced with duloxetine or pregabalin. In this prospective, randomized clinical study, we recruited 65 participants, aged 40–75 years, with a Numerical Rating Scale (NRS) for pain of at least 5. Participants were randomized to one of the following three groups: duloxetine, pregabalin, and placebo. The primary endpoint was the NRS pain score, and the secondary endpoints included the Australian and Canadian Hand Osteoarthritis Index (AUSCAN) pain, stiffness, and function scores and quantitative sensory testing by pain pressure algometry. After 13 weeks, compared to placebo, ANOVA found significant differences between the three groups (P=0.0078). In the intention-to-treat analysis, the pregabalin group showed improvement for NRS pain (P=0.023), AUSCAN pain (P=0.008), and AUSCAN function (P=0.009), but no difference between duloxetine and placebo (P>0.05) was observed. In the per protocol analysis, NRS pain was reduced for pregabalin (P<0.0001) and duloxetine (P=0.029) compared to placebo. We conclude that centrally acting analgesics improve pain outcomes in people with hand arthritis, offering new treatment paradigms for OA pain.

Systematic review of non-surgical therapies for osteoarthritis of the hand: an update

OBJECTIVE

To update our earlier systematic reviews which evaluated all published randomized controlled trials (RCTs) evaluating pharmacological and non-pharmacological therapies in patients with hand osteoarthritis (OA). Surgical therapies were not evaluated.

DESIGN

RCTs published between March 2008 and December 2015 were added to the previous systematic reviews.

RESULTS

A total of 95 RCTs evaluating various pharmacological and non-pharmacological therapies in hand OA were analyzed in this update. Generally, the methodological quality of these RCTs has improved since the last update, with more studies describing their methods for randomization, blinding, and allocation concealment. However, RCTs continue to be weakened by a lack of consistent case definition and a lack of standardized outcome assessments specific to hand OA. The number and location of evaluated hand joints continues to be underreported, and only 25% of RCTs adequately described the method used to ensure allocation concealment. These remain major weaknesses of published RCTs. A meta-analysis could not be performed because of marked study heterogeneity, insufficient statistical data available in the published RCTs, and a small number of identical comparators.

CONCLUSION

Hand OA is a complex area in which to study the efficacy of therapies. There has been an improvement in the overall design and conduct of RCTs, however, additional large RCTs with a more robust methodological approach specific to hand OA are needed in order to make clinically relevant conclusions about the efficacy of the diverse treatment options available.

Reference curves for the Australian/Canadian Hand Osteoarthritis Index in the middle-aged Dutch population

Objective

The aim was to establish reference curves of the Australian/Canadian Hand Osteoarthritis Index (AUSCAN), a widely used questionnaire assessing hand complaints.

Methods

Analyses were performed in a population-based sample, The Netherlands Epidemiology of Obesity study (n = 6671, aged 45-65 years). Factors associated with AUSCAN scores were analysed with ordered logistic regression, because AUSCAN data were zero inflated, dividing AUSCAN into three categories (0 vs 1-5 vs >5). Age- and sex-specific reference curves for the AUSCAN (range 0-60; higher is worse) were developed using quantile regression in conjunction with fractional polynomials. Observed scores in relevant subgroups were compared with the reference curves.

Results

The median age was 56 [interquartile range (IQR): 50-61] years; 56% were women and 12% had hand OA according to ACR criteria. AUSCAN scores were low (median 1; IQR: 0-4). Reference curves where higher for women, and increased moderately with age: 95% percentiles for AUSCAN in men and women were, respectively, 5.0 and 12.3 points for a 45-year-old, and 15.2 and 33.6 points for a 65-year-old individual. Additional associated factors included hand OA, inflammatory rheumatic diseases, FM, socio-economic status and BMI. Median AUSCAN pain subscale scores of women with hand OA lay between the 75th and 90th centiles of the general population.

