Prevalence and determinants of one month hand pain and hand related disability in the elderly (Rotterdam study)

Prevalence and distribution of ultrasound-detected hand synovial abnormalities in a middle-aged and older population

OBJECTIVE

Synovial abnormalities are modifiable targets for hand pain and osteoarthritis. We examined the prevalence and distribution of ultrasound-detected hand synovial abnormalities in a community-derived sample of older people in China.

METHODS

Within the Xiangya Osteoarthritis Study, a community-based study, we assessed synovial hypertrophy (SH), joint effusion, and Power Doppler signal (PDS) on all fingers and thumbs of both hands using standardized ultrasound examinations (score: 0-3). We assessed distribution patterns of SH and effusion using χ2-test and interrelationships of SH and effusