Joint-specific hand symptoms and self-reported and performance-based functional status in African Americans and Caucasians: The Johnston County Osteoarthritis Project

Galectin-9 as an indicator of functional limitations and radiographic joint damage in patients with rheumatoid arthritis

Background

Previous studies have revealed that Galectin-9 (Gal-9) acts as an apoptosis modulator in autoimmunity and rheumatic inflammation. In the present study, we investigated the potential role of Gal-9 as a biomarker in patients with rheumatoid arthritis (RA), especially as an indicator of functional limitations and radiographic joint damage.

Methods

A total of 146 patients with RA and 52 age- and sex-matched healthy controls were included in this study. Clinical data including disease activity, physical function, and radiographic joint damage were assessed. Functional limitation was defined as the Stanford Health Assessment Questionnaire (HAQ) disability index >1. Subjects with joint erosion >0 or joint space narrowing >0 were considered to have radiographic joint damage. Serum Gal-9 levels were detected by an enzyme-linked immunosorbent assay. Univariate and multivariate logistic regression analysis were used to evaluate the association between Gal-9 and high disease activity and functional limitations, and a prediction model was established to construct predictive nomograms.

Results

Serum levels of Gal-9 were significantly increased in patients with RA compared to those in healthy controls (median 13.1 ng/mL vs. 7.6 ng/mL). Patients with RA who were older (>65 years), had a longer disease duration (>5 years), longer morning stiffness (>60mins), elevated serum erythrocyte sedimentation rate and C-reactive protein, and difficult-to-treat RA had significantly higher Gal-9 levels than those in the corresponding control subgroups (all p <0.05). Patients with RA were divided into two subgroups according to the cut-off value of Gal-9 of 11.6 ng/mL. Patients with RA with Gal-9 >11.6 ng/mL had a significantly higher core clinical disease activity index, HAQ scores, Sharp/van der Heijde modified Sharp scores, as well as a higher percentage of advanced joint damage (all p<0.05) than patients with Gal-9 ≤11.6 ng/mL. Accordingly, patients with RA presenting either functional limitations or radiographic joint damage had significantly higher serum Gal-9 levels than those without (both p <0.05). Furthermore, multivariate logistic regression analysis showed that a serum level of Gal-9 >11.6 ng/mL was an independent risk factor for high disease activity (OR=3.138, 95% CI 1.150-8.567, p=0.026) and presence of functional limitations (OR=2.455, 95% CI 1.017-5.926, p=0.046), respectively.

Conclusion

Gal-9 could be considered as a potential indicator in patients with RA, especially with respect to functional limitations and joint damage.

The Measure of Activity Performance of the hand (MAP-Hand) - A reliable and valid questionnaire for use in patients with hand osteoarthritis with specific involvement of the thumb

STUDY DESIGN

Cross-sectional methodological study with test-retest design.

INTRODUCTION

The Measure of Activity Performance of the Hand (MAP-Hand) is an assessment tool measuring hand-related activity limitations.

PURPOSE

To assess reliability, validity, and interpretability of the MAP-Hand in patients with hand osteoarthritis with specific involvement of the thumb (CMC1).

METHODS

One hundred-and-eighty patients referred to surgical consultation for hand osteoarthritis affecting the CMC1 were included in the evaluation of validity and interpretability. Among these, 59 stable patients were included in reliability analyses, completing the questionnaire twice with a 2-week retest interval. The MAP-Hand has 18 predefined and 5 optional patient-specific items, scored on a 4-point scale (1 = no difficulty to 4 = not able to do). Relative (ICC_2.1) and absolute (SDC_95%ind) reliability were calculated. An ICC of >0.70 was considered acceptable. Nine (75%) or more of 12 predetermined hypotheses had to be confirmed for acceptable construct validity. Interpretability was assessed using floor and ceiling effects and considered present if 15% scored at eitherend of the scale.

RESULTS

Mean (SD) age was 63 (8) years, and most patients were women (79%). The mean total score of predefined items showed acceptable reliability (ICC_2.1 0.74, SDC_95%ind 0.60) and construct validity. The mean total score of the patient-specific items did not reach acceptable reliability. Ceiling effect was found for the predefined items.

