A controlled study of hand function in nodal and erosive osteoarthritis

Erosive hand osteoarthritis and sarcopenia: data from Osteoarthritis Initiative cohort

OBJECTIVES

There is no evidence linking specific osteoarthritis (OA) types, such as erosive hand OA (EHOA), with distant generalised changes in muscle composition (sarcopenia), which can potentially be modified. This study pioneers the exploration of the association between EHOA and sarcopenia, both of which are predominantly observed in the older adults.

METHODS

Using the Osteoarthritis Initiative cohort, we selected hand OA (modified Kellgren and Lawrence (grade ≥2 in ≥1 hand joint) participants with radiographic central erosions in ≥1 joints (EHOA group) and propensity score-matched hand OA participants with no erosion (non-EHOA group). MRI biomarkers of thigh muscles were measured at baseline, year 2 and year 4 using a validated deep-learning algorithm. To adjust for 'local' effects of coexisting knee OA (KOA), participants were further stratified according to presence of radiographic KOA. The outcomes were the differences between EHOA and non-EHOA groups in the 4-year rate of change for both intramuscular adipose tissue (intra-MAT) deposition and contractile (non-fat) area of thigh muscles.

RESULTS

After adjusting for potential confounders, 844 thighs were included (211 EHOA:633 non-EHOA; 67.1±7.5 years, female/male:2.9). Multilevel mixed-effect regression models showed that EHOA is associated a different 4-year rate of change in intra-MAT deposition (estimate, 95% CI: 71.5 mm2/4 years, 27.9 to 115.1) and contractile area (estimate, 95% CI: -1.8%/4 years, -2.6 to -1.0) of the Quadriceps. Stratified analyses showed that EHOA presence is associated with adverse changes in thigh muscle quality only in participants without KOA.

CONCLUSIONS

EHOA is associated with longitudinal worsening of thigh muscle composition only in participants without concomitant KOA. Further research is needed to understand the systemic factors linking EHOA and sarcopenia, which unlike EHOA is modifiable through specific interventions.

Associations of inflammatory and metabolic biomarkers with incident erosive hand osteoarthritis in the osteoarthritis initiative cohort

OBJECTIVE

Erosive hand osteoarthritis (eHOA) is a subtype of hand osteoarthritis (OA) that develops in finger joints with pre-existing OA and is differentiated by clinical characteristics (hand pain/disability, inflammation, and erosions) that suggest inflammatory or metabolic processes.

METHOD

This was a longitudinal nested case-cohort design among Osteoarthritis Initiative participants who had hand radiographs at baseline and 48-months, and biospecimens collected at baseline. We classified incident radiographic eHOA in individuals with ≥1 joint with Kellgren-Lawrence ≥2 and a central erosion present at 48-months but not at baseline. We used a random representative sample (n = 1282) for comparison. We measured serum biomarkers of inflammation, insulin resistance and dysglycemia, and adipokines using immunoassays and enzymatic colorimetric procedures, blinded to case status.

RESULTS

Eighty-six participants developed incident radiographic eHOA. In the multivariate analyses adjusted for age, gender, race, smoking, and body mass index, and after adjustment for multiple analyses, incident radiographic eHOA was associated with elevated levels of interleukin-7 (risk ratio (RR) per SD = 1.30 [95% confidence interval (CI) 1.09, 1.55] p trend 0.01).

CONCLUSION

This exploratory study suggests an association of elevated interleukin-7, an inflammatory cytokine, with incident eHOA, while other cytokines or biomarkers of metabolic inflammation were not associated. Interleukin-7 may mediate inflammation and tissue damage in susceptible osteoarthritic finger joints and participate in erosive progression.

The High Clinical Burden of Erosive Hand Osteoarthritis is Associated with Clinical Findings, Pain, and Radiographic Severity

Varying reports exist on the clinical impact of erosive hand osteoarthritis (EHOA) in terms of pain and articular function. Few studies have assessed the association of a patient's clinical features with the presence of more severe radiographic disease. The aim was to evaluate clinical and radiographic characteristics in EHOA comparing with non-erosive (NEHOA); to examine pain and functional impairment between EHOA and NEHOA; and correlate functional impairment with clinical findings, pain, and radiographic severity.

METHODS

62 patients with EHOA and 57 with NEHO were included. Pain was assessed through Visual Analogue Scale (VAS) and Australian/Canadian Osteoarthritis Hand Index (AUSCAN) pain subdomain. Functioning was evaluated with the Health Assessment Questionnaire (HAQ) concerning hand function and AUSCAN. Radiographs were scored with the Kallman scale and subchondral erosions with the Verbruggen-Veys method. Student t-tests were used for comparing quantitative data, chi-squared tests for categorical variables, and Pearson or Spearman tests for assessing correlation.

RESULTS

Patients with EHOA reported significantly higher levels of pain on the VAS and AUSCAN (p<0.01). In EHOA, VAS positively correlated with the HAQ and AUSCAN scales (rho=0.68 and 0.77). In NEHOA, Visual Analogue Scale (VAS) positively and strongly correlated with HAQ and AUSCAN (rho=0.84 and 0.89). Nodes, Kallman score and erosions showed a positive but weak correlation with HAQ and AUSCAN in both groups.

CONCLUSION

Both EHOA and NEHOA participants had functional impairment, but the erosive subtype had higher clinical burden and increased joint damage. This higher clinical burden is attributed mainly to pain.

Transcutaneous vagus nerve stimulation in erosive hand osteoarthritis: protocol for the randomised, double-blind, sham-controlled ESTIVAL trial

INTRODUCTION

Patients with erosive hand osteoarthritis (EHOA) experience pain and inflammation, two features that can be targeted by vagus nerve stimulation using electrical auricular transcutaneous vagus nerve stimulation (tVNS). A pilot study demonstrated the feasibility of the procedure, so we designed a randomised sham-controlled trial to determine the safety and efficacy of tVNS in EHOA.

METHODS AND ANALYSIS

ESTIVAL Study (Essai randomisé comparant la STImulation auriculaire transcutanée du nerf Vague versus sham stimulation dans l'Arthrose DigitaLe Érosive symptomatique et inflammatoire) is a superiority, randomised, double-blind sham-controlled trial comparing two parallel arms: active and sham tVNSs in a 1:1 ratio. Patients with symptomatic EHOA (score ≥40/100 mm on a visual analogue scale (VAS) for pain of 0-100 mm) and inflammatory EHOA (≥1 clinical and ultrasonography-determined interphalangeal synovitis) are included in 18 hospital centres (17 rheumatology and 1 rehabilitation departments) in France. Active and sham tVNSs use an auricular electrode connected to the Vagustim device, with no electric current delivered in the sham group. Patients undergo stimulation for 20 min/day for 12 weeks. The follow-up visits take place at weeks 4, 8 and 12. The enrolment duration is 2 years and started in April 2021; 156 patients are scheduled to be included. The primary outcome is the difference in self-reported hand pain in the previous 48 hours measured on a VAS of 0-100 mm between baseline and week 12. Secondary outcomes include other pain outcomes, function, quality of life, serum biomarker levels, compliance and tolerance. For a subset of patients, MRI of the hand is performed at baseline and week 12 to compare the change in Outcome Measures in Rheumatology/Hand Osteoarthritis MRI Scoring System subscores. The primary analysis will be performed at the end of the study according to the intent-to-treat principle.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the institutional review board (Comité de Protection des Personnes, 2020-A02213-36). All participants will be required to provide written informed consent. The findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04520516; Pre-results.

PROTOCOL VERSION AND NUMBER

V.2 of 11 March 2021.

Erosive hand osteoarthritis: latest findings and outlook

Osteoarthritis (OA) most commonly affects knee joints, and the next most commonly affected sites are the hands and hips. Three distinct hand OA phenotypes have been described: erosive hand OA (EHOA), nodal hand OA - also known as non-erosive hand OA (non-EHOA) - and first carpometacarpal joint OA. EHOA predominantly affects women and is the most aggressive form of hand OA, characterized by a severe clinical onset and progression, leading to joint damage, disability and reduction of quality of life. Clinical signs of inflammation associated with EHOA include the acute onset of pain, swelling and redness. Moreover, EHOA is characterized by radiographic features such as central erosion, saw-tooth and gull-wing lesions and, rarely, ankylosis. The aim of this Review is to report the latest findings on epidemiology, clinical features, pathology and aetiopathogenesis, biomarkers, imaging modalities and treatments for EHOA. The ongoing development of new hand OA classification criteria should facilitate standardization between studies.

The High Clinical Burden of Erosive Hand Osteoarthritis is Associated with Clinical Findings, Pain, and Radiographic Severity

Varying reports exist on the clinical impact of erosive hand osteoarthritis (EHOA) in terms of pain and articular function. Few studies have assessed the association of a patient's clinical features with the presence of more severe radiographic disease. The aim was to evaluate clinical and radiographic characteristics in EHOA comparing with non-erosive (NEHOA); to examine pain and functional impairment between EHOA and NEHOA; and correlate functional impairment with clinical findings, pain, and radiographic severity.

METHODS

62 patients with EHOA and 57 with NEHO were included. Pain was assessed through Visual Analogue Scale (VAS) and Australian/Canadian Osteoarthritis Hand Index (AUSCAN) pain subdomain. Functioning was evaluated with the Health Assessment Questionnaire (HAQ) concerning hand function and AUSCAN. Radiographs were scored with the Kallman scale and subchondral erosions with the Verbruggen-Veys method. Student t-tests were used for comparing quantitative data, chi-squared tests for categorical variables, and Pearson or Spearman tests for assessing correlation.

RESULTS

Patients with EHOA reported significantly higher levels of pain on the VAS and AUSCAN (p<0.01). In EHOA, VAS positively correlated with the HAQ and AUSCAN scales (rho=0.68 and 0.77). In NEHOA, Visual Analogue Scale (VAS) positively and strongly correlated with HAQ and AUSCAN (rho=0.84 and 0.89). Nodes, Kallman score and erosions showed a positive but weak correlation with HAQ and AUSCAN in both groups.

CONCLUSION

Both EHOA and NEHOA participants had functional impairment, but the erosive subtype had higher clinical burden and increased joint damage. This higher clinical burden is attributed mainly to pain.

Erosive Hand Osteoarthritis: Incidence and Predictive Characteristics among Participants in the Osteoarthritis Initiative

OBJECTIVE

To evaluate age, sex, race, osteoarthritis severity, metabolic factors, and bone health as risk factors for incident erosive hand osteoarthritis (EHOA) at baseline and over 48-month period.

METHODS

This study was a longitudinal cohort design including participants from the Osteoarthritis Initiative with complete hand radiographs from baseline and 48-month visits who were eligible at baseline for incident EHOA. Individuals were classified as having EHOA if they had Kellgren-Lawrence (KL) grade≥2 in at least one interphalangeal joint on two different fingers and central erosion in at least one joint.

RESULTS

Of the 3365 individuals identified without prevalent EHOA at baseline, 86 (2.6%) developed EHOA during the 48-month period. Risk factors included being older [relative risk (RR) per standard deviation=0.76 (95% confidence interval 0.59, 0.98)], female [RR=1.73 (1.05, 2.85)], greater osteoarthritis severity (sum of KL grade 13.9 vs. 5.3, p<0.001) and less cortical width (1.38 vs 1.52 mm, p<0.001). After 48 months, people who developed EHOA were characterized by greater progressions of radiographic osteoarthritis (i.e., joint space narrowing, KL grade progression [RRs = 1.35 to 1.9] and loss of cortical thickness [RR = 1.23], adjusted for age, sex, race, body mass index, and baseline osteoarthritis severity (sum KL scores).

CONCLUSION

These findings present EHOA as a disorder of advanced age and female sex, strongly associated with severity of articular structural damage and its progression. Individuals who develop EHOA have thinner bones prior to EHOA development and as it progresses, suggesting EHOA as a disorder of skeletal frailty.

Measuring intrinsic hand strength in healthy adults: The accuracy intrarater and inter-rater reliability of the Rotterdam Intrinsic Hand Myometer

STUDY DESIGN

Clinical measurement study.

INTRODUCTION

Measuring the isometric strength generated during isolated hand joint motions is a challenging feat. The Rotterdam Intrinsic Hand Myometer (RIHM; med.engineers, Rotterdam, Netherlands) permits measurement of isolated movements of the hand. To date, there is limited evidence on the inter-rater reliability and limited adult normative data of RIHM. Given that multiple raters, often with varying degrees of experience, are needed to collect normative data, inter-rater reliability testing and a comparison of novice and experienced raters are needed.

PURPOSES OF THE STUDY

The purposes of this study were to test the accuracy, intrarater reliability, and inter-rater reliability of the RIHM in healthy-handed adults.

METHODS

RIHM accuracy was tested through use of precision class F weights. Adults 18 years or older without upper limb dysfunction were recruited. Each participant was tested by 4 raters, 3 occupational therapy graduate students, and an experienced certified hand therapist, through use of a calibrated RIHM. Five strength measures were tested bilaterally (ie, thumb carpometacarpal palmar abduction, index finger metacarpophalangeal [MP] abduction, index finger MP flexion, thumb MP flexion, and small finger MP abduction) 3 times per a standardized protocol. Statistical methods were used to test accuracy, inter-rater reliability, and intrarater/response stability.

RESULTS

The accuracy of RIHM device error was 5% or less. Reliability testing included the participation of 19 women and 10 men (n = 29). All raters were in excellent agreement across all muscles (intraclass correlation coefficient, ≥0.81). Low standard error of measurement values of ≤8.3 N (1.9 lb) across raters were found. The response stability and/or intrarater reliability of the novice and certified hand therapist raters were not statistically different.

DISCUSSION

The RIHM has an acceptable instrument error; the RIHM and its standardized procedure have excellent inter-rater reliability and response stability when testing those without hand limitations; and the response stability and/or intrarater reliability of expert and novice raters were consistent.

CONCLUSIONS

The use of the RIHM is justified when multiple raters of varying expertise collect normative data or conduct cohort studies on persons with healthy hands. Future research is warranted.

LEVEL OF EVIDENCE

Not applicable.

