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

Reduced pain and improved daily activities for individuals with hand osteoarthritis using a silicone wrist hand orthosis

BACKGROUND

Symptoms of hand osteoarthritis (OA), such as pain, reduced grip strength, loss of range of motion (ROM) and joint stiffness, can lead to impaired hand function and difficulty with daily activities. Rehabilitative interventions with orthoses are commonly in the treatment of hand OA to reduce pain, improve hand strength and ROM, provide support for improved function and help with joint stability.

PURPOSE

The objectives of this perception-based study were to evaluate the effect of a silicone wrist hand orthoses (SWHO) on pain and daily functioning.

STUDY DESIGN

This study is a qualitative descriptive study. The patient received outcome (PRO) questions in the study were based on the Patient Rated Wrist and/or Hand Evaluation (PRWHE), a 15-item questionnaire designed to measure wrist pain and disability in activities of daily living.

METHODS

Patients with OA using a SWHO were asked to complete a questionnaire about the effectiveness of the brace after wearing it for 3 weeks. Primary outcome measure was general daily functioning with and without the use of the SWHO. Secondary outcome measures were change in pain symptoms and limitations for certain activities with and without the aid.

RESULTS

The results of this large-scale PROM study of 551 patients on the effectiveness of SWHOs in patients with hand OA show an improvement in overall daily functioning of 77% and a 61% reduction in perceived pain. This study adds to the evidence reported by systematic reviews of conservative interventions for hand OA and further quantifies the effects of a tailor made SWHO. This study confirms that wearing a wrist orthosis has a particularly significant impact on the execution of static and repetitive wrist-straining activities.

CONCLUSION

The study on the effectiveness of a SWHO in patients with hand OA shows that the use of a SWHO contributes to general daily function, reduces pain and increases the breadth of potential daily activities. This study shows that the use of a SWHO appears to offer pain relief and suitable support to the joint.

Intra-articular triamcinolone hexacetonide injections in hands osteoarthritis ‒ A double-blinded randomized controlled trial with a one year follow-up

OBJECTIVE

to evaluate the effectiveness of triamcinolone Hexacetonide (TH) Intra-Articular Injection (IAI) in hand Interphalangeal Joints (IP) of Osteoarthritis (OA) patients to improve pain and joint swelling; improve function, goniometry, and grasping force, and assess IAI influence on radiographic evolution over 1-year.

METHODS

A randomized, double-blind study. 60 patients who underwent IAI at the most symptomatic IP joint were randomly assigned to receive TH+Lidocaine (LD) (TH/LD group) or just LD (LD group). Patients were assessed blindly for 1-year, at baseline and 1, 4, 8, 12, and 48 weeks. The following variables were assessed: articular pain and swelling, AUSCAN and COCHIN functional questionnaires, grip and pinch strength, goniometry, perception of improvement, acetaminophen consumption, and simple radiography. Repeated-measures ANOVA test was used to analyze the intervention response.

RESULTS

Sixty patients completed the follow-up. There were nine missed assessments. 97% were women; mean age of 61-years (SD = 8.2), and approximately 5-years of disease (SD = 3.6). Half of the patients present radiographic classification Kellgren and Lawrence (KL) grades I and II, and the other half grades III and IV. The two groups evolved similarly at 48-weeks. TH/LD group had a better evaluation in joint swelling and acetaminophen consumption (p = 0.04 and p < 0.001, respectively) at 48-weeks. Radiographically there was no statistical difference between groups (KL, p = 0.564; erosive OA, p = 0.999; worsening, p = 0.573).

CONCLUSION

The IAI IP hands OA is effective for the improvement of joint swelling and decrease of analgesic consumption and does not influence the radiographic evolution of the injected joint.

Comparison of efficacy of fluidotherapy and paraffin bath in hand osteoarthritis: A randomized controlled trial

Objectives

This study aims to compare the efficacy of paraffin bath therapy and fluidotherapy on pain, hand muscle strength, functional status, and quality of life (QoL) in patients with hand osteoarthritis (OA).

Patients and methods

This prospective randomized controlled study included 77 patients (8 males, 69 females; mean age: 63.1±10.3 years; range 39 to 88 years) with primary hand OA who applied between July 2017 and March 2018. The patients were randomized into two groups with the sealed envelope method: Paraffin bath therapy (20 min, one session per day, for two weeks) was applied for 36 patients whereas 41 patients received fluidotherapy for the same period. The pain severity of the patients, both at rest and during activities of daily living (ADL) within the last 48 hours was questioned and scored using Visual Analog Scale. Duruöz Hand Index (DHI) was used to evaluate hand functions. Gross grip strength was measured using Jamar dynamometer whereas fine grip strength was measured using pinch meter in three different positions (lateral pinch, tip pinch, and palmar pinch). The 36-Item Short Form (SF-36) was used to analyze the QoL. All measurements were performed before, immediately after, and three months after treatment.

Results

Improvement was observed in pain score at rest and during ADL, DHI scores, gross and fine grip strengths, and SF-36 subscores in both groups after treatment. However, no significant difference was observed between the groups.

Conclusion

Both fluidotherapy and paraffin bath therapy have been found to have positive effects on pain, hand muscle strength, functional status, and QoL in the treatment of hand OA. However, no superiority was observed between the two treatment modalities.

Effects of a progressive resistance exercise program in patients with hand osteoarthritis: A randomized, controlled trial with a blinded assessor

OBJECTIVE

To assess the effectiveness of a progressive resistance strength program on pain, function and strength in hand osteoarthritis patients.

DESIGN

Randomized controlled trial.

SETTINGS

Outpatients, University Hospital.

SUBJECTS

Sixty hand osteoarthritis patients were randomly allocated to exercise group (n = 30) or control group (n = 30).

INTERVENTION

The exercise group performed a progressive resistance strength program for hand muscles over 12 weeks. Both groups had a single education session.

MAIN MEASURES

The primary outcome was pain intensity (numeric pain scale). The secondary outcomes were - AUSCAN Hand Osteoarthritis Index, Cochin Hand Functional Scale for function and grip and pinch strength. A blinded evaluator performed the evaluations at baseline, 6 and 12 weeks.

RESULTS

The mean age were 68.9 (8.8) and 64.7 (8.9) for control and exercise groups, respectively. No significant differences between-group was observed for pain after 12 weeks (mean difference between groups was -1.30 (-0.02 to 2.62) for dominant hand and -1.33 (0.01-2.65) for non-dominant hand at T12, with P = 0.085 and 0.295, respectively). Regarding secondary outcomes, statistically significant differences between groups were found in exercise group: AUSCAN index - total score (P = 0.005), pain (P = 0.006), function (P = 0.047), and Cochin scale (P = 0.042) with the following mean difference between groups: -9.9 (4.07-15.73), -3.26 (1.06-5.46), -5.03 (1.20-8.86), and -6.27 (0.18-12.36), respectively.

CONCLUSION

No difference was observed for pain (numerical pain scale) after the progressive resistance exercise program performed, however in exercise group, an improvement was observed on secondary outcomes such as pain during activities and function for patients with hand osteoarthritis.

LEVEL OF EVIDENCE

1b.

Equivalent PROMIS Scores after Nonoperative or Operative Treatment of Trapeziometacarpal Osteoarthritis

Background

Patient-Reported Outcomes Measurement Information System (PROMIS) scores can quantify symptoms and limitations after upper extremity surgery. Our objective was to determine how these scores compare amongst patients with trapeziometacarpal osteoarthritis treated either nonoperatively or operatively.

Methods

In this retrospective comparative study, we compared PROMIS scores (upper extremity function [UEF], pain interference, and depression) between 43 patients who underwent nonoperative treatment (nonsteroidal anti-inflammatory drugs/splinting/injections) and 33 patients who underwent trapeziectomy with ligament reconstruction and tendon interposition for trapeziometacarpal osteoarthritis (minimum 6-month recovery period) by 4 surgeons from 2014-2018. PROMIS scores were compared across all patients by Eaton-Littler staging. We used linear regression to assess correlations between time-since-surgery and each PROMIS domain. Multivariable linear regression was used to identify patient and disease factors independently associated with PROMIS scores.

Results

Surgery was not associated with better UEF (37 vs. 40, P=0.23), less pain interference (58 vs. 56, P=0.42), or fewer symptoms of depression (47 vs. 46, P=0.59). Similarly, no differences were observed across all patient by Eaton-Littler stage for UEF (P=0.49), pain (P=0.48), or depression (P=0.90). For the operative group, greater time-since-surgery, or patient recovery period, correlated moderately with worse UEF (R=0.41) and increased pain (R=0.37).

Conclusion

In small retrospective comparative cohorts, surgery was not associated with better UEF, pain, or depression scores compared with nonoperative treatment for trapeziometacarpal osteoarthritis.

Development of classification criteria for hand osteoarthritis: comparative analyses of persons with and without hand osteoarthritis

OBJECTIVES

Further knowledge about typical hand osteoarthritis (OA) characteristics is needed for the development of new classification criteria for hand OA.

METHODS

In a cross-sectional multi-centre international study, a convenience sample of patients from primary and secondary/tertiary care with a physician-based hand OA diagnosis (n = 128) were compared with controls with hand complaints due to inflammatory or non-inflammatory conditions (n = 70). We examined whether self-reported, clinical, radiographic and laboratory findings were associated with hand OA using logistic regression analyses. Discrimination between groups was assessed by calculating the area under receiver operating curves (AUC).

RESULTS

Strong associations with hand OA were observed for radiographic osteophytes (OR = 1.62, 95% CI 1.40 to 1.88) and joint space narrowing (JSN) (OR = 1.57, 95% CI 1.36 to 1.82) in the distal interphalangeal (DIP) joints with excellent discrimination (AUC = 0.82 for both). For osteophytes and JSN, we found acceptable discrimination between groups in the proximal interphalangeal joints (AUC = 0.77 and 0.78, respectively), but poorer discrimination in the first carpometacarpal joints (AUC = 0.67 and 0.63, respectively). Painful DIP joints were associated with hand OA, but were less able to discriminate between groups (AUC = 0.67). Age and family history of OA were positively associated with hand OA, whereas negative associations were found for pain, stiffness and soft tissue swelling in metacarpophalangeal joints, pain and marginal erosions in wrists, longer morning stiffness, inflammatory biomarkers and autoantibodies.

CONCLUSIONS

Differences in symptoms, clinical findings, radiographic changes and laboratory tests were found in patients with hand OA versus controls. Radiographic OA features, especially in DIP joints, were best suited to discriminate between groups.

Study of Medical Ultrasound for Rhizarthrosis (SUR): study protocol for a randomized controlled single-center pilot-trial

BACKGROUND

Rhizarthrosis (trapeziometacarpal osteoarthritis) is the second most common site of osteoarthritis in the hand affecting 10-30% of adults over the age of 50. Up to four times as many women as men have rhizarthrosis. Clinical symptoms include functional disability of the thumb, pain, joint swelling, and reduced strength. The first carpometacarpal joint is pivotal in the opposition of the thumb and allows a high degree in flexibility to humans. Current therapies focus mainly on surgical strategies, which should be considered in advanced, therapy-resistant stages to relieve pain and improve function. However, conservative treatment methods are urgently required in presurgical stages. The efficacy of conservative treatment options for rhizarthrosis, which are intended to preserve function, joint integrity and to relieve pain, has not been adequately studied. In the clinical study protocol presented here, we investigate the efficacy of multimodal hand therapy versus therapeutic ultrasound versus combination therapy with both hand therapy and therapeutic ultrasound.

METHODS

This study is a single-center, randomized, controlled, parallel-group pilot trial. One hundred fifty patients with rhizarthrosis and current disease activity will be randomized to one of three conservative interventions over 6 months. Interventions are (1) multimodal hand therapy (2) therapeutic ultrasound, and (3) combination therapy with both hand therapy and ultrasound therapy. The primary outcome measure is the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score after 6 months. Secondary endpoints are changes in pain, quality of life, disability progression, and changes of hand function. Safety will also be assessed.

DISCUSSION

Clinical data suggest that multimodal hand therapy may improve functionality and reduce pain in rhizarthrosis. Clinical data regarding therapeutic ultrasound are not available. Clinical evidence is lacking. This study is the first clinical study investigating the effects of multimodal hand therapy in direct comparison to therapeutic ultrasound and to a combination therapy with both hand therapy and ultrasound therapy for rhizarthrosis.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT04115085; Registered on September 30, 2019.

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.

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.

Orthosis for rhizarthrosis: A systematic review and meta-analysis

OBJECTIVE

investigating the effectiveness of orthosis for rhizarthrosis by means of a systematic review and meta-analysis.

METHODS

A systematic review was carried out using eight electronic databases. The randomized controlled trials included were those presenting subjects using orthosis for rhizarthrosis compared with individuals without orthosis or other rehabilitation interventions, as well as studies that compared different types of orthosis. The systematic review was performed according to the Cochrane methodology. The statistical software Review Manager 5.3 was employed to analyze the data.

RESULTS

Fourteen studies were included in the review and three of them participated in the meta-analysis. The orthosis group had a reduction in pain in the long term as compared to the control group with a statistically significant difference, a medium effect size, and low-quality evidence [Effect size -0.52, Confidence Interval 95% -0.94 to -0.11, p = 0.01), I²= 50%]. The orthosis group presented improvements regarding function in the long term as compared to control group, with a statistically significant difference, a medium effect size, and moderate quality of evidence [Effect size -0.44, Confidence Interval 95% -0.72 to -0.15, p = 0.002), I²= 0%].

CONCLUSION

the orthosis for rhizarthrosis presents low-quality evidence for reducing pain in the long term and moderate evidence for an increase in function in the long term. Since imprecision and inconsistency of the data were aspects which influenced the quality of the evidence, future studies with larger samples and standardized data are needed.

Thumb Basal Joint Arthritis

The thumb basal joint is the second most common site of osteoarthritis in the hand, and osteoarthritis of this joint can contribute to painful movement and debilitating function. To achieve a high degree of prehensile and manipulative function, this highly mobile joint is constrained by both the saddle morphology of the trapezium and a stout complement of ligamentous constraints. The disease proceeds progressively with several wear patterns. Substantial new biomechanical and longitudinal clinical studies have changed some of the prevailing opinions on the process of serial degenerative changes. Diagnosis is made with a thorough clinical examination and radiographic staging, as described by Eaton and Littler. Thumb basal joint arthritis can be initially managed with medications, orthoses, and steroid injections; however, it frequently progresses despite these interventions. Surgical management commonly consists of trapeziectomy with or without interposition or suspension, arthroplasty with implant, volar ligament reconstruction, osteotomy, or arthrodesis; none of these techniques has been proved to be superior to the others.

A Pulsed Electrical Joint Stimulator for the Treatment of Osteoarthritis of the Hand and Wrist

The hand is commonly affected by osteoarthritis (OA). The development and progression of OA are believed to involve inflammation, even in the early stages of the disease. Inflammatory and proinflammatory cytokines have also been shown to be elevated in the flexor tenosynovium of idiopathic carpal tunnel syndrome (CTS). A large percentage of patients with hand OA also have a concomitant CTS. This study evaluated the results of a pulsed electrical joint stimulator in patients who had hand OA with or without CTS. Pain, tenderness, and swelling; grip strength and pinch force; and Patient and Physician Global Assessment and Disabilities of the Arm, Shoulder and Hand (DASH) results were evaluated. The primary efficacy outcome was pain due to OA in the study hand in the past 48 hours. Secondary outcomes consisted of OA pain in the study thumb in the past 48 hours, grip strength, pinch force, and Patient and Physician Global Assessment and DASH results. All 7 outcome parameters improved in OA patients. On physical examination, individual finger and wrist joints had also improved regarding pain, swelling, and tenderness. In the subset of patients with CTS, CTS pain, paresthesia, weakness, and all CTS symptoms had significantly improved. Patient and Physician Global Assessment and DASH results and pinch force were also significantly improved. This pulsed electrical joint stimulator is effective in providing clinically relevant and statistically significant reductions in the signs and symptoms of OA of the hand and CTS. It could be a useful modality for the treatment of patients who have one of these conditions or both. [Orthopedics. 2018; 41(4):e550-e556.].

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.

Improved Hand Function, Self-Rated Health, and Decreased Activity Limitations: Results After a Two-Month Hand Osteoarthritis Group Intervention

OBJECTIVE

To evaluate the effects on hand function, activity limitations, and self-rated health of a primary care hand osteoarthritis (OA) group intervention. Hand OA causes pain, impaired mobility, and reduced grip force, which cause activity limitations. OA group interventions in primary care settings are sparsely reported.

METHODS

Sixty-four individuals with hand OA agreed to participate; 15 were excluded due to not fulfilling the inclusion criteria. The 49 remaining (90% female) participated in an OA group intervention at a primary care unit with education, paraffin wax bath, and hand exercise over a 6-week period. Data were collected at baseline, end of intervention, and after 1 year. Instruments used were the Grip Ability Test (GAT), the Signals of Functional Impairment (SOFI), dynamometry (grip force), hand pain at rest using a visual analog scale (VAS), the Patient-Specific Functional Scale (PSFS), the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH), and the EuroQol VAS (EQ VAS). Data were analyzed using nonparametric statistics.

RESULTS

Hand function, activity limitation, and self-rated health significantly improved from baseline to end of intervention, grip force (right hand: P < 0.001; left hand: P = 0.008), SOFI (P = 0.011), GAT (P < 0.001), hand pain at rest (P < 0.001), PSFS (1: P = 0.008, 2: P < 0.001, and 3: P = 0.004), Quick-DASH (P = 0.001), and EQ VAS (P = 0.039), and the effects were sustained after 1 year.

CONCLUSION

The hand OA group intervention in primary care improves hand function, activity limitation, and self-rated health. The benefits are sustained 1 year after completion of the intervention.

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.

Exercise for Hand Osteoarthritis: A Cochrane Systematic Review

OBJECTIVE

To assess the benefits and harms of exercise compared with other interventions, including placebo or no intervention, in people with hand osteoarthritis (OA).

METHODS

Systematic review using Cochrane Collaboration methodology. Six electronic databases were searched up until September 2015.

INCLUSION CRITERIA

randomized or controlled clinical trials comparing therapeutic exercise versus no exercise, or comparing different exercise programs.

MAIN OUTCOMES

hand pain, hand function, finger joint stiffness, quality of life, adverse events, and withdrawals because of adverse effects. Risk of bias and quality of the evidence were assessed.

RESULTS

Seven trials were included in the review, and up to 5 trials (n = 381) were included in the pooled analyses with data from postintervention. Compared to no exercise, low-quality evidence indicated that exercise may improve hand pain [5 trials, standardized mean difference (SMD) -0.27, 95% CI -0.47 to -0.07], hand function (4 trials, SMD -0.28, 95% CI -0.58 to 0.02), and finger joint stiffness (4 trials, SMD -0.36, 95% CI -0.58 to -0.15) in people with hand OA. Quality of life was evaluated by 1 study (113 participants) showing very low-quality evidence for no difference. Three studies reported on adverse events, which were very few and not severe.

CONCLUSION

Pooled results from 5 studies with low risk of bias showed low-quality evidence for small to moderate beneficial effects of exercise on hand pain, function, and finger joint stiffness postintervention. Estimated effect sizes were small, and whether they represent a clinically important change may be debated.

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.

The effects of resistance training on muscle strength, joint pain, and hand function in individuals with hand osteoarthritis: a systematic review and meta-analysis

Background

Hand osteoarthritis is a common condition characterised by joint pain and muscle weakness. These factors are thought to contribute to ongoing disability. Some evidence exists that resistance training decreases pain, improves muscle strength, and enhances function in people with knee and hip osteoarthritis. However, there is currently a lack of consensus regarding its effectiveness in people with hand osteoarthritis. Therefore, the aim of this systematic review and meta-analysis was to establish whether resistance training in people with hand osteoarthritis increases grip strength, decreases joint pain, and improves hand function.

Methods

Seven databases were searched from 1975 until July 1, 2016. Randomised controlled trials were included. The Cochrane Risk of Bias Tool was used to assess studies’ methodological quality. The Grade of Recommendations Assessment, Development, and Evaluation system was adopted to rate overall quality of evidence. Suitable studies were pooled using a random-effects meta-analysis.

Results

Five studies were included with a total of 350 participants. The majority of the training programs did not meet recommended intensity, frequency, or progression criteria for muscle strengthening. There was moderate-quality evidence that resistance training does not improve grip strength (mean difference = 1.35; 95% confidence interval (CI) = –0.84, 3.54; I² = 50%; p = 0.23 ). Low-quality evidence showed significant improvements in joint pain (standardised mean difference (SMD) = –0.23; 95% CI = –0.42, –0.04; I² = 0%; p = 0.02) which were not clinically relevant. Low-quality evidence demonstrated no improvements in hand function following resistance training (SMD = –0.1; 95% CI = –0.33, 0.13; I² = 28%; p = 0.39).

Conclusion

There is no evidence that resistance training has a significant effect on grip strength or hand function in people with hand osteoarthritis. Low-quality evidence suggests it has a small, clinically unimportant pain-relieving effect. Future studies should investigate resistance training regimes with adequate intensity, frequency, and progressions to achieve gains in muscle strength.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1348-3) contains supplementary material, which is available to authorized users.

PANLAR Consensus Recommendations for the Management in Osteoarthritis of Hand, Hip, and Knee

OBJECTIVE

The objective of this consensus is to update the recommendations for the treatment of hand, hip, and knee osteoarthritis (OA) by agreeing on key propositions relating to the management of hand, hip, and knee OA, by identifying and critically appraising research evidence for the effectiveness of the treatments and by generating recommendations based on a combination of the available evidence and expert opinion of 18 countries of America.

METHODS

Recommendations were developed by a group of 48 specialists of rheumatologists, members of other medical disciplines (orthopedics and physiatrists), and three patients, one for each location of OA. A systematic review of existing articles, meta-analyses, and guidelines for the management of hand, hip, and knee OA published between 2008 and January 2014 was undertaken. The scores for Level of Evidence and Grade of Recommendation were proposed and fully consented within the committee based on The American Heart Association Evidence-Based Scoring System. The level of agreement was established through a variation of Delphi technique.

RESULTS

Both "strong" and "conditional" recommendations are given for management of hand, hip, and knee OA and nonpharmacological, pharmacological, and surgical modalities of treatment are presented according to the different levels of agreement.

CONCLUSIONS

These recommendations are based on the consensus of clinical experts from a wide range of disciplines taking available evidence into account while balancing the benefits and risks of nonpharmacological, pharmacological, and surgical treatment modalities, and incorporating their preferences and values. Different backgrounds in terms of patient education or drug availability in different countries were not evaluated but will be important.

X-ray Guided Steroid Injections for Proximal Interphalangeal Joint Osteoarthritis of the Fingers

BACKGROUND

Osteoarthritis of the finger proximal interphalangeal joints (PIPJ's) is common and severely limits hand function. Intra-articular steroid injections are frequently used, but there is little research assessing this treatment option.

METHODS

This was a prospective audit of patients undergoing intra-articular steroid injections into the PIPJ under image intensifier guidance. The aims were to assess the duration of pain relief, hand function and range of movement following this procedure. Fifty injected joints were followed up at six weeks, three and six months.

RESULTS

There were significant improvements in both pain scores and the range of movement for up to three months. Analgesia requirements decreased and hand function improved up to three months. By six months, patients were approaching their preinjection scores.

CONCLUSIONS

X-ray guided injections are a simple procedure which can be effectively performed in the out- patient setting, resulting in satisfied patients with improved hand function and pain scores.

Effects of client-centered multimodal treatment on impairment, function, and satisfaction of people with thumb carpometacarpal osteoarthritis

STUDY DESIGN

Prepost design.

INTRODUCTION

Previous research regarding the non-surgical treatment of thumb carpometacarpal joint osteoarthritis has been based on protocol driven research designs that primarily examined impairment level changes. Exploration is therefore needed to determine the benefits of individually prescribed orthoses, joint protection and assistive device education programs that are based on the activities the person needs to regularly perform.

PURPOSE OF THE STUDY

The primary objective of this study was to examine the effect of client-centered multimodal treatment on activity, participation, impairment, and satisfaction of people with thumb carpometacarpal joint osteoarthritis.

METHODS

A total of 60 participants completed the study that used a prepost design. The Canadian Occupational Performance Measure (COPM) was used to identify the participants' performance and satisfaction concerning their self-identified occupational performance issues. Additional outcome measures that were used included the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, total active range of motion (TAROM), lateral pinch strength, and the visual analog scale for pain. All participants completed a client-centered 6-week program that consisted of the use of an orthosis, joint protection, and assistive device education as well as exercises.

RESULTS

At 6 weeks after initiation of treatment, pain, pinch strength, TAROM, the DASH questionnaire and the performance and satisfaction scales of the COPM had significantly improved. The changes in pain, TAROM, and the performance and satisfaction scales of the COPM were all greater than the minimal clinically important difference. The changes in pain and lateral pinch strength were significantly associated with changes in activity and participation.

DISCUSSION

This study demonstrated that a multimodal, client-centered treatment approach resulted in statistically and clinically significant improvement in pain, TAROM and performance and satisfaction as measured by the COPM. The improvement in pain was associated with the participants' improved ability to engage in activities assessed by the DASH.

CONCLUSIONS

Our results support the use of client-centered treatment strategies that are targeted to control pain during meaningful activity when working with patients with thumb carpometacarpal joint osteoarthritis therapists.

LEVEL OF EVIDENCE

4.

Exercise for hand osteoarthritis

BACKGROUND

Hand osteoarthritis (OA) is a prevalent joint disease that may lead to pain, stiffness and problems in performing hand-related activities of daily living. Currently, no cure for OA is known, and non-pharmacological modalities are recommended as first-line care. A positive effect of exercise in hip and knee OA has been documented, but the effect of exercise on hand OA remains uncertain.

OBJECTIVES

To assess the benefits and harms of exercise compared with other interventions, including placebo or no intervention, in people with hand OA. Main outcomes are hand pain and hand function.

SEARCH METHODS

We searched six electronic databases up until September 2015.

SELECTION CRITERIA

All randomised and controlled clinical trials comparing therapeutic exercise versus no exercise or comparing different exercise programmes.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, assessed risk of bias and assessed the quality of the body of evidence using the GRADE approach. Outcomes consisted of both continuous (hand pain, physical function, finger joint stiffness and quality of life) and dichotomous outcomes (proportions of adverse events and withdrawals).

MAIN RESULTS

We included seven studies in the review. Most studies were free from selection and reporting bias, but one study was available only as a congress abstract. It was not possible to blind participants to treatment allocation, and although most studies reported blinded outcome assessors, some outcomes (pain, function, stiffness and quality of life) were self-reported. The results may be vulnerable to performance and detection bias owing to unblinded participants and self-reported outcomes. Two studies with high drop-out rates may be vulnerable to attrition bias. We downgraded the overall quality of the body of evidence to low owing to potential detection bias (lack of blinding of participants on self-reported outcomes) and imprecision (studies were few, the number of participants was limited and confidence intervals were wide for the outcomes pain, function and joint stiffness). For quality of life, adverse events and withdrawals due to adverse events, we further downgraded the overall quality of the body of evidence to very low because studies were very few and confidence intervals were very wide.Low-quality evidence from five trials (381 participants) indicated that exercise reduced hand pain (standardised mean difference (SMD) -0.27, 95% confidence interval (CI) -0.47 to -0.07) post intervention. The absolute reduction in pain for the exercise group, compared with the control group, was 5% (1% to 9%) on a 0 to 10 point scale. Pain was estimated to be 3.9 points on this scale (0 = no pain) in the control group, and exercise reduced pain by 0.5 points (95% CI 0.1 to 0.9; number needed to treat for an additional beneficial outcome (NNTB) 9).Four studies (369 participants) indicated that exercise improved hand function (SMD -0.28, 95% CI -0.58 to 0.02) post intervention. The absolute improvement in function noted in the exercise group, compared with the control group, was 6% (0.4% worsening to 13% improvement). Function was estimated at 14.5 points on a 0 to 36 point scale (0 = no physical disability) in the control group, and exercise improved function by 2.2 points (95% CI -0.2 to 4.6; NNTB 9).One study (113 participants) evaluated quality of life, and the effect of exercise on quality of life is currently uncertain (mean difference (MD) 0.30, 95% CI -3.72 to 4.32). The absolute improvement in quality of life for the exercise group, compared with the control group, was 0.3% (4% worsening to 4% improvement). Quality of life was 50.4 points on a 0 to 100 point scale (100 = maximum quality of life) in the control group, and the mean score in the exercise group was 0.3 points higher (3.5 points lower to 4.1 points higher).Four studies (369 participants) indicated that exercise reduced finger joint stiffness (SMD -0.36, 95% CI -0.58 to -0.15) post intervention. The absolute reduction in finger joint stiffness for the exercise group, compared with the control group, was 7% (3% to 10%). Finger joint stiffness was estimated at 4.5 points on a 0 to 10 point scale (0 = no stiffness) in the control group, and exercise improved stiffness by 0.7 points (95% CI 0.3 to 1.0; NNTB 7).Three studies reported intervention-related adverse events and withdrawals due to adverse events. The few reported adverse events consisted of increased finger joint inflammation and hand pain. Low-quality evidence from the three studies showed an increased likelihood of adverse events (risk ratio (RR) 4.55, 95% CI 0.53 to 39.31) and of withdrawals due to adverse events in the exercise group compared with the control group (RR 2.88, 95% CI 0.30 to 27.18), but the effect is uncertain and further research may change the estimates.Included studies did not measure radiographic joint structure changes. Two studies provided six-month follow-up data (220 participants), and one (102 participants) provided 12-month follow-up data. The positive effect of exercise on pain, function and joint stiffness was not sustained at medium- and long-term follow-up.The exercise intervention varied largely in terms of dosage, content and number of supervised sessions. Participants were instructed to exercise two to three times a week in four studies, daily in two studies and three to four times daily in another study. Exercise interventions in all seven studies aimed to improve muscle strength and joint stability or function, but the numbers and types of exercises varied largely across studies. Four studies reported adherence to the exercise programme; in three studies, this was self-reported. Self-reported adherence to the recommended frequency of exercise sessions ranged between 78% and 94%. In the fourth study, 67% fulfilled at least 16 of the 18 scheduled exercise sessions.