DISCUSSION AND CONCLUSIONS

We found that the mean total score of the predefined items on MAP-Hand had acceptable reliability and construct validity but a ceiling effect in patients with hand osteoarthritis with CMC1 affection.

Nonunion and Reoperation Following Proximal Interphalangeal Joint Arthrodesis and Associated Patient Factors

BACKGROUND

Proximal interphalangeal joint (PIPJ) arthrodesis can provide reliable pain relief and restore hand function in patients with PIPJ arthritis. However, there is a paucity of literature on patient-specific preoperative risk factors that are associated with adverse outcomes after PIPJ arthrodeses. Therefore, the primary purpose of this study was to assess preoperative predictors of nonunion and reoperation after PIPJ arthrodesis.

METHODS

This study identified all patients who underwent PIPJ arthrodesis at a single community practice between 1987 and 2013. The final analysis included 415 PIPJs treated with arthrodesis. The mean follow-up was 1.3 years. Data on preoperative diagnosis, demographics, comorbidities, and operative techniques were recorded, as well as the occurrence of nonunions and reoperations. Logistic regression models were used to identify independent risk factors of nonunion and reoperation.

RESULTS

There were 40 nonunions (10%) and 62 reoperations (15%). Of the reoperations, there were 39 incidences of isolated hardware removal, 9 irrigation and debridement, 8 amputations, 5 revision arthrodeses, and 1 corrective osteotomy. The highest number of nonunions occurred in the traumatic diagnosis group (37%), followed by the rheumatoid group (23%) and the scleroderma group (15%). The highest number of reoperations occurred within the traumatic joint disorder group (40%), followed by the rheumatoid group (24%) and the scleroderma group (11%). Multivariate analysis revealed that male sex (P < .01) and hepatic disease (P = .03) were significant risk factors of nonunion. Male sex was also significantly associated with increased reoperation risk (P < .01).

CONCLUSION

Risks of nonunions and reoperations after PIPJ arthrodeses are low; however, these findings may guide clinicians and patients in the preoperative decision-making process and help with targeted postoperative surveillance to mitigate these risks.

Proximal interphalangeal joint arthroplasty with the Tactys® prosthesis: Clinical and radiological outcomes at a mean 3.1 years' follow-up

Preliminary results with the Tactys® modular gliding prosthesis for proximal interphalangeal joint (PIPJ) replacement were encouraging, with notable improvement in clinical and functional scores at 1 and 2 years' follow-up. However, a recent study found a trend for deterioration over time. We wanted to check this by analyzing medium-term outcomes. Sixty-four arthroplasties were performed in 48 patients in single facility between January 2015 and January 2020. Clinical, functional, and radiographic outcomes were analyzed at short- and medium-term follow-up for 15 of these arthroplasties. Mean follow-up of the 48 patients was 3.1 years. Pain significantly decreased on the numeric rating scale (p < 0.01) and the functional QuickDASH score improved from 67.3 to 55.9 (p < 0.01). Grip and pinch strengths were lower in the operated than in the contralateral hand (p = 0.04 and p = 0.6, respectively). PIPJ active range of motion (ROM) in flexion/extension improved from 44° to 49.4° (p = 0.17). 70% of the 48 patients were satisfied. Fifteen arthroplasties were analyzed at 17 and 61 months' follow-up. Pain relief continued. ROM decreased from 57° to 46° (p < 0.05) and the functional QuickDASH score deteriorated from 25.8 to 54.7 (p < 0.01). Both grip and pinch strength increased, with a significant difference in pinch (p = 0.003). The main complication was swan-neck deformity (46%), with a mean 11 months' onset. Our results confirmed the deterioration trend observed over time in the functional results of the Tactys® prosthesis despite, good patient satisfaction. LEVEL OF EVIDENCE: 4.

Pain-related psychological issues in hand therapy

STUDY DESIGN

Literature review.

INTRODUCTION

Pain is a subjective experience that results from the modulation of nociception conveyed to the brain via the nervous system. Perception of pain takes place when potential or actual noxious stimuli are appraised as threats of injury. This appraisal is influenced by one's cognitions and emotions based on her/his pain-related experiences, which are processed in the forebrain and limbic areas of the brain. Unarguably, patients' psychological factors such as cognitions (eg, pain catastrophizing), emotions (eg, depression), and pain-related behaviors (eg, avoidance) can influence perceived pain intensity, disability, and treatment outcomes. Therefore, hand therapists should address the patient pain experience using a biopsychosocial approach. However, in hand therapy, a biomedical perspective predominates in pain management by focusing solely on tissue healing.