An Assessment of Hand Erosive Osteoarthritis: Correlation of Radiographic Severity with Clinical, Functional and Laboratory Findings

INTRODUCTION

The present study aimed (a) to evaluate the clinical and radiographic characteristics of hand erosive osteoarthritis (EOA) in a group of consecutive patients, (b) to correlate the severity of radiographic involvement with clinical and laboratory findings and (c) to associate the levels of pain and functional impairment with some radiographic findings.

METHODS

Patients with EOA were consecutively enrolled. Inclusion criteria required the American College of Rheumatology (ACR) criteria for hand osteoarthritis and the presence of at least one joint in "E" or "R" phase according to Verbruggen-Veys. For each patient, demographic and clinical data were collected including evaluation of pain and function with the Australian Canadian Osteoarthritis Hand Index (AUSCAN) scale and Health Assessment Questionnaire (HAQ). Laboratory parameters and plain radiography of both hands were also collected. Each radiograph was evaluated in accordance with the Verbruggen-Veys classification and scored with the Kallman score.

RESULTS

During the study period 60 patients (M/F 13:47) with EAO were enrolled. More severe radiographic disease ("E" or "R") was often found at II and III distal interphalangeal (IP) joints. In addition, Kallman score, presence of osteophytes, erosions and joint space narrowing correlated significantly with duration of symptoms, AUSCAN, pain and active joints. More severe radiographic involvement was associated with AUSCAN and with the presence of ankylosis only at proximal IP joints.

CONCLUSION

The present study showed that EOA is characterised by a significant correlation between radiographic involvement and some clinical characteristics of the disease. However, an impairment of joint function was mainly associated to radiological proximal IP joint involvement, but not with other symptoms such as pain.

Upper limb functional capacity of working patients with osteoarthritis of the hands: A cross-sectional study

STUDY DESIGN

A cross-sectional design was used.

INTRODUCTION

Little is known about the effects of osteoarthritis of the hands (OAH) on work ability in working patients with OAH.

PURPOSE OF THE STUDY

The study aimed to analyze the differences in upper limb functional capacity (ULFC) between working patients with OAH and healthy workers and to evaluate variables associated with ULFC and with self-reported disability (SRD) in working patients with OAH.

METHODS

Forty-one patients performed the ULFC Evaluation (ULFCE) and also completed 2 SRD measures. The patients' results were compared with the ULFCE results of 82 matched healthy workers from a reference database. Three sets of multivariate regression analyses were used to reveal the predictors of ULFC and SRD.

RESULTS

Patients scored 12%-45% lower on all ULFCE tests (P values ranging from P P Discussion Working patients with OAH had a considerably lower ULFC compared with healthy workers. Female gender and the presence of OAH predicted lower ULFC. Pain and lower finger strength predicted worse scores on SRD.

CONCLUSION(S)

In the case of professionals advising working patients with OAH, our results suggest that a careful evaluation of the ULFC and SRD is warranted. Subsequently, advice regarding exercises or adjustments at work can be given.

LEVEL OF EVIDENCE

3b.

Erosive osteoarthritis: A systematic analysis of definitions used in the literature

BACKGROUND

Erosive osteoarthritis (EOA) is a commonly invoked diagnosis representing an important variant of hand osteoarthritis (OA). There is increasing literature on the prevalence, risk factors, etiology, and management of EOA.

METHODS

We systematically reviewed the literature to assess variability in the diagnostic definitions used to define EOA in these studies.

RESULTS

We reviewed 336 articles and found 62 articles citing diagnostic definitions for EOA. Radiographic appearance was the most commonly used criterion, but there was little agreement on the details or extent of the radiographic changes. Overall, 56 of the 62 studies included clinical features in the diagnostic definitions, yet these features varied considerably. Exclusion criteria were mentioned in 43 of the studies.

CONCLUSION

Based on the widely disparate definitions of EOA, we urge caution in interpretation of this literature, and propose that further understanding of EOA will require consensus on its definition.

The prevalence of erosive osteoarthritis in carpometacarpal joints and its clinical burden in symptomatic community-dwelling adults

OBJECTIVE

To estimate the prevalence of erosive disease in first carpometacarpal joints (CMCJs) and investigate its clinical impact compared with radiographic thumb base (TB) osteoarthritis (OA).

PATIENT AND METHODS

Standardized assessments with hand radiographs were performed in participants of two population-based cohort studies in North Staffordshire with hand symptoms lasting ≥1 day in the past month. Erosive disease was defined as the presence of eroded or remodeled phase in ≥1 interphalangeal joint (IPJ) or first CMCJ following the Verbruggen-Veys classification. Hand pain and function were assessed with Australian/Canadian Hand Osteoarthritis Index (AUSCAN). Prevalence was estimated by dividing the number of persons with erosive lesions by population size. Linear and logistic regression analyses were used to contrast clinical determinants between persons with erosions and with radiographic TB OA. Results were presented as mean differences and odds ratios (ORs) with 95% confidence intervals (95% CI), adjusted for age, sex and radiographic severity.

RESULTS

1,076 participants were studied (60% women, mean age 64.7 years (SD 8.3); 24 persons had erosive disease in the TB. The prevalence of erosive disease in first CMCJs was 2.2% (95% CI 1.4, 3.3). Only 0.5% (95% CI 0.2, 1.2) had erosive disease affecting IPJs and first CMCJs combined. More persons with erosive disease of first CMCJs reported pain in their TB than persons with radiographic TB OA, AUSCAN pain and function scores were similar.

CONCLUSION

Erosive disease of first CMCJs was present in 2.2% of subjects with hand pain and was often not accompanied by erosions in IPJs. Erosive disease was associated with TB pain, but not with the level of pain, when compared with radiographic TB OA.

Subsets of symptomatic hand osteoarthritis in community-dwelling older adults in the United Kingdom: prevalence, inter-relationships, risk factor profiles and clinical characteristics at baseline and 3-years

OBJECTIVE

To compare the population prevalence, inter-relationships, risk factor profiles and clinical characteristics of subsets of symptomatic hand osteoarthritis (OA) with a view to understanding their relative frequency and distinctiveness.

METHOD

1076 community-dwelling adults with hand symptoms (60% women, mean age 64.7 years) were recruited and classified into pre-defined subsets using physical examination and standardised hand radiographs, scored with the Kellgren & Lawrence (K&L) and Verbruggen-Veys grading systems. Detailed information on selected risk factors was obtained from direct measurement (Body Mass Index (BMI)), self-complete questionnaires (excessive use of hands, previous hand injury) and medical record review (hypertension, dyslipidaemia, type 2 diabetes). Hand pain and disability were self-reported at baseline and 3-year follow-up using Australian/Canadian Osteoarthritis Hand Index (AUSCAN).

RESULTS

Crude population prevalence estimates for symptomatic hand OA subsets in the adult population aged 50 years and over were: thumb base OA (22.4%), nodal interphalangeal joint (IPJ) OA (15.5%), generalised hand OA (10.4%), non-nodal IPJ OA (4.9%), erosive OA (1.0%). Apart from thumb base OA, there was considerable overlap between the subsets. Erosive OA appeared the most distinctive with the highest female: male ratio, and the most disability at baseline and 3-years. A higher frequency of obesity, hypertension, dyslipidaemia, and metabolic syndrome was observed in this subset.