AUTHORS' CONCLUSIONS

When we pooled results from five studies, we found low-quality evidence showing small beneficial effects of exercise on hand pain, function and finger joint stiffness. Estimated effect sizes were small, and whether they represent a clinically important change may be debated. One study reported quality of life, and the effect is uncertain. Three studies reported on adverse events, which were very few and were not severe.

Does occupational therapy reduce the need for surgery in carpometacarpal osteoarthritis? Protocol for a randomized controlled trial

BACKGROUND

In the absence of disease-modifying interventions for hand osteoarthritis (OA), occupational therapy (OT) comprising patient education, hand exercises, assistive devices and orthoses are considered as core treatments, whereas surgery are recommended for those with severe carpometacarpal (CMC1) OA. However, even though CMC1 surgery may reduce pain and improve function, the risk of adverse effects is high, and randomized controlled trials comparing surgery with non-surgical interventions are warranted. This multicentre randomized controlled trial aims to address the following questions: Does OT in the period before surgical consultation reduce the need for surgery in CMC1-OA? What are patients' motivation and reasons for wanting CMC1-surgery? Are there differences between departments of rheumatology concerning the degree of CMC1-OA, pain and functional limitations in patients who are referred for surgical consultation for CMC1 surgery? Is the Measure of Activity Performance of the Hand a reliable measure in patients with CMC1-OA? Do patients with CMC1-OA with and without affection of the distal and proximal interphalangeal finger joints differ with regard to symptoms and function? Do the degree of CMC1-OA, symptoms and functional limitations significantly predict improvement after 2 years following OT or CMC1-surgery? Is OT more cost-effective than surgery in the management of CMC1-OA?

METHODS/DESIGN

All persons referred for surgical consultation due to their CMC1-OA at one of three Norwegian departments of rheumatology are invited to participate. Those who agree attend a clinical assessment and report their symptoms, function and motivation for surgery in validated outcome measures, before they are randomly selected to receive OT in the period before surgical consultation (estimated n = 180). The primary outcome will be the number of participants in each group who have received surgical treatment after 2 years. Secondary and tertiary outcomes are pain, function and satisfaction with care over the 2-year trial period. Outcomes will be collected at baseline, 4, 18 and 24 months. The main analysis will be on an intention-to-treat basis, using logistic regression, comparing the number of participants in each group who have received surgical treatment after 2 years.

DISCUSSION

The findings will improve the evidence-based management of HOA.

TRIAL REGISTRATION IDENTIFIER

NCT01794754 . First registrated February 15^th 2013.

May spa therapy be a valid opportunity to treat hand osteoarthritis? A review of clinical trials and mechanisms of action

Osteoarthritis (OA) is the most common form of arthritis and its current treatment includes non-pharmacological and pharmacological modalities. Spa therapy represents a popular treatment for many rheumatic diseases. The aim of this review was to summarize the currently available information on clinical effects and mechanisms of action of spa therapy in OA of the hand. We conducted a search of the literature to extract articles describing randomized clinical trials (RCTs) in hand OA published in the period 1952-2015. We identified three assessable articles reporting RCTs on spa therapy in hand OA. Data from these clinical trials support a beneficial effect of spa therapy on pain, function and quality of life in hand OA. Spa therapy seems to have a role in the treatment of hand OA. However, additional RCTs are necessary to clarify the mechanisms of action and the effects of the application of thermal treatments.

Efficacy and safety of topical NSAIDs in the management of osteoarthritis: Evidence from real-life setting trials and surveys

Topical non-steroidal anti-inflammatory drugs (NSAIDs) are recommended in international and national guidelines as an early treatment option for the symptomatic management of knee and hand osteoarthritis (OA), and may be used ahead of oral NSAIDs due to their superior safety profile. The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) treatment algorithm recommends topical NSAIDs for knee OA in addition to the pharmacological background of symptomatic slow-acting drugs for osteoarthritis (SYSADOAs) and rescue analgesia with paracetamol and non-pharmacological treatment, if the patient is still symptomatic. Topical NSAIDs have a moderate effect on pain relief, with efficacy similar to that of oral NSAIDs, with the advantage of a better risk:benefit ratio. In real-life studies, topical and oral NSAIDs demonstrate an equivalent effect on knee pain over 1 year of treatment, with fewer adverse events due to lower systemic absorption of topical NSAIDs compared with oral NSAIDs. As a result, topical NSAIDs may be the preferred treatment option, especially in OA patients aged ≥75 years, and those with co-morbidities or at an increased risk of cardiovascular, gastrointestinal, or renal side effects. Furthermore, using topical NSAIDs in inflammatory rheumatic diseases leads to a 40% reduction in the need for concomitant oral NSAIDs. When selecting a topical NSAID, absorption and bioavailability are important because of heterogeneity among topical drug formulations. Molecules like etofenamate have a bioavailability of >20% and evidence for accumulation in synovial tissues, with efficacy demonstrated as improvement in pain and function in real-life studies of OA patients. Diclofenac also shows good efficacy alongside evidence that diclofenac accumulates in the synovium.

Instruments Measuring Pain, Physical Function, or Patient’s Global Assessment in Hand Osteoarthritis: A Systematic Literature Search

Objective.

Description of use and metric properties of instruments measuring pain, physical function, or patient’s global assessment (PtGA) in hand osteoarthritis (OA).

Methods.

Medical literature databases up to January 2014 were systematically reviewed for studies reporting on instruments measuring pain, physical function, or PtGA in hand OA. The frequency of the use of these instruments were described, as well as their metric properties, including discrimination (reliability, sensitivity to change), feasibility, and validity.

Results.