Conclusion

AUSCAN scores in the middle-aged Dutch population were low overall, and higher in women than in men. AUSCAN reference curves could serve as a benchmark in research and clinical practice settings. However, the AUSCAN does not measure hand complaints specific for hand OA.

Coronary heart disease is associated with a worse clinical outcome of hand osteoarthritis: a cross-sectional and longitudinal study

Objective

To determine whether cardiometabolic factors are associated with hand osteoarthritis (HOA) symptoms, radiographic severity and progression in a post hoc analysis of the phase III Strontium ranelate Efficacy in Knee OsteoarthrItis triAl (SEKOIA) trial, designed to determine the effect of strontium ranelate on knee osteoarthritis (OA).

Methods

Among the 1683 patients randomised in the SEKOIA study, 869 with radiographic HOA at baseline (rHOA≥2 joints with Kellgren-Lawrence grade ≥2) were included in a cross-sectional analysis. For longitudinal study, we included only the 307 patients with rHOA at baseline from the placebo group. We evaluated whether baseline symptomatic HOA, radiographic severity and clinical and rHOA progression were associated with coronary heart disease and/or metabolic diseases (obesity, diabetes and hypertension, dyslipidaemia) by multivariate regression analysis.

Results

At baseline, 869 patients (72% women) were included in the cross-sectional analysis; 26% were symptomatic. On multivariate analysis, symptomatic HOA was associated with coronary heart disease (OR 3.59, 95% CI (1.78 to 7.26)) but not metabolic diseases. After a mean follow-up of 2.6 years, for the 307 participants in the placebo group, on multivariate analysis, worse clinical HOA outcome was associated with coronary heart disease (OR 2.91, 95% CI (1.02 to 8.26)). The slow radiographic progression did not allow for revealing any associated factors.

Conclusions

Symptomatic HOA and worse HOA clinical course are associated with coronary heart disease. These results strengthen the systemic component of HOA and the association between OA pain and cardiac events.

Trial registration number

ISRCTN41323372.

Efficacy of combined conservative therapies on clinical outcomes in patients with thumb base osteoarthritis: protocol for a randomised, controlled trial (COMBO)

INTRODUCTION

Management of thumb base osteoarthritis (OA) using a combination of therapies is common in clinical practice; however, evidence for the efficacy of this approach is lacking. The aim of this study is to determine the effect of a combination of conservative therapies for the treatment of thumb base OA compared with an education control group.

METHODS AND ANALYSIS

This is a randomised, controlled, single-centre, two-arm superiority trial with 1:1 allocation ratio; with assessor and statistician blinded. Participants are blinded to the trial's hypothesis and to the interventions received by the opposite group. A total of 204 participants will be recruited from the community and randomised using a computer-generated schedule. The intervention group will receive education for joint protection and OA, a splint for the base of the thumb, hand exercises and topical diclofenac sodium 1% gel over 6 weeks. The control group will receive education for joint protection and OA alone. Main inclusion criteria are pain ≥40 mm (Visual Analogue Scale, 0-100) at the base of the thumb, impairment in hand function ≥6 (Functional Index for Hand Osteoarthritis, 0-30) and radiographic thumb base OA (Kellgren Lawrence grade ≥2). Participants currently receiving any of the intervention components will be excluded. Outcomes will be measured at 2, 6 and 12 weeks. The primary outcome is change in pain and hand function from baseline to 6 weeks. Other outcomes include changes in grip and pinch strength, quality of life, presence of joint swelling and tenderness, duration of joint stiffness, patient's global assessment and use of rescue medication. Analysis will be performed according to the intention-to-treat principle. Adverse events will be monitored throughout the study.

ETHICS AND DISSEMINATION

This protocol is approved by the local ethics committee (HREC/15/HAWKE/479). Dissemination will occur through presentations at international conferences and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12616000353493; Pre-results.