CONCLUSION

Overlap in the occurrence of hand OA subsets poses conceptual and practical challenges to the pursuit of distinct phenotypes. Erosive OA may nevertheless provide particular insight into the role of metabolic and cardiovascular risk factors in the pathogenesis of OA.

Joint and bone assessment in hand osteoarthritis

Hand osteoarthritis (OA) is a common disease frequently affecting middle-aged women. Prevalence estimates for OA vary widely depending on the age and sex of the population studied, the assessment tools used, and the specific joint sites analyzed OA is characterized by the degradation of articular cartilage, subchondral bone changes and osteophyte formation at the joint margins leading to joint failure. The pathogenesis of the disease and its evolution are multifactorial involving biomechanical, metabolic, hormonal, and genetic factors. Moreover, the role of inflammation has recently been advanced as pivotal in OA onset and progression. In particular, an uncommon variant of hand OA, erosive hand OA, is characterized by inflammatory and degenerative interphalangeal proximal and distal joints. The diagnosis of different types of hand OA is centered on clinical and laboratory investigations which can distinguish the peculiar aspects of these forms. Joint and bone assessments in hand OA are widely studied but there is no agreement with regard to established parameters to make a definitive diagnosis. This report focuses on the laboratory and clinimetric assessments that can be used to distinguish hand OA subtypes and addresses the debatable association with low bone mineral density in osteoporosis.

Erosive osteoarthritis: a more severe form of radiographic hand osteoarthritis rather than a distinct entity?

Objectives

To determine whether erosive osteoarthritis shares the same pattern of joint involvement and risk profile as increasing grades of non-erosive hand osteoarthritis.

Methods

Participants were from two population-based cohorts, aged ≥50 years, reporting hand symptoms in the previous month. Interphalangeal joints were assessed for erosive osteoarthritis (Verbruggen–Veys erosive or remodelled phase) and radiographic osteoarthritis (sliding cut-offs of K&L≥2, K&L≥3 and K&L=4). At the joint level, similarities in the frequency and pattern of erosive and non-erosive osteoarthritis were assessed by Spearman's rank correlation coefficients and generalised estimating equations. At the person level, individuals with erosive osteoarthritis were compared to those with non-erosive osteoarthritis using logistic regression, adjusted for age and gender (aOR), for the following exposures: family history, previous injury, overuse and metabolic factors (BMI, dyslipidaemia, hypertension, diabetes).

Results

In 1076 symptomatic participants the ranked frequency of involvement for erosive joints was comparable to joints with K&L≥3 and K&L=4 (r>0.95). Patterns of joint involvement in erosive osteoarthritis were strongest for symmetry (aOR=6.5; 95% CI 3.0 to 14.1), followed by row (2.0; 0.8 to 5.0) and ray (0.3; 0.0 to 2.5), which was similar to joints with K&L≥3 and K&L=4. Individuals with erosive osteoarthritis (n=80) had an increased risk of metabolic syndrome (2.7; 1.0 to 7.1), notably dyslipidaemia (4.7; 2.1 to 10.6) compared with non-erosive osteoarthritis classed K&L≥3 (n=193).

Conclusions

The similar frequency of radiographic joint involvement and patterning in erosive osteoarthritis and more severe non-erosive osteoarthritis is consistent with prevalent erosive osteoarthritis being a severe form of hand osteoarthritis rather than a distinct entity. Metabolic exposures, dyslipidaemia in particular, may be implicated in erosive osteoarthritis.

Comparison of clinical burden between patients with erosive hand osteoarthritis and inflammatory arthritis in symptomatic community-dwelling adults: the Keele clinical assessment studies

OBJECTIVE

To investigate in the general population the clinical impact of erosive OA in interphalangeal joints (IPJs) compared with symptomatic radiographic hand OA and inflammatory arthritis.

METHODS

Standardized assessments with hand radiographs were performed in participants of two population-based cohorts in North Staffordshire with hand symptoms lasting ≥1 day in the past month. Erosive OA was defined as the presence of an eroded or remodelled phase in ≥1 IPJ using the Verbruggen-Veys method. Radiographic hand OA was defined as the presence of ≥1 IPJ/first carpometacarpal joint with a Kellgren-Lawrence score of ≥2. Diagnoses of inflammatory arthritis were based on medical records. Hand pain and disability were assessed with the Australian/Canadian Hand Osteoarthritis Index (AUSCAN). Linear regression analyses were used to compare clinical determinants between groups and calculate mean differences with 95% CIs, adjusted for age and sex.

RESULTS

Of 1076 participants with hand symptoms [60% women, mean age 64.8 years (s.d. 8.3 years)]; 80 persons (7.4%) had erosive OA. The population prevalence of erosive OA in ≥1 IPJ was 2.4% (95% CI 1.8, 3.0). Persons with erosive OA reported more pain and disability than persons with symptomatic radiographic hand OA [adjusted mean difference 1.3 (95% CI 0.3, 2.3) and 2.3 (95% CI 0.4, 4.2), respectively]. Individuals with inflammatory arthritis (n = 44) reported more pain and disability than those with erosive OA [adjusted mean difference 1.7 (95% CI 0.05, 3.4) and 6.3 (95% CI 2.8, 9.9), respectively].

CONCLUSION

While erosive OA has a greater impact than symptomatic radiographic hand OA in the general population, it is not as severe in terms of hand pain and disability as inflammatory RA.

Distinguishing erosive osteoarthritis and calcium pyrophosphate deposition disease

Erosive osteoarthritis is a term utilized to describe a specific inflammatory condition of the interphalangeal and first carpal metacarpal joints of the hands. The term has become a part of medical philosophical semantics and paradigms, but the issue is actually more complicated. Even the term osteoarthritis (non-erosive) has been controversial, with some suggesting osteoarthrosis to be more appropriate in view of the perspective that it is a non-inflammatory process undeserving of the “itis” suffix. The term “erosion” has also been a source of confusion in osteoarthritis, as it has been used to describe cartilage, not bone lesions. Inflammation in individuals with osteoarthritis actually appears to be related to complicating phenomena, such as calcium pyrophosphate and hydroxyapatite crystal deposition producing arthritis. Erosive osteoarthritis is the contentious term. It is used to describe a specific form of joint damage to specific joints. The damage has been termed erosions and the distribution of the damage is to the interphalangeal joints of the hand and first carpal metacarpal joint. Inflammation is recognized by joint redness and warmth, while X-rays reveal alteration of the articular surfaces, producing a smudged appearance. This ill-defined, joint damage has a crumbling appearance and is quite distinct from the sharply defined erosions of rheumatoid arthritis and spondyloarthropathy. The appearance is identical to those found with calcium pyrophosphate deposition disease, both in character and their unique responsiveness to hydroxychloroquine treatment. Low doses of the latter often resolve symptoms within weeks, in contrast to higher doses and the months required for response in other forms of inflammatory arthritis. Reconsidering erosive osteoarthritis as a form of calcium pyrophosphate deposition disease guides physicians to more effective therapeutic intervention.