In 66 included studies, various questionnaires and performance- or assessor-based instruments were applied for evaluation of pain, physical function, or PtGA. No major differences regarding metric properties were observed between the instruments, although the amount of supporting evidence varied. The most frequently evaluated questionnaires were the Australian/Canadian Hand OA Index (AUSCAN) pain subscale and visual analog scale (VAS) pain for pain assessment, and the AUSCAN function subscale and Functional Index for Hand OA (FIHOA) for physical function assessment. Excellent reliability was shown for the AUSCAN and FIHOA, and good sensitivity to change for all mentioned instruments; additionally, the FIHOA had good feasibility. Good construct validity was suggested for all mentioned questionnaires. The most commonly applied performance- or assessor-based instruments were the grip and pinch strength for the assessment of physical function, and the assessment of pain by palpation. For these measures, good sensitivity to change and construct validity were established.

Conclusion.

The AUSCAN, FIHOA, VAS pain, grip and pinch strength, and pain on palpation were most frequently used and provided most supporting evidence for good metric properties. More research has to be performed to compare the different instruments with each other.

The effectiveness of the Push Brace™ orthosis and corticosteroid injection for managing first carpometacarpal joint osteoarthritis: A factorial randomised controlled trial protocol

Introduction

Various conservative treatments for first carpometacarpal joint osteoarthritis have been reported. We aim to investigate the short-term effectiveness of conservative management interventions used to improve pain and function for adults with first carpometacarpal joint arthritis in a randomised controlled trial.

Methods

A pragmatic 2 × 2 factorial randomised controlled trial will be conducted. This randomised controlled trial will have one control group (hand therapy) and three intervention groups. Interventions will include Push Brace™ orthosis and hand therapy, ultrasound-guided intra-articular corticosteroid injection and hand therapy and a combination of all three interventions. A total of 276 participants will be recruited for the trial. The primary outcomes will be pain (reported using a Visual Analogue Scale) and function (using the Patient Rated Wrist/Hand Evaluation). Secondary outcomes will include osteoarthritis specific function, pinch strength, global change and quality of life. Adverse events and complications will be reported. Outcomes assessments will be completed prior to the intervention and at 3, 6, 12 and 24 months post-intervention. The trial will be conducted at a private hand surgery clinic in Queensland, Australia.

Conclusions

Results from this trial will contribute to the evidence on conservative management of first carpometacarpal osteoarthritis.

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

Hand osteoarthritis (OA) is a very frequent disease, but yet understudied. However, a lot of works have been published in the past 10 years, and much has been done to better understand its clinical course and structural progression. Despite this new knowledge, few therapeutic trials have been conducted in hand OA. The last OARSI recommendations for the conduct of clinical trials in hand OA dates back to 2006. The present recommendations aimed at updating previous recommendations, by incorporating new data. The purpose of this expert opinion, consensus driven exercise is to provide evidence-based guidance on the design, execution and analysis of clinical trials in hand OA, where published evidence is available, supplemented by expert opinion, where evidence is lacking, to perform clinical trials in hand OA, both for symptom and for structure-modification. They indicate core outcome measurement sets for studies in hand OA, and list the methods and instruments that should be used to measure symptoms or structure. For both symptom- and structure-modification, at least pain, physical function, patient global assessment, HR-QoL, joint activity and hand strength should be assessed. In addition, for structure-modification trials, structural progression should be measured by radiographic changes. We also provide a research agenda listing many unsolved issues that seem to most urgently need to be addressed from the perspective of performing "good" clinical trials in hand OA. These updated OARSI recommendations should allow for better standardizing the conduct of clinical trials in hand OA in the next future.

Test-retest reliability and convergent validity of a computer based hand function test protocol in people with arthritis

OBJECTIVES

A computer based hand function assessment tool has been developed to provide a standardized method for quantifying task performance during manipulations of common objects/tools/utensils with diverse physical properties and grip/grasp requirements for handling. The study objectives were to determine test-retest reliability and convergent validity of the test protocol in people with arthritis.

METHODS

Three different object manipulation tasks were evaluated twice in forty people with rheumatoid arthritis (RA) or hand osteoarthritis (HOA). Each object was instrumented with a motion sensor and moved in concert with a computer generated visual target. Self-reported joint pain and stiffness levels were recorded before and after each task. Task performance was determined by comparing the object movement with the computer target motion. This was correlated with grip strength, nine hole peg test, Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire, and the Health Assessment Questionnaire (HAQ) scores.

RESULTS

The test protocol indicated moderate to high test-retest reliability of performance measures for three manipulation tasks, intraclass correlation coefficients (ICCs) ranging between 0.5 to 0.84, p<0.05. Strength of association between task performance measures with self- reported activity/participation composite scores was low to moderate (Spearman rho <0.7). Low correlations (Spearman rho < 0.4) were observed between task performance measures and grip strength; and between three objects' performance measures. Significant reduction in pain and joint stiffness (p<0.05) was observed after performing each task.

CONCLUSION

The study presents initial evidence on the test retest reliability and convergent validity of a computer based hand function assessment protocol in people with rheumatoid arthritis or hand osteoarthritis. The novel tool objectively measures overall task performance during a variety of object manipulation tasks done by tracking a computer based visual target. This allows an innovative method of assessing performance than considering the time taken to complete a task or relying on subjective measures of self-reports on a limited range of objects and tasks covered. In addition, joint pain and stiffness levels before and after a manipulation task are tracked, which is lacking in other hand outcome measures. Performance measures during a broad range of object manipulation tasks relate to many activities relevant to life role participation. Therefore, task performance evaluation of common objects, utensils, or tools would be more valuable to gauge the difficulties encountered in daily life by people with arthritis. Future studies should consider a few revisions of the present protocol and evaluate a number of different objects targeting strength, fine, and gross dexterity based tasks for a broader application of the tool in arthritis populations.

The effects of compression gloves on hand symptoms and hand function in rheumatoid arthritis and hand osteoarthritis: a systematic review

Objective:

to evaluate the effects of compression gloves in adults with rheumatoid arthritis and hand osteoarthritis.

Data sources:

Systematic review of randomized controlled trials identified from MEDLINE, CINAHL, AMED, PEDro, OT Seeker, The Cochrane Library, ISI Web of Knowledge, Science Direct and PubMed from their inceptions to January 2015.

Review methods:

Methodological quality of identified trials was evaluated using the PEDro scale by three independent assessors. Effects were summarized descriptively.

Results:

Four trials ( n=8-24; total n=74), comparing night wear of full-length finger compression gloves with placebo gloves, were assessed. Three were of moderate (PEDro score 4-5) and one low (score 3) methodological quality. Effect sizes or standardized mean differences could not be calculated to compare trials due to poor data reporting. In rheumatoid arthritis, finger joint swelling was significantly reduced, but results for pain and stiffness were inconclusive and no differences in grip strength and dexterity were identified. One study reported similar effects in pain, stiffness and finger joint swelling from both compression and thermal placebo gloves. Only one study evaluated gloves in hand osteoarthritis ( n=5) with no differences.

Conclusions:

All the trials identified were small with a high risk of Type I and II errors. Evidence for the effectiveness of compression gloves worn at night is inconclusive in rheumatoid arthritis and hand osteoarthritis.

Conservative treatment of thumb base osteoarthritis: a systematic review

PURPOSE

To provide a systematic review of randomized controlled trials regarding the conservative treatment of thumb base osteoarthritis (OA).

METHODS

A systematic literature search was conducted in the electronic bibliographic databases Medline (Pubmed) and Embase (both starting year to May 2014) using predetermined criteria for studies on nonoperative treatment of thumb base OA.