PURPOSE OF THE STUDY

This review aims to raise awareness among hand therapists of the impact of pain-related psychological factors.

METHODS AND RESULTS

This literature review allowed to describe (1) how the neurophysiological mechanisms of pain can be influenced by various psychological factors, (2) several evidence-based interventions that can be integrated into hand therapy to address these psychological issues, and (3) some approaches of psychotherapy for patients with maladaptive pain experiences.

DISCUSSION AND CONCLUSION

Restoration of sensory and motor functions as well as alleviating pain is at the core of hand therapy. Numerous psychological factors including patients' beliefs, cognitions, and emotions alter their pain experience and may impact on their outcomes. Decoding the biopsychosocial components of the patients' pain is thus essential for hand therapists.

Racial-Ethnic Differences in Osteoarthritis Pain and Disability: A Meta-Analysis

Osteoarthritis (OA), a leading cause of disability and pain, affects 32.5 million Americans, producing tremendous economic burden. Although some findings suggest that racial/ethnic minorities experience increased OA pain severity, other studies have shown conflicting results. This meta-analysis examined differences in clinical pain severity between African Americans (AAs) and non-Hispanic whites with OA. Articles were initially identified between October 1 and 5, 2016, and updated May 30, 2018, using PubMed, Web of Science, PsycINFO, and the Cochrane Library Database. Eligibility included English-language peer-reviewed articles comparing clinical pain severity in adult black/AA and non-Hispanic white/Caucasian patients with OA. Nonduplicate article abstracts (N = 1,194) were screened by 4 reviewers, 224 articles underwent full-text review, and 61 articles reported effect sizes of pain severity stratified by race. Forest plots of the standard mean difference showed higher pain severity in AAs for studies using the Western Ontario and McMasters Universities Osteoarthritis Index (0.57; 95% confidence interval [CI], 0.54-0.61) and non-Western Ontario and McMasters Universities Osteoarthritis Index studies (0.35, 95% CI, 0.23-0.47). AAs also showed higher self-reported disability (0.38, 95% CI, 0.22-0.54) and poorer performance testing (-0.58, 95% CI, -0.72 to -0.44). Clinical pain severity and disability in OA is higher among AAs and future studies should explore the reasons for these differences to improve pain management. PERSPECTIVE: This meta-analysis shows that differences exist in clinical pain severity, functional limitations, and poor performance between AAs and non-Hispanic whites with OA. This research may lead to a better understanding of racial/ethnic differences in OA-related pain.

Washer and Post Augmentation of 90/90 Wiring for Proximal Interphalangeal Joint Arthrodesis: A Biomechanical Study

PURPOSE

To describe a novel construct for proximal interphalangeal (PIP) joint arthrodesis using headless cannulated screws as an intramedullary washer to augment 90/90 intraosseous wiring and compare the biomechanical properties of this construct with those of the 90/90 intraosseous wiring without headless screw augmentation.

METHODS

Biomechanical evaluation of augmented 90/90 intraosseous wiring with headless cannulated screws (group 1) or 90/90 intraosseous wiring without augmentation (group 2) for PIP joint arthrodesis was performed in 3 matched-pair cadaveric specimens (12 digits per group). Each group was loaded to 10 N in the sagittal and coronal planes and the resultant stiffness from the load-displacement curve was calculated. In extension, each group then underwent load to permanent deformation and load to catastrophic failure.

RESULTS

The augmented 90/90 intraosseous wiring with cannulated screws construct demonstrated significantly greater stiffness by 132%, 64%, 79%, and 75% in flexion, extension, ulnar, and radial displacement, respectively. During load to permanent deformation testing, a 42% greater force was required to create permanent deformation in group 1 compared than group 2. There was no significant difference between the 2 groups during load to catastrophic failure testing.