Discrepancy between Radiographic Damage and Functional Disability in Elderly People with Osteoarthritis: The Role of Pain Coping Strategies

The aim of this study is twofold. First, to assess the level of agreement between radiographic damage and functional disability in older people with osteoarthritis. And second, to assess the role of coping skills and sensory pain parameters as sources of disagreement between these variables. To achieve this objective we assess, in a sample of 104 older people with osteoarthritis, the following variables: functional capacity, radiographic damage, pain coping strategies, pain intensity, pain frequency and pain duration. The results show a non-linear relationship between radiographic damage and functional disability, modified by the levels of the two variables. There was maximum agreement between low levels of radiographic damage and of functional impairment, whilst agreement decreased for moderate and high levels of radiographic damage. Certain coping strategies may help to explain this disparity.

Pentosidine, an advanced glycation end-product, may reflect clinical and morphological features of hand osteoarthritis

The study investigates pentosidine levels, an advanced glycation end-product, in patients with erosive and non-erosive hand osteoarthritis (HOA) and determine its potential association with clinical findings and imaging-defined joint damage.Pentosidine was measured by HPLC in serum and urine of 53 females with HOA (31 erosive and 22 non-erosive HOA) and normalised to the total serum protein or urinary creatinine, respectively. Pain, joint stiffness and disability were assessed by the Australian/Canadian OA hand index (AUSCAN). The hand radiographs scored according to the Kallman grading scale were assessed to determine a baseline value and reassessed after two years.The levels of urine pentosidine, but not of serum pentosidine, were higher in patients with erosive HOA than in non-erosive HOA (p=0.039). Urinary pentosidine correlated with CRP (r=0.302, p=0.031), ESR (r=0.288, p=0.041) and AUSCAN (r=0.408, p=0.003). Serum pentosidine, but not in urine, significantly correlated with the Kallman radiographic score in erosive HOA at the baseline (r=0.409, p=0.022) and after 2 years (r=0.385, p=0.032). However, when corrected for age and disease duration, only correlation between urine pentosidine and AUSCAN remained significant (r=0.397, p=0.004).Our data suggest that serum and urine pentosidine levels may relate to the distinctive clinical and morphological features of HOA.

Grip force control in individuals with hand osteoarthritis

Individuals with hand osteoarthritis (OA) experience pain and stiffness that could result in significant limitations in the performance of everyday activities involving upper extremities. The purpose of the study was to evaluate grip force control in individuals with hand OA during the lifting of an object. The study design used was a case-control study. Ten females with hand OA and a group of age-matched females performed two functional tasks: lifting an instrumented object vertically while the load was suddenly changed and lifting and placing the object on a shelf. Load Force Peak, Grip force at liftoff, Grip Force Peak, Time Lag, and Latency were measured and analyzed. Individuals with hand OA were able to modulate the magnitude and temporal parameters of grip force; however, they applied higher grip forces (at liftoff [p=0.002]; Grip Force Peak [p=0.039]) and demonstrated a longer Latency (p=0.015) to manipulate the instrumented object when compared with the control subjects. The Load Force Peak and Time Lag were not significantly different between the two groups. Detailed information about how individuals with hand OA perform prehension activities of daily living will help to better understand the limitations of grip force control in these individuals.

Tumour necrosis factor blockade for the treatment of erosive osteoarthritis of the interphalangeal finger joints: a double blind, randomised trial on structure modification

Background

Adalimumab blocks the action of tumor necrosis factor-α and reduces disease progression in rheumatoid arthritis and psoriatic arthritis. The effects of adalimumab in controlling progression of structural damage in erosive hand osteoarthritis (HOA) were assessed.

Methods

Sixty patients with erosive HOA on radiology received 40 mg adalimumab or placebo subcutaneously every two weeks during a 12-month randomized double-blind trial. Response was defined as the reduction in progression of structural damage according to the categorical anatomic phase scoring system. Furthermore, subchondral bone, bone plate erosion, and joint-space narrowing were scored according to the continuous Ghent University Score System (GUSSTM).

Results

The disease appeared to be active since 40.0% and 26,7% of patients out of the placebo and adalimumab group, respectively, showed at least one new interphalangeal (IP) joint that became erosive during the 12 months follow-up. These differences were not significant and the overall results showed no effect of adalimumab.

Risk factors for progression were then identified and the presence of palpable soft tissue swelling at baseline was recognized as the strongest predictor for erosive progression. In this subpopulation at risk, statistically significant less erosive evolution on the radiological image (3.7%) was seen in the adalimumab treated group compared to the placebo group (14.5%) (P = 0.009). GUSSTM scoring confirmed a less rapid rate of mean increase in the erosion scores during the first 6 months of treatment in patients in adalimumab-treated patients.

Conclusion

Palpable soft tissue swelling in IP joints in patients with erosive HOA is a strong predictor for erosive progression. In these joints adalimumab significantly halted the progression of joint damage compared to placebo.

Hand osteoarthritis--a heterogeneous disorder

Hand osteoarthritis (OA) is a prevalent disorder. Hand OA is not one single disease, but a heterogeneous group of disorders. Radiographic signs of hand OA, such as osteophytes or joint space narrowing, can be found in up to 81% of the elderly population. Several hand OA subsets--such as nodal interphalangeal OA, thumb base OA and erosive OA--can be discriminated. Furthermore, the experience of symptoms and the course of the disease differ between patients. Studies that used well-defined study populations with longitudinal follow-up have shown that similarities and differences can be observed in the pathogenesis, epidemiology and risk factors of the various hand OA subsets. Erosive OA in particular, characterized by erosive lesions on radiographical images, has a higher clinical burden and worse outcome than nonerosive hand OA. Imaging modalities (such as ultrasonography) have increased our knowledge of the role of inflammation of the disease. Our understanding of the heterogeneous nature of hand OA can eventually lead to increased knowledge of the pathogenesis of, and ultimately new treatment modalities for, this complex disease.

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.

Hand osteoarthritis and pinch grip strength among middle-aged female dentists and teachers

OBJECTIVES

Among female dentists and teachers, we investigated the relationship of pinch grip strength with radiographic hand osteoarthritis (OA) and hand joint pain.

MATERIALS AND METHODS

We studied 295 female dentists and 248 female teachers aged 45-63 years for pinch grip strength using the Martin Vigorimeter. Hand radiographs were examined for the presence of OA in the wrist and each joint of the first, second, and third fingers. Joint pain and tasks with high hand loading during leisure were assessed by questionnaire. Glove size was used as proxy for hand size.

RESULTS

Symptomatic hand OA (jointwise co-occurrence of radiological findings and pain) increased the risk of low pinch grip strength in both hands, with an odds ratio (OR) of 3.3 (95% CI 1.8-6.2) for the right and 2.0 (95% CI 1.1-3.8) for the left hand, allowing for age, occupation, body mass index (BMI), hand size, and hand-loading leisure-time activity. The occurrence of findings and pain in non-corresponding joints was also associated with pinch grip strength in the right hand, but not in the left. Having only radiographic findings or pain was not associated with pinch grip strength.

CONCLUSIONS

Our findings support the view that hand function is related to the severity of hand OA.