RESULTS

Twenty-three articles fulfilled our inclusion criteria. Systematic evaluation demonstrated the following: (1) Hand therapy can possibly reduce pain. However, owing to the lack of good-quality (randomized controlled) trials with sufficient follow-up time, no proper conclusions can be drawn. (2) Although both steroid and hyaluronate intra-articular injections can provide pain relief, most authors conclude that injection of hyaluronate is more effective. Follow-up is rather short with a maximum of 12 months in 1 study. Furthermore, study comparison is hampered by heterogeneity of study design and outcome parameters. (3) The use of orthoses reduces pain without effect on function, strength, or dexterity. Included studies used various types of orthoses. Follow-up times varied (2 wk-7 y). (4) There is no justification for the use of transdermal steroid delivery. (5) There is insufficient evidence justifying the use of leech therapy. (6) There are no high-level evidence studies specifically evaluating the effect of analgesics and patient education in joint protection in patients with thumb base OA.

CONCLUSIONS

There are only a few high-quality studies addressing the conservative treatment of trapeziometacarpal OA. Available evidence suggests only some effect of orthoses and intra-articular hyaluronate or steroid injections.

Radiographic scoring methods in hand osteoarthritis--a systematic literature search and descriptive review

OBJECTIVE

This systematic literature review aimed to evaluate the use of conventional radiography (CR) in hand osteoarthritis (OA) and to assess the metric properties of the different radiographic scoring methods.

DESIGN

Medical literature databases up to November 2013 were systematically reviewed for studies reporting on radiographic scoring of structural damage in hand OA. The use and metric properties of the scoring methods, including discrimination (reliability, sensitivity to change), feasibility and validity, were evaluated.

RESULTS

Of the 48 included studies, 10 provided data on reliability, 11 on sensitivity to change, four on feasibility and 36 on validity of radiographic scoring methods. Thirteen different scoring methods have been used in studies evaluating radiographic hand OA. The number of examined joints differed extensively and the obtained scores were analyzed in various ways. The reliability of the assessed radiographic scoring methods was good for all evaluated scoring methods, for both cross-sectional and longitudinal radiographic scoring. The responsiveness to change was similar for all evaluated scoring methods. There were no major differences in feasibility between the evaluated scoring methods, although the evidence was limited. There was limited knowledge about the validity of radiographic OA findings compared with clinical nodules and deformities, whereas there was better evidence for an association between radiographic findings and symptoms and hand function.

CONCLUSIONS

Several radiographic scoring methods are used in hand OA literature. To enhance comparability across studies in hand OA, consensus has to be reached on a preferred scoring method, the examined joints and the used presentation of data.

Adalimumab in patients with hand osteoarthritis refractory to analgesics and NSAIDs: a randomised, multicentre, double-blind, placebo-controlled trial

AIM

To test the efficiency of tumour necrosis factor blockers (adalimumab) in patients with painful refractory (non-responders to analgesics and non-steroidal anti-inflammatory drugs (NSAIDs)) hand osteoarthritis (OA).

METHODS

We performed a randomised, double-blind, placebo-controlled, parallel group, multicentre study. Patients were randomised to: 1/1 adalimumab 40 mg for two subcutaneous injections at a 15-day interval or placebo and monitored for 6 months. The primary outcome was the percentage of patients with an improvement of more than 50% in global pain (Visual Analogue Scale) between week 0 (W0) and week 6 (W6). Secondary outcomes included the number of painful joints, swollen joints, morning stiffness duration, patient and practitioner global assessments, functional indexes for hand OA, and consumption of analgesics. Analysis on the mean primary outcome measure was done on patients who received at least one injection.

RESULTS

99 patients were recruited and 85 patients were randomised. Among them, 37 patients in the placebo group and 41 in the adalimumab group received at least one injection and were evaluated at W6 (n=78) on the main efficacy outcome. Mean age was 62 years, 85% were women, and mean level of pain was 62 mm at W0. At W6, 35.1% in the adalimumab group versus 27.3% in the placebo group had a pain reduction ≥50% (RR 1.12 (95% CI 0.82 to 1.54; p=0.48). There were no statistical differences for all secondary end points. The rate of adverse events was similar in the two groups.

CONCLUSIONS

Adalimumab was not superior to placebo to alleviate pain in patients with hand OA not responding to analgesics and NSAIDs.

TRIALS REGISTRATION NUMBER

NCT00597623.

Effect of home-based hand exercises in women with hand osteoarthritis: a randomised controlled trial

BACKGROUND

Hand exercises are recommended for patients with hand osteoarthritis (HOA), though evidence for their effect is conflicting.

OBJECTIVE

To evaluate, in a randomised controlled trial, the effect of HOA information plus home-based hand exercises (exercise group) compared with information only (control group) in women with HOA.

METHODS

Interventions were delivered by two occupational therapists. Exercise group participants received eight follow-up calls over the 3-month study and recorded adherence, pain after exercises and adverse events in a diary. Primary outcome was activity performance measured after 3 months by the Patient-Specific Functional Scale (PSFS), with a range of 0-10. Secondary outcomes were measurements of hand function, disease activity, symptoms and number of responders to treatment according to the OMERACT-OARSI criteria.

RESULTS

Of 80 women randomised (40 : 40) (mean age (SD) 60.8 years (7.0)), follow-up was 89% (n=71). An intention-to-treat analysis was performed. The adjusted mean difference for the exercise versus control group was 1.4 points (95% CI 0.6 to 2.2, effect size 1.0) for the PSFS score. Thirteen patients in the exercise group versus three participants in the control group reached a positive minimal clinical important difference of 2.2 points in the PSFS total score, while none versus two, respectively, had a negative change (p=0.007). For secondary outcomes, significant mean differences were found in grip strength and thumb web space, in fatigue, joint pain and the Functional Index for HOA activity performance scores. Sixteen exercise-group participants fulfilled the OMERACT-OARSI response criteria versus two control-group participants (p<0.001).

CONCLUSIONS

Hand exercises were well tolerated and significantly improved activity performance, grip strength, pain and fatigue in women with HOA.

TRIAL REGISTRATION NUMBER

ISRTCN79019063.

Report from the OMERACT Hand Osteoarthritis Special Interest Group: advances and future research priorities

Osteoarthritis (OA) is one of the most common musculoskeletal disorders, frequently affecting the hands. In the last decade there has been increased awareness concerning this disorder because of its clinical burden. Unfortunately, only limited treatments for symptom alleviation are available, and no effective treatment for disease modification exists. The lack of treatment is due not only to a lack of understanding of the disease process, but also to poor outcome measures to assess the condition. The OMERACT Hand OA Special Interest Group (SIG) has started to develop a core set of outcome measures for hand OA clinical trials, observational studies, and clinical record keeping. At OMERACT 11, results from a Delphi exercise were presented, and a preliminary set of core domains was discussed. The group attempted to adopt the new OMERACT Filter 2.0 in the process, and literature overviews of conventional radiographs, ultrasonography, and magnetic resonance imaging as outcome measures in hand OA were presented. Discussions that followed highlighted further suggestions for core domains, the heterogeneity of hand OA, and future research priorities.

Short- and long-term effects of mud-bath treatment on hand osteoarthritis: a randomized clinical trial

The aim of this study was to evaluate both the short-term and the long-term effectiveness of spa therapy in patients with primary hand osteoarthritis (OA). This was a prospective randomized, single blind controlled trial. Sixty outpatients with primary bilateral hand OA were included in the study and randomized to one of two groups. One group (n = 30) was treated with 12 daily local mud packs and generalized thermal baths with a sulfate-calcium-magnesium-fluorides mineral water added to usual treatment. The control group (n = 30) continued regular outpatient care routine (exercise, NSAIDs and/or analgesics). Each patient was examined at baseline, after 2 weeks, and after 3, 6, 9 and 12 months. Primary outcome measures were global spontaneous hand pain on a visual analogue scale (VAS) and the functional index for hand osteoarthritis (FIHOA) score; secondary outcomes were health assessment questionnaire (HAQ), duration of morning stiffness, medical outcomes study 36-item short form (SF-36) and symptomatic drugs consumption. Our results demonstrated that the efficacy of spa therapy was significant in all the assessed parameters, both at the end of therapy and after 3 months; the values of FIHOA, HAQ and drugs consumption continued to be significantly better after 6 months in comparison with baseline. There were no significant modifications of the parameters throughout the follow-up in the control group. Differences between the two groups were significant for all parameters at the 15th day and at 3 months follow-up; regarding FIHOA, HAQ, and symptomatic drugs consumption, the difference between the two groups persisted and was significant at 6month follow-up. Tolerability of spa therapy seemed to be good. In conclusion, our results confirm that the beneficial effects of spa therapy in patients with hand OA last over time.

Activity problems in everyday life--patients' perspectives of hand osteoarthritis: "try imagining what it would be like having no hands"

PURPOSE

To explore first-person perspectives on activities and participation in everyday life among people with hand osteoarthritis (OA).

METHOD

Semi-structured interviews were carried out with 5 men and 26 women of different ages living with hand OA. Supplemental data were collected via photo-interviews of two of the men and nine of the women. The analytical process was inspired by the interpretive phenomenological analysis and informed by the interpretive frameworks of critical psychology and social practice theory.

RESULTS

Empirical findings indicate that persons with hand OA experience activity problems and participation limitations in the conduct of everyday life. Activity problems were related to self-care, paid work, as well as leisure activities. The participants also reported employing different strategies attempting to overcome the challenges of their everyday lives in order to keep actively performing valued activities. They reported environmental support of utmost importance for these attempts. Social participation in networks was also reported to be affected by the participants' activity problems.

CONCLUSIONS

Arranging everyday life is complex and is carried out in structures of social practice. A supportive physical and social environment facilitates participation. The findings highlight the importance of paying attention to individual needs in rehabilitation processes.

Effects of a soft prefabricated thumb orthosis in carpometacarpal osteoarthritis

AIMS

To explore the feasibility and assess the effect of a prefabricated soft thumb-base orthosis on pain, hand strength, and activity performance in persons with osteoarthritis of the CMC joint.

METHODS

In this randomized controlled trial, 29 patients received hand exercises only (control group) and 30 patients received hand exercises and an orthosis (orthosis group). The primary outcome was pain, while secondary outcomes included grip and pinch strength, and self-reported symptoms and activity performance. Outcome assessments, and measures of grip strength and pain with and without orthosis in the orthosis group, were made after two months.

RESULTS

55 participants (mean age 70.5 years) completed all assessments. There were no significant differences between the groups in primary or secondary outcomes after two months. However, in the orthosis group, pain was significantly less when wearing the orthosis than when not wearing it. Participants reported that the orthosis felt uncomfortable during activities involving water and one-third wanted more support of the CMC joint.

CONCLUSIONS

A soft prefabricated orthosis seems to have an immediate pain-relieving effect during use, but no effects in terms of less hand pain, or improved strength or activity performance when not worn.

Outcome measures and their measurement properties for trapeziometacarpal osteoarthritis: a systematic literature review

The objective was to identify all outcome measures used in studies on trapeziometacarpal osteoarthritis (TMC OA) and evaluate their measurement properties. In a two-step systematic literature review, we first identified studies including TMC OA patients and extracted all outcome measures. They were categorized according to the Outcome Measures in Rheumatology (OMERACT) core set for OA including five dimensions: pain, physical function, global assessment, imaging, and quality of life (QoL). Secondly, we retrieved articles on the measurement properties of the identified outcome measures for TMC OA patients. First, 316 articles including 101 different outcome measures were identified, addressing the OMERACT pain and function domains most frequently but under-representing QoL. Second, 12 articles investigating measurement properties of 12 outcome measures were identified. The methodological quality of these studies was poor to fair, implying that based on the literature no recommendations to use any of the outcome measures can yet be made.

No evidence for the effectiveness of a multidisciplinary group based treatment program in patients with osteoarthritis of hands on the short term; results of a randomized controlled trial

OBJECTIVE

To examine the efficacy of a multidisciplinary non-pharmacological intervention in patients with hand osteoarthritis (OA).

METHOD

Parallel group randomized controlled trial was performed in three participating rheumatology outpatient clinics in the Netherlands. Block randomization was performed using a computer generated permuted block scheme (blocks of four). An independent person randomly assigned 151 participants with clinical hand OA to four sessions of multidisciplinary non-pharmacological treatment, or 30 min education followed by 3 months waiting time. Participants and therapists were not blinded to the assigned intervention. The research assistant who assessed all outcomes was blinded to the assigned intervention. Subscale limitations in activities of the Australian Canadian Osteoarthritis Hand Index (AUSCAN) and OARSI responder criteria (primary outcomes) and secondary outcome measures, were assessed at baseline and 12 weeks. Linear or logistic regression analyses were used, where appropriate, with the outcome as dependent and the intervention group as independent variable. The analyses were adjusted for baseline values.

RESULTS

At 3 months no significant and no relevant differences were observed between the experimental (n = 76) and control group (n = 75) in any of the primary or secondary outcome measures. In both groups about one-third of patients were classified as responder.

CONCLUSION

There is insufficient evidence to confirm a clinically relevant treatment effect on the short term, between patients who followed a multidisciplinary treatment program and those who received only written information. Since hand OA causes a range of impairments and limitations in activities, programs with more guidance to formulate and implement individually tailored treatment plans could be probably more effective. Furthermore, more research is needed on the efficacy of single treatment elements. (Dutch Trial Register trial number NTR1191).

Pharmacologic treatment of hand-, knee- and hip-osteoarthritis

Osteoarthritis (OA) is a joint disease of high prevalence and affects > 90 % of the population, depending on several risk factors. Symptomatic OA is less frequent, but requires an individually tailored therapeutic regimen consisting of non-pharmacological and pharmacological treatment modalities. Pharmacologic therapy, however, is mainly limited to analgetic and anti-inflammatory agents; structure modifying remedies do not exist. The therapeutic approach to hand-, knee- and hip-OA is basically similar and differs only at some minor points. Generally, topical agents or paracetamol are recommended as first-line agents. If unsuccessful oral non-steroidal anti-inflammatory drugs (NSAIDs) or COX-2-selctive inhibitors should be introduced. Tramadol is an option in the case patients will not respond satisfactorily to NSAIDs. Glucosamine and chondroitine sulphate are no longer recommended in knee and hip OA, but chondroitine might be efficient in treating hand OA. Oral NSAIDs should be prescribed with caution due to potential side effects. Opioids are not recommended as their benefits are outweighed by an increased risk for serious adverse events.