Automated selection of bone texture regions on hand radiographs: Data from the Osteoarthritis Initiative

Manual selection of finger trabecular bone texture regions on hand X-ray images is time-consuming, tedious, and observer-dependent. Therefore, we developed an automated method for the region selection. The method selects square trabecular bone regions of interest above and below the second to fifth distal and proximal interphalangeal joints. Two regions are selected per joint (16 regions per hand). The method consists of four integral parts: (1) segmentation of a radiograph into hand and background, (2) identification of finger regions, (3) localization of center points of heads of distal phalanges and the distal interphalangeal, proximal interphalangeal, and metacarpophalangeal joints, and (4) placement of the regions of interest under and above the distal and proximal interphalangeal joints. A gold standard was constructed from regions selected by two observers on 40 hand X-ray images taken from Osteoarthritis Initiative cohort. Datasets of 520 images were generated from the 40 images to study the effects of hand and finger positioning. The accuracy in regions selection and the agreement in calculating five directional fractal parameters were evaluated against the gold standard. The accuracy, agreement, and effects of hand and finger positioning were measured using similarity index (0 for no overlap and 1 for entire overlap) and interclass correlation coefficient as appropriate. A high accuracy in selecting regions (similarity index ≥ 0.79) and a good agreement in fractal parameters (interclass correlation coefficient ≥ 0.58) were achieved. Hand and finger positioning did not affect considerably the region selection (similarity index ≥ 0.70). These results indicate that the method developed selects bone regions on hand X-ray images with accuracy sufficient for fractal analyses of bone texture.

Imaging of osteoarthritis (OA): What is new?

In daily clinical practice, conventional radiography is still the most applied imaging technique to supplement clinical examination of patients with suspected osteoarthritis (OA); it may not always be needed for diagnosis. Modern imaging modalities can visualize multiple aspects of the joint, and depending on the diagnostic need, radiography may no longer be the modality of choice. Magnetic resonance imaging (MRI) provides a complete assessment of the joint and has a pivotal role in OA research. Computed tomography (CT) and nuclear medicine offer alternatives in research scenarios, while ultrasound can visualize bony and soft-tissue pathologies and is highly feasible in the clinic. In this chapter, we overview the recent literature on established and newer imaging modalities, summarizing their ability to detect and quantify the range of OA pathologies and determining how they may contribute to early OA diagnosis. This accurate imaging-based detection of pathologies will underpin true understanding of much needed structure-modifying therapies.

Bone marrow lesions and synovitis on MRI associate with radiographic progression after 2 years in hand osteoarthritis

OBJECTIVE

To study the association of magnetic resonance (MR) features with radiographic progression of hand osteoarthritis over 2 years.

METHODS

Of 87 primary patients with hand osteoarthritis (82% women, mean age 59 years), baseline distal and proximal interphalangeal joint contrast-enhanced MR images were scored 0-3 for bone marrow lesions (BMLs) and synovitis following the Oslo score. Baseline and 2-year follow-up radiographs were scored following Kellgren-Lawrence (KL) (0-4) and OsteoArthritis Research Society International (OARSI) scoring methods (0-3 osteophytes, joint space narrowing (JSN)). Increase ≥1 defined progression. Associations between MR features and radiographic progression were explored on joint and on patient level, adjusting for age, sex, body mass index, synovitis and BML. Joints in end-stage were excluded.

RESULTS

Of 696 analysed joints, 324 had baseline KL=0, 28 KL=4 and after 2 years 78 joints progressed. BML grade 2/3 was associated with KL progression (2/3 vs 0: adjusted risk ratio (RR) (95% CI) 3.3 (2.1 to 5.3)) and with osteophyte or JSN progression, as was synovitis. Summated scores were associated with radiographic progression on patient level (RR crude BML 1.08 (1.01 to 1.2), synovitis 1.09 (1.04 to 1.1), adjusted synovitis 1.08 (1.03 to 1.1)).

CONCLUSIONS

BMLs, next to synovitis, show, already after 2 years, graded associations with radiographic progression, suggesting that both joint tissues could be important targets for therapy.