Grip and pinch strength in healthy subjects and patients with primary osteoarthritis of the hand: a reproducibility study

Grip, Key Pinch (KP), 3 Point Pinch (3PP) and 2 Point Pinch (2PP) strengths were measured twice weekly in 32 women with primary osteoarthritis of the hand (POAH) and 25 healthy women. Reproducibility was assessed by standard error of measurement (SEM) and the coefficient of variation (CV). Cutoff values for significant improvement or deterioration were determined and expressed, respectively, as either the smallest detectable difference (SDD) or critical difference (CD). The SDD and CD of grip and pinch strengths were higher in POAH patients than in the healthy group. Among the pinch tests the 2PP findings were least reproducible. The relatively high SDD and CD scores indicate that improvement may be detected only in patients with moderate to severe weakness of grip and pinch. Furthermore, in POAH patients, diagnosing strength changes using the 2PP test is invalid due to low reproducibility.

The effect of radiological hand osteoarthritis on hand function

The aim of the study was to investigate the effect of osteoarthritis (OA) on hand function in elderly patients. One hundred elderly patients with a mean age of 68.50 +/- 6.37 years (87 women, 13 men) were enrolled to the study. Radiological hand OA was defined as the presence of Kellgren-Lawrence (K-L) grade > or = 2. Grip strength, and lateral, tip, and three-fingered pinches were measured. Hand function was assessed by Dreiser's functional index. Subjective hand disability was assessed by the hand disability index of Stanford Health Assessment Questionnaire (HAQ) and by self-reported functional limitation. Coordination was evaluated by testing for rapid alternating movement (RAM) and fine finger movement (FFM). The Jebsen test of hand function was used to determine functional hand use. Forty patients had K-L > or = 2 radiological hand OA, and 60 patients had K-L = 0 and 1 and were accepted as the control group. In the clinical examination, 54 patients had Heberden's nodules and 35 had Bouchard's nodules. Self-reported functional limitation tests (activities like carrying a bundle and handling or fingering small objects) were significantly worse in patients with radiographic hand OA, and also, non-dominant hand RAM was slower in the same group. According to the evaluation of the radiologic grades of OA, grades 3-4 OA had higher scores than the control and grade 2 OA group. Our results suggest that there is a lack of association between radiological hand OA and Jebsen test and objective hand functions like grip and pinch strength, but the patients with radiological hand OA have restrictions in the self-reported functional limitation test. The presence of tenderness, pain, and Heberden's and Bouchard's nodules had a negative effect on hand functions. Dreiser's functional index and the hand disability index of HAQ were found as related parameters with the radiological grade of OA.

Symptomatic Hand Osteoarthritis in the United States

OBJECTIVE

To estimate the United States prevalence of symptomatic hand osteoarthritis using American College of Rheumatology (ACR) physical examination criteria.

DESIGN

The Third National Health and Nutrition Examination Survey (NHANES III), a nationally representative cross-sectional health examination survey, performed upper-extremity physical examinations on a sample of United States adults age 60+ yrs. Data for demographics, pain history, analgesic use, and activity limitations were obtained by interview.

RESULTS

Among United States adults, 58% had Heberden's nodes, 29.9% had Bouchard's nodes, and 18.2% had first carpal-metacarpal deformities. Women had significantly more first carpal-metacarpal deformities (24.3%) than men (10.3%). Symptomatic osteoarthritis prevalence at these sites was 5.4, 4.7, and 1.9%, respectively. Overall, symptomatic hand osteoarthritis prevalence by ACR criteria was 8% (95% CI 6.5-9.5%), or 2.9 million persons. Symptomatic hand osteoarthritis significantly increased with age and was decreased among non-Hispanic blacks, but there were no gender differences. Symptomatic hand osteoarthritis was associated with self-reported difficulty lifting 10 lbs (OR 2.31; 95% CI 1.23-4.33), dressing (OR 3.77; 95% CI 1.99-7.13), and eating (OR 3.44; 95% CI 1.76-6.73). Frequent monthly use was significantly increased for analgesics, especially acetaminophen, but not nonsteroidal antiinflammatory drugs.

CONCLUSION

Symptomatic hand osteoarthritis affects 1 in 12 older United States adults. NHANES III data provide a population-based assessment of the impact and associated functional impairments of symptomatic hand osteoarthritis.

Activity limitations and participation restrictions in women with hand osteoarthritis: patients' descriptions and associations between dimensions of functioning

OBJECTIVE

To describe the functional consequences of hand osteoarthritis, and analyse associations between personal factors, hand impairment, activity limitations, and participation restrictions within the framework of the International Classification of Functioning (ICF).

METHODS

87 women with hand osteoarthritis completed a clinical examination including recording of sociodemographic data, measures of hand impairment, and completion of self reported health status measures. The function subscale of the AUSCAN Osteoarthritis Hand Index was used as a measure of hand related activity limitations, while the Canadian Occupational Performance Measure (COPM) was used to describe and measure activity limitations and participation restrictions as perceived by the individual. The study variables were categorised using the dimensions in the ICF framework and analysed using bivariate and multivariate statistical approaches.

RESULTS

The patients described problems in many domains of activity and participation. The most frequently described hand related problems were activities requiring considerable grip strength combined with twisting of the hands. On the impairment level, the patients had reduced grip force and joint mobility in the hands, and resisted motion was painful. Regression analyses showed that hand related activity limitations were associated with measures of hand impairment, while activity and participation (as measured by the COPM) were more strongly associated with personal factors than with hand impairment.

CONCLUSIONS

Hand osteoarthritis has important functional consequences in terms of pain, reduced hand mobility and grip force, activity limitations, and participation restrictions. Rehabilitation programmes should therefore be multidisciplinary and multidimensional, focusing on hand function, occupational performance, and coping strategies.

The effect of hand osteoarthritis on grip and pinch strength and hand function in postmenopausal women

The aim of the study was to investigate the effect of osteoarthritis on hand function in postmenopausal women. One hundred patients with hand OA and 70 healthy volunteers as controls were evaluated. Grip and pinch strength measurements and Dreiser's functional index were used for hand function. Pain was assessed by a visual analog scale, and tenderness was assessed by palpation and scored, depending on the severity of tenderness, as 0, 1 or 2. Heberden's and Bouchard's nodules and joint involvement were also recorded. The number of patients with only distal interphalangeal joint involvement was 50 (50%), those with distal interphalangeal joint plus proximal interphalangeal joint involvement was 49 (49%), and those with carpometacarpal joint involvement numbered 18 (18%). The incidence of Heberden's and Bouchard's nodules was 85% and 36%, respectively. Eighty-six (86%) patients were suffering from pain and 57 were found to have tenderness. Grip and pinch strength was significantly lower (p<0.05) and Dreiser's functional index score was significantly higher (p<0.001) in the study group (particularly in grade 4 OA). Grip strength was lower in hand OA patients with distal interphalangeal joint plus proximal interphalangeal joint involvement than in those with only distal interphalangeal joint and carpometacarpal joint involvement. Pinch strength was also lower in patients with distal interphalangeal joint plus proximal interphalangeal joint plus carpometacarpal joint involvement. The patients with Heberden's and Bouchard's nodules had lower grip and pinch strength than controls. Also, pain and tenderness had significant (p<0.05) effects on hand function. Dreiser's total score ranged from 0 to 10 in 80 (80%) patients and from 11 to 20 in 20 patients. In conclusion, hand osteoarthritis contributes to hand dysfunction, mainly related to the severity of osteoarthritis, pain, joint involvement and the presence of nodules.