CONCLUSIONS

Augmenting 90/90 intraosseous wiring for PIP joint arthrodesis with 2 headless cannulated screws in the sagittal plane that serve as intramedullary washers for the sagittal wire and posts for the coronal wire significantly increases stiffness in all directions as well as load to permanent deformation compared with 90/90 intraosseous wiring without cannulated screw augmentation.

CLINICAL RELEVANCE

Augmentation of the 90/90 intraosseous wire construct with headless cannulated screws can be considered in patients at risk for wire cutout or implant failure.

Contributions of symptomatic osteoarthritis and physical function to incident cardiovascular disease

Background

Osteoarthritis (OA) is associated with worsening physical function and a high prevalence of comorbid health conditions. In particular, cardiovascular disease (CVD) risk is higher in individuals with OA than the general population. Limitations in physical function may be one pathway to the development of CVD among individuals with OA. This study evaluated associations of symptomatic knee OA (sxKOA), baseline physical function and worsening of function over time with self-reported incident CVD in a community-based cohort.

Methods

Our sample consisted of individuals from the Johnston County Osteoarthritis Project who did not report having CVD at baseline. Variables used to evaluate physical function were the Health Assessment Questionnaire (HAQ), time to complete 5 chair stands, and the 8-ft walk. Worsening function for these variables was defined based on previous literature and cutoffs from our sample. Logistic regression analyses examined associations of sxKOA, baseline function and worsening of function over time with self-reported incident CVD, unadjusted and adjusted for relevant demographic and clinical characteristics.

Results

Among 1709 participants included in these analyses, the mean age was 59.5 ± 9.5 years, 63.6% were women, 15% had sxKOA, and the follow up time was 5.9 ± 1.2 years. About a third of participants reported worsening HAQ score, about two-fifths had worsened chair stand time, half had worsened walking speed during the 8-ft walk, and 16% self-reported incident CVD. In unadjusted analyses, sxKOA, baseline function, and worsening function were all associated with self-reported incident CVD. In multivariable models including all of these variables, sxKOA was not associated with incident CVD, but worsening function was significantly associated with increased CVD risk, for all three functional measures: HAQ odds ratio (OR) = 2.49 (95% confidence interval (CI) 1.90–3.25), chair stands OR = 1.58 (95% CI 1.20–2.08), 8-ft walk OR = 1.53 (95%CI 1.15–2.04). These associations for worsening function remained in models additionally adjusted for demographic and clinical characteristics related to CVD risk.

Conclusions

The association between symptomatic knee osteoarthritis and cardiovascular disease risk was explained by measures of physical function. This highlights the importance of physical activity and other strategies to prevent functional loss among individuals with symptomatic knee osteoarthritis.

Understanding Patient Preferences in Proximal Interphalangeal Joint Surgery for Osteoarthritis: A Conjoint Analysis

PURPOSE

We sought to compare preferences for arthroplasty versus arthrodesis among patients with proximal interphalangeal (PIP) joint osteoarthritis (OA) by quantifying the patient-assigned utility of each operation's attributes.

METHODS

We undertook a multistep process to identify relevant surgical attributes, including a literature review, surgeon survey, and pretest patient pilot test to build a set of discrete choice experiments. Patients with PIP joint osteoarthritis were identified using a single university electronic medical record and were recruited via electronic message or postcard. Participants completed a demographic survey and 11 discrete choice experiments designed using Sawtooth Software's Discover tool. Utility and importance scores were generated for each attribute.

RESULTS

Pretest analysis identified out-of-pocket cost, joint stiffness, need for future surgery, change in grip strength, and total recovery time as the most important surgical attributes. Initial response rate to the conjoint survey was 75% and survey completion rate was 61%. The study sample was predominantly white (91%) and female (72%), mean age 64.3 years (range, 34-90 years), and mean daily pain score was 4.32 (range, 0-10). Attribute importance scores demonstrated that joint stiffness (32%) and grip strength (29%) were most important to patients. Cost (17%) and need for future surgery (19%) were intermediate patient-preference drivers. Recovery time was the least important attribute (2%).

CONCLUSIONS

In aggregate, patients prefer surgical attributes characteristic of arthroplasty (ability to preserve joint motion and grip strength) relative to those associated with arthrodesis (decreased need for reoperation, lower costs, and shorter reoperation times).

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analysis III.

Linking ICF components to outcome measures for orthotic intervention for CMC OA: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION/PURPOSE

The purpose of this study was to systematically review outcome measures used for assessment of orthotic intervention in the conservative management of thumb carpometacarpal osteoarthritis to determine if they characterize International Classification of Functioning, Disability, and Health (ICF) components. The determinants of patient satisfaction regarding the orthotic intervention were also extracted from the studies.

METHODS

A comprehensive literature search was conducted. Outcome measures in the included studies were linked to the ICF. Determinants of patient satisfaction regarding the orthotic intervention were also extracted.

RESULTS

Nine studies met inclusion criteria. Eight (47.1%) outcomes were linked to body structures and functions, 8 (47.1%) to activity limitations and participation restrictions, and 1 (5.9%) outcome fell into the nondefinable quality of life category. Four studies assessed patient satisfaction.

DISCUSSION/CONCLUSIONS

This systematic review on orthotic intervention for thumb carpometacarpal osteoarthritis found opportunities related to assessment and outcome measures when present studies are linked to the ICF.

LEVEL OF EVIDENCE

2a.

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.

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.

Factors associated with disability among middle-aged and older African American women with osteoarthritis

BACKGROUND

Middle-aged and older African American women experience disproportionate rates of functional limitations and disability from osteoarthritis (OA) compared to other racial ethnic groups; however, little is known about what factors contribute to this disparity within African American women.

OBJECTIVE

To examine factors associated with physical function and disability among African American women ages 50-80 with OA using the disablement process model.

METHODS

This descriptive study included 120 African American women with OA from the Southwestern region of the United States. Regression techniques were used to model the correlates of physical function and disability and to test a mediation model.

RESULTS

BMI and pain severity were significantly related to functional limitations. Depressive symptoms mediated the relationship between racial discrimination and disability.

CONCLUSION

Biological, intra-individual, and extra-individual factors are related to disablement outcomes in this sample of African American women, which is consistent with theory suggesting the need for treatment coupled with environmental modifications. This study can inform the development of future bio-behavioral interventions.

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.

OUTCOME OF PYROCARBON PROXIMAL INTERPHALENGEAL JOINT REPLACEMENT

Pyrocarbon arthroplasty of the proximal interphalangeal joint (PIPJ) has been reported to provide excellent pain relief when treating osteoarthritis of the hand. We retrospectively reviewed 20 PIPJ arthroplasties performed on 14 patients by a single surgeon using Ascension prosthesis. The mean follow up period was 3.5 years (range 1–7 years). Excellent pain relief was noted at the final follows-up. The mean range of motion improved from 40° pre-operatively to 70° post-operatively which was statistically significant. Twelve patients had significant improvement in quality of life and would consider similar procedure for other fingers. Radiological assessment revealed an average of 1 mm subsidence and there was no correlation noted between subsidence, migration and ROM at the final follow-up. Stiffness was the main complication and was comparable with other studies. The results of this series are encouraging and demonstrate excellent to good outcome in 86% of patients at the mid-term follow-up.

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.

Composite measures of multi-joint symptoms, but not of radiographic osteoarthritis, are associated with functional outcomes: the Johnston County Osteoarthritis Project

PURPOSE

To determine associations between multiple joint symptoms and radiographic osteoarthritis (rOA) and functional outcomes.

METHOD

Complete cross-sectional data for multi-joint symptoms and radiographs, Health Assessment Questionnaire (HAQ) scores, and gait speed were available for 1307 Johnston County Osteoarthritis Project participants (34% men, 32% African American, mean age 66 years). Factor analysis of symptom scores and radiographic grades for the lumbosacral spine, bilateral hands, knees, and hips provided composite scores. Regression models were used to determine associations between composite scores, HAQ, and gait speed, adjusting for age, body mass index, gender, and race.

RESULTS

Five rOA factors were identified: (1) IP/CMC factor (carpometacarpal [CMC] and all interphalangeal [IP] joints); (2) MCP factor (metacarpophalangeal joints 2-5); (3) Knee factor (tibiofemoral and patellofemoral joints); (4) Spine factor (L1/2 to L5/S1); and (5) Symptom factor. After adjustment, only the Symptom composite was significantly associated with HAQ and gait speed; a 1-standard deviation increase in Symptom score was associated with 9 times higher odds of having poorer function on the HAQ (odds ratio 9.32, 95% confidence interval [CI] 6.80, 12.77), and a clinically significant decline in gait speed (0.06 m/s, 95% CI -0.07, -0.05).

CONCLUSIONS

A novel Symptom composite score was associated with poorer functional outcomes.

IMPLICATIONS FOR REHABILITATION

Osteoarthritis (OA) commonly affects multiple joints and is the most common form of arthritis. Symptomatic assessments, which can be easily executed by rehabilitation practitioners, are more closely related to self-reported and performance-based functional status than are less accessible and more costly radiographs. Symptomatic assessments are likely to be more informative for understanding, treating, and potentially preventing functional limitations than radiographic assessments.

Systematic review of design and effects of splints and exercise programs in hand osteoarthritis

OBJECTIVE

To describe and evaluate the design and effects of splints and exercise programs in hand osteoarthritis.

METHODS

Controlled trials identified through systematic literature reviews were included. Design of splints and exercise programs were evaluated according to existing recommendations and classification systems. The risk of bias was assessed by 2 independent reviewers and effects were summarized descriptively or by meta-analyses.

RESULTS

Twelve trials were included in the review: 7 assessed the effect of splints, 3 the effect of exercises, and 2 a combination of splints and exercises. The results revealed a great variety in the design of splint and exercise programs. A meta-analysis of the 2 randomized trials with low risk of bias demonstrated that splints significantly reduced hand pain at short-term (<3 months) and long-term (≥3 months) followup, with a standardized mean difference of 0.37 (95% confidence interval [95% CI] 0.03, 0.71) and 0.80 (95% CI 0.45, 1.15), respectively. Further, results from single trials indicated that hand exercises may reduce pain and increase range of motion and strength, while a combination of splints and daily exercises may reduce pain and stiffness and improve function.

CONCLUSION

There is consistent evidence that splints reduce hand pain, but limited evidence for the effects of hand exercises and a combination of hand exercises and splints in hand osteoarthritis.

Proximal interphalangeal joint arthritis

Proximal interphalangeal joint function is critical for proper finger and hand function and arthritis of this joint can lead to considerable hand impairment. Proximal interphalangeal joint arthritides are broadly categorized into nonerosive and erosive osteoarthritis (OA), posttraumatic arthritis, and inflammatory arthritis. The nonerosive type is considered idiopathic or primary OA, whereas the erosive form exhibits an inflammatory component. Idiopathic or primary OA occurs as a consequence of abnormal mechanical stress that leads to damage of cartilage and subchondral bone, with subsequent cytokine and growth factor activation. Individual genetics then mediate the cellular responses. Although erosive OA is described as a separate entity, this remains controversial, with many suggesting that it is merely a more aggressive form of nonerosive, primary OA. Inflammatory OA occurs when connective tissues are diseased, allowing for normal use to incite arthritic damage. Treatment modalities for proximal interphalangeal joint arthritis are currently limited.

Occupational therapy-based and evidence-supported recommendations for assessment and exercises in hand osteoarthritis

AIMS

The aims of this study were to develop recommendations for occupational therapy assessment and design of hand exercise programmes in patients with hand osteoarthritis.

METHODS

An expert group followed a Delphi procedure to reach consensus for up to 10 recommendations for assessment and exercises, respectively. Thereafter, an evidence-based approach was used to identify and appraise research evidence supporting each recommendation, before the recommendations were validated by the expert group.

RESULTS

The process resulted in 10 recommendations for assessment and eight for design of exercise programmes. The literature search revealed that there is a paucity of clinical trials to guide recommendations for hand osteoarthritis, and the evidence for the majority of the recommendations was based on expert opinions. Also, even if a systematic review demonstrates some evidence for the efficacy of strength training exercises in hand OA, the evidence for any specific exercise is limited to expert opinions.

CONCLUSIONS

A first set of recommendations for assessment and exercise in hand osteoarthritis has been developed. For many of the recommendations there is a paucity of research evidence. High-quality studies are therefore needed to establish a high level of evidence concerning functional assessment and the effect of hand exercises in hand osteoarthritis.