The clinical and cost effectiveness of splints for thumb base osteoarthritis: a randomized controlled clinical trial

Effect of physical therapy interventions in individuals with primary thumb carpometacarpal osteoarthritis: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to investigate the effect of physiotherapeutic interventions in individuals with thumb primary CMC OA on the outcomes of pain, hand function, grip or pinch strength.

METHODS

RCTs that used some type of physiotherapeutic intervention compared to a passive or active control group were included. The quality of the evidence was assessed using the GRADE approach and, for the calculation of the meta-analysis, the standardized difference of means (SMD) was used.

RESULTS

Nineteen studies (n = 1477) were included and eight studies (n = 568) underwent meta-analysis. Orthosis intervention was superior to passive control group for pain improvement (SMD = -1.02, p = 0.03, very low evidence), grip strength (SMD = 0.45, p = 0.02, very low evidence) and pinch strength (SMD = 1.78, p = 0.01, very low evidence), but there was no improvement in hand function (p = 0.54). The use of a neoprene orthosis was similar to the use of a thermoplastic orthosis in improving pain (p = 0.38), hand function (p = 0.50), grip strength (p = 0.42) and pinch strength (p = 0.14). The use of short thermoplastic orthosis was also similar to long thermoplastic orthosis in improving pain (p = 0.88) and hand function (p = 0.58).

CONCLUSION

The use of orthoses is superior to no intervention in all outcomes, exception hand function.IMPLICATIONS FOR REHABILITATIONThe use of orthosis is recommended for the treatment of patients with rhizoarthrosisUse of orthosis is better than no intervention in improving pain, grip and pinch strength.The type of orthosis (neoprene or thermoplastic, short or long thermoplastic) does not affect the clinical improvement of the individual to the outcomes of pain, hand physical function, grip and pinch strength.

Biopsychosocial factors associated with pain severity and hand disability in trapeziometacarpal osteoarthritis and non-surgical management

BACKGROUND

Trapeziometacarpal osteoarthritis (TMO) is one of the most prevalent and painful forms of hand osteoarthritis.

PURPOSE

This study aimed at (1) describing the TMO pain experience, (2) identifying biopsychosocial factors associated with pain intensity and disability, and 3) documenting the use of non-surgical management modalities.

STUDY DESIGN

Cross-sectional.

METHODS

Participants who presented for care for TMO were recruited from 15 healthcare institutions. They completed a questionnaire addressing sociodemographic, pain, disability, psychological well-being, quality of life (QoL), productivity, and treatment modalities employed. Multivariable regression analyses identified biopsychosocial factors associated with pain intensity and magnitude of disability.

RESULTS

Among our 228 participants aged 62.6 years, 78.1% were women. More than 80% of the participants reported average pain of moderate to severe intensity in the last 7 days. Nearly 30 % of them scored clinically significant levels of anxiodepressive symptoms. The participants' norm-based physical QoL score on the SF-12v2 was 41/100. Among the 79 employed respondents, 13 reported having missed complete or part of workdays in the previous month and 18 reported being at risk of losing their job due to TMO. Factors independently associated with more intense pain included higher pain frequency and greater disability, accounting for 59.0% of the variance. The mean DASH score was 46.1 of 100, and the factors associated with greater magnitude of disability were higher pain intensity, greater levels of depression, female sex, and lower level of education, explaining 60.1% of the variance. Acetaminophen, oral non-steroid anti-inflammatory drugs, cortisone injections, orthoses, hand massage/exercises, and heat/cold application were the most frequently employed modalities. Most participants never used assistive devices, ergonomic techniques, and psychosocial services.

CONCLUSIONS

Patients with TMO can experience severe pain, disability, disturbed emotional well-being, limited QoL and reduced productivity. As disability is associated with TMO pain, and depressive symptoms with disability, reducing such modifiable factors should be one of the clinicians' priorities.

Is multimodal occupational therapy in addition to usual care cost-effective in people with thumb carpometacarpal osteoarthritis? A cost-utility analysis of a randomised controlled trial

OBJECTIVE

The aim was to evaluate the cost-utility of a 3-month multimodal occupational therapy intervention in addition to usual care in patients with thumb carpometacarpal osteoarthritis (CMC1 OA).

METHODS

A cost-utility analysis was performed alongside a multicentre randomised controlled trial including three rheumatology departments in Norway. A total of 180 patients referred to surgical consultation due to CMC1 OA were randomised to either multimodal occupational therapy including patient education, hand exercises, assistive devices and orthoses (n=90), or usual care receiving only information on OA (n=90). The outcome measure was quality-adjusted life-years (QALYs) derived from the generic questionnaire EQ-5D-5L over a 2-year period. Resource use and health-related quality of life of the patients were prospectively collected at baseline, 4, 18 and 24 months. Costs were estimated by taking a healthcare and societal perspective. The results were expressed as incremental cost-effectiveness ratios, and a probabilistic sensitivity analysis with 1000 replications following intention-to-treat principle was done to account for uncertainty in the analysis.

RESULTS

During the 2-year follow-up period, patients receiving multimodal occupational therapy gained 0.06 more QALYs than patients receiving usual care. The mean (SD) direct costs were €3227 (3546) in the intervention group and €4378 (5487) in the usual care group, mean difference €-1151 (95% CI -2564, 262). The intervention was the dominant treatment with a probability of 94.5% being cost-effective given the willingness-to-pay threshold of €27 500.

CONCLUSIONS

The within-trial analysis demonstrated that the multimodal occupational therapy in addition to usual care was cost-effective at 2 years in patients with CMC1 OA.

TRIAL REGISTRATION NUMBER

NCT01794754.

Osteoarthritis year in review 2022: rehabilitation

This year in review presents key highlights from research relating to osteoarthritis (OA) rehabilitation published from the 1^st April 2021 to the 18^th March 2022. To identify studies for inclusion in the review, an electronic database search was carried out in Medline, Embase and CINAHLplus. Following screening, included studies were grouped according to their predominant topic area, including core OA rehabilitation treatments (education, exercise, weight loss), adjunctive treatments, novel and emerging treatments or research methods, and translation of rehabilitation evidence into practice. Studies of perceived high clinical importance, quality, or controversy in the field were selected for inclusion in the review. Headline findings include: the positive role of technology to support remote delivery of core OA rehabilitation treatments, the importance of delivering educational interventions alongside exercise, the clinical and cost-effectiveness of a stepped approach to exercise, controversy around the potential mechanisms of action of exercise, mixed findings regarding the use of splinting for thumb base OA, increasing research on blood flow restriction training as a potential new intervention for OA, and evidence that the beneficial effects from core OA treatments seen in randomised controlled trials can be seen when implemented in clinical practice. A consistent finding across several recently published systematic reviews is that randomised controlled trials testing OA rehabilitation interventions are often small, with some risk of bias. Whilst future research is warranted, it needs to be large scale and robust, to enable definitive answers to important remaining questions in the field of OA rehabilitation.

Mobilisation or immobilisation-based treatments for first carpometacarpal joint osteoarthritis: A systematic review and meta-analysis with subgroup analyses

Introduction

Both joint mobilisation and immobilisation are thought to be effective in the treatment of first carpometacarpal joint (CMCJ) osteoarthritis (OA). The objective of this review was to establish whether either intervention reduced pain and improved pinch strength in people with first CMCJ OA in the short term and assess whether one intervention is superior to the other.

Method

This was a systematic review and meta-analysis. Seven databases were searched until May 2021. Only RCTs were included. The Cochrane Risk of Bias Tool and the Grade of Recommendations Assessment, Development and Evaluation system were utilised to rate the evidence. Random-effects meta-analysis with subgroup analyses were used.

Results

Eight studies were included with a total of 417 participants. Mobilisation treatments included manual therapy with or without exercise while immobilisation interventions utilised thumb splinting with several different designs. Very low-quality and low-quality evidence showed that mobilisation led to statistically but not clinically significant improvements in pain (standardised mean difference (SMD) = 0.53; 95% confidence interval (CI) = 0.03 to 1; I2 = 60%; p = 0.06) and pinch strength (SMD = 0.35; 95% CI = 0.03 to 0.7; I2 = 12%; p = 0.3) compared to placebo. Very low-quality and low-quality evidence showed no effect on pain and pinch strength compared to a control or no intervention. Subgroup analyses revealed no difference between interventions.

Discussion

Neither mobilisation nor immobilisation alone led to clinically important improvements in pain or pinch strength in the short term in people with symptomatic first CMCJ OA. Neither therapeutic strategy appeared to be superior.

HAILO: A Sensorised Hand Splint for the Exploration of Interaction Forces

This study presents the design and development of an instrumented splint for measuring the biomechanical effects of hand splinting, and for assessing interface loading characteristics for people with arthritis. Sixteen multi-axial soft load-sensing nodes were mounted on the splint-skin interface of a custom 3D printed thumb splint. The splint was used to measure the interface forces between splint and hand in 12 healthy participants in 6 everyday tasks. Forces were compared between a baseline relaxed hand position and during states of active use. These data were used to generate a measure of sensor activity across the splint surface. Through direct comparison with a commercial splint, the 3D printed splint was deemed to provide similar levels of support. Observation of the activity across the 16 sensors showed that active areas of the splint surface varied between tasks but were commonly focused at the base of the thumb. Our findings show promise in the ability to detect the changing forces imparted on the hand by the splint surface, objectively characterising their behaviour. This opens the opportunity for future study into the biomechanical effects of splints on arthritic thumbs to improve this important intervention and improve quality of life.