Radiographic assessment of osteoarthritis: analysis of disease progression

Osteoarthritis (OA) is one of the most prevalent and disabling chronic conditions affecting older adults, and is a significant public health problem among adults of working age. The knee is the most frequently involved joint site associated with disability in OA. Diagnosis of OA is primarily based on history and physical examination, but radiographic findings, including asymmetric joint space narrowing (JSN), subchondral sclerosis, osteophyte formation, subluxation, and distribution patterns of osteoarthritic changes are all helpful when diagnosis is uncertain. Structural morphological changes on X-rays are also considered the primary outcome variables for assessing the progression of OA. The development of new methods for prevention and treatment of OA requires improved understanding of the factors that influence its progression. The ability to assess progression quantitatively is a necessary first step in understanding factors that influence the disease process. Depending on the joint studied, several indices are currently used for assessing radiological progression of OA, including individual radiographic features (e.g., marginal osteophytes), composite indices (e.g., Kellgren and Lawrence scoring systems), and quantitative measures (e.g., joint space width measurement). Unfortunately, the review of studies evaluating the longitudinal rate of JSN indicates that the yearly change may be very small and of doubtful clinical significance. This emphasizes the need for further refinement in the definition of radiographic outcomes in prospective clinical trials. This review focuses on the available scoring methods used for the sites most frequently involved in OA (hand, knee, hip) and their various advantages and disadvantages.

Association of erosive hand osteoarthritis with a single nucleotide polymorphism on the gene encoding interleukin-1 beta

OBJECTIVE

Certain forms of primary osteoarthritis (OA), particularly those affecting hand joints, have a genetic component. Recent studies have shown suggestive evidence that hand and knee OA are linked with the interleukin-1 (IL-1) region on human chromosome 2q. This study was undertaken to assess the association of primary OA of the hand (hand OA) with IL-1 region markers.

METHODS

Sixty-eight US Caucasoid cases and 51 US Caucasoid controls aged 60 years or older were recruited from the Mid-Atlantic region of the United States. Hand OA was classified by American College of Rheumatology (ACR) Clinical Criteria, and cases were subjected to radiographic examination for subgrouping. Genotyping was done for seven previously described single nucleotide polymorphisms (SNPs) of genes for IL-1alpha (encoded by IL1A), IL-1beta (IL1B), and the IL-1 receptor antagonist (IL1RN), as well as an IL1RN variable number of tandem repeat (VNTR) marker. Six microsatellite markers on other chromosomes (null loci) were also typed.

RESULTS

The IL1B 5810 G>A SNP genotypes marker were not in Hardy-Weinberg equilibrium (p<0.05 in both non-erosive and erosive hand OA subgroups). Statistically significant association with the IL1B 5810 AA genotype was found in the erosive hand OA subgroup (relative risk 3.8, p=0.007). This IL1B 5810 AA genotype association was also significant between erosive and non-erosive hand OA subjects (relative risk 4.01, p=0.008). As expected, significant linkage disequilibrium was present between IL1B 5810 SNP and IL1A (-)889 SNP, other IL1B SNPs, and the nearest IL1RN SNP examined. The IL1B 5810A allele occurs most frequently on haplotypes with the SNP alleles IL1B 1423C, IL1B 1903T, IL1B 5887C, and IL1A (-)889C. Genotypes at null loci failed to show evidence suggesting population stratification that might account for spurious association.

CONCLUSION

Statistical evidence shows association between erosive hand OA and a genomic region containing the IL1B 5810 SNP in a US Caucasoid population. This supports a potential role for IL-1 in the pathogenesis of a severe phenotype of hand OA.

A cross-sectional study of the association between Heberden's nodes, radiographic osteoarthritis of the hands, grip strength, disability and pain

OBJECTIVE

To describe the associations between hand osteoarthritis (OA), pain and disability in males and females and to further validate the Australian/Canadian OA hand index (AUSCAN LK3.0).

DESIGN

Cross-sectional study of 522 subjects from 101 Tasmanian families (males N=174, females N=348). Hand OA was assessed by two observers using the Altman atlas for joint space narrowing and osteophytes at distal interphalangeal and first carpometacarpal joints as well as a score for Heberden's nodes based on hand photography. Hand pain and function were assessed by the AUSCAN LK3.0 and grip strength by dynamometry in both hands on two occasions.

RESULTS

The prevalence of hand OA was high in this sample at 44-71% (depending on site). Pain and dysfunction increased with age while grip strength decreased (all P< 0.001). All three measures were markedly worse in women, even after taking the severity of arthritis into account. Hand OA explained 5.7-10% of the variation in function, grip strength and pain scores, even after adjustment for age and sex. Further adjustment suggested that the osteoarthritic associations with function and grip strength were largely mediated by pain. Severity of disease was more strongly associated with these scores than presence or absence. Lastly, the AUSCAN LK3.0 showed a comparable association to grip strength with structural damage providing further evidence of index validity.

CONCLUSIONS

Hand OA at these two sites makes substantial contributions to hand function, strength and pain. The associations with function and strength measures appear mediated by pain. Gender differences in all three measures persist after adjustment for variation in age and OA severity indicating that factors apart from radiographic disease are responsible.

The patterns and prevalence of hand osteoarthritis in a population of disabled older women: The Women's Health and Aging Study

OBJECTIVE

To describe the prevalence of hand osteoarthritis (OA) by joint site, joint count and severity in a representative population of older disabled women.

METHODS

1,002 moderately to severely disabled women aged > or = 65 years were selected from a representative population of community-dwelling women. Hand OA was established using a reproducible algorithm based on self-reported pain, standardized physical examinations, hand photographs, and physician questionnaire responses. OA was categorized as either symptomatic disease, intermittently symptomatic/ asymptomatic disease, possible disease, or no disease.

RESULTS

Symptomatic OA, requiring the presence of hand pain on most days for at least 1 month, occurred in approximately 23% of disabled older women in each age group, and most reported pain in the moderate to severe range. The prevalence of intermittently symptomatic/ asymptomatic OA was higher with increasing age. Finally, the most commonly affected hand OA sites were the distal interphalangeal (DIP) and the first carpometacarpal (CMC1) joint groups.

CONCLUSION

These findings demonstrate the very high prevalence of clinical hand OA in disabled older women and show that a large proportion of hand OA results in substantial symptoms.

Screening for hand osteoarthritis (OA) using a postal survey

OBJECTIVE

The aim of this study was to determine the feasibility of screening for hand osteoarthritis (OA) using a postal survey.

METHODS

Men and women aged 40-79, selected at random from a general practice in Nottingham, were sent a postal survey concerning arm pain. Subjects were asked to identify presence of any nodes, based on a diagrammatic example, and to document specific distal (DIP) and proximal (PIP) nodes. One hundred and thirty-nine subjects were subsequently assessed by a nurse metrologist, blinded to the subjects assessment. Subject-observer agreement was measured by calculating unweighted kappa (kappa). In addition, sensitivity and specificity were calculated, taking observer-identified nodes as the 'gold standard'. Intraobserver reproducibility was assessed on 10 subjects with nodes.

RESULTS

Intraobserver reproducibility was reasonable at all sites (kappa>/=0.59). Of the 56 subjects with observer-identified 'any nodes', 40 subjects had correctly identified them (sensitivity 71.4%); with three subjects incorrectly identifying nodes (specificity 96.4%). Corresponding kappa was 0.70. Subject-observer agreement was higher for presence/absence of any DIP nodes than PIP nodes (kappa=0.67 and 0.36 respectively). As with nodes overall, specificity was high (100% and 96.6% respectively). Agreement was generally poor for specific joint involvement.

CONCLUSION

A postal survey is a useful screening tool for identifying subjects with nodes. Although sensitivity may not be sufficient to permit assessment of prevalence of hand OA in the community, it has potential applications in terms of identifying and defining cases for further study.

Severity of hand osteoarthritis and its association with upper extremity impairment in a population of disabled older women: the Women's Health and Aging Study

Most severity indices of osteoarthritis (OA) include measures of physical function which render them unsuitable for assessing the impact of OA on disability. Data from 1002 moderate to severely disabled community-dwelling women > or = 65 years were used to develop hand OA severity indices which are independent of functional status. Baseline exams and strength tests were conducted by trained nurse examiners. Each distal and proximal interphalangeal joint, and first carpometacarpal joint (20 joints in all) was scored for the presence of a) bony enlargement or deformity, and b) pain on motion or tenderness on palpation. Severity indices were then created: Deformity index (DEF) = sum of joints with bony changes (0-20); Pain/Tenderness index (PT) = sum of joints with pain or tenderness (0-20); and Combined Deformity/Pain index = sum of DEF and PT (0-40). These indices were then validated against grip and pinch strength. All three indices showed a significant trend for weaker grip strength as severity index scores increased. When the 25th, 50th and 75th percentiles were used to divide each severity index into levels of involvement, a threshold effect was observed with significantly poorer grip strength performance above the 75th percentile for each index. Similar results were seen for pinch strength. In conclusion, these hand OA severity indices, based on examination findings alone, help distinguish disease status, and may provide a valuable research tool for investigating the role of hand OA in impairment and disability.

Osteoarthritis. A continuing challenge

Osteoarthritis is a disorder of cartilage that affects almost 85% of the population by age 75. A lack of rigorous clinical and radiographic criteria for defining the disorder makes precise determination of its prevalence impossible. The process of wear and tear explains many manifestations of osteoarthritis, but it does not account for some of the clinical findings or the biochemical changes in osteoarthritic cartilage. Thus, other factors such as heredity, hormones, and diet may play a role. Treatment consists of teaching patients about their disease, alleviating pain, and preserving joint function. Nonsteroidal anti-inflammatory drugs may be no more effective than simple analgesics in relieving the pain of this disorder. Moreover, some nonsteroidal anti-inflammatory drugs can adversely affect cartilage metabolism, and most are possibly dangerous in elderly patients. Drugs that inhibit the production or activity of chondrolytic enzymes can slow the degeneration of cartilage in some animals, but their effects on humans with osteoarthritis are unproved. The surgical repair of severely damaged joints can have gratifying results.

Erosive osteoarthritis

Erosive osteoarthritis is a disorder that most often involves the hands of postmenopausal women. It can begin abruptly with pain, swelling, and tenderness. Distal interphalangeal joints are involved most frequently, followed by proximal interphalangeal joints. Occasionally there is metacarpophalangeal, carpal, or large joint involvement. The female-to-male ratio is approximately 12:1. There are no known HLA associations. Laboratory studies generally are negative. A mild elevation of the sedimentation rate may occur. Radiologically, the disorder is characterized by central erosions and the "gull wing" deformity. Synovial pathology has shown changes consistent with both rheumatoid arthritis and osteoarthritis and manifests the stage of disease at the time of biopsy. The etiology remains obscure, but hormonal influences, metabolic disorders, and autoimmunity have been implicated. Treatment is largely supportive with physical therapy, nonsteroidal antiinflammatory drugs, and occasionally prednisone. Overall prognosis is good, although deformity and impairment of hand function may occur. For this reason, a reassessment of treatment strategies may be in order.

The effect of elbow flexion and time of assessment on the measurement of grip strength in rheumatoid arthritis

Grip strength is one of the traditional outcome measures commonly used in rheumatoid arthritis trials. This study evaluated the degree of morning variation and the effect of elbow flexion in the assessment of grip strength in patients with rheumatoid arthritis. Grip strength was measured in 37 patients (1987 American Rheumatism Association criteria) at 8, 10, and 12 AM with a sphygmomanometer cuff folded on itself, taped permanently, and inflated to 20 mm Hg, with the elbow flexed at 90 degrees. At 10 AM grip strength was also measured with the elbow flexed at 30 and 130 degrees. Mean values for grip strength at 8, 10, and 12 AM were, respectively, 69, 79, and 83 mm Hg. Mean grip strength values with the elbow flexed at 30, 90, and 130 degrees were, respectively, 78, 79, and 75 mm Hg. There was a statistically significant correlation between grip strength and morning stiffness, grip strength and hand function, and grip strength and number of active joints. In rheumatoid arthritis trials, grip strength should be assessed at the same time of the day. Elbow flexion does not play a role in grip strength measurement.

The treatment of osteoarthritis

1. The treatment of osteoarthritis is currently purely symptomatic. To enable rational therapy, careful clinical assessment is necessary to identify the origin of symptoms. Often, effective therapy can result from a biomechanical approach such as surgery, orthotics, physiotherapy and dieting. If drugs are required, there is little evidence that the current over-reliance on non-steroidal anti-inflammatory drugs (NSAIDs) is justified. Full dose regular paracetamol should be the first line of analgesic therapy. In the majority of patients, simple analgesics are probably as effective as NSAIDs. If NSAIDs are used it is necessary to review regularly their use and to be aware of potential toxicity. 2. Many alternative strategies of pain management such as topical preparations, intra-articular steroid injections, acupuncture, radiosynovectomy, transcutaneous nerve stimulation and anti-depressants, may be effective but their precise place in the armamentarium is not yet fully established. 3. The realisation that osteoarthritis is not a passive 'wear and tear' phenomenon but an active process that may be potentially modified, has led to interest in 'chondroprotective' agents, which may beneficially affect the osteoarthritic process. To date there are no convincing data available that such agents are, in fact, chondroprotective in humans.

Pain and disability in osteoarthritis: a review of biobehavioral mechanisms

Pain and disability are cardinal symptoms in osteoarthritis. The literature is reviewed in order to identify causes of these symptoms at the articular, kinesiological, and psychological level. It is concluded that pain and disability are associated with degeneration of cartilage and bone (articular level), with muscle weakness and limitations in joint motion (kinesiological level), and with anxiety, coping style, attentional focus on symptoms, and possibly depression (psychological level). Biobehavioral mechanisms of pain and disability which explain the observed associations are described and the empirical evidence for these mechanisms is evaluated. Methodological and conceptual deficiencies in the research reviewed are pointed out and suggestions for further research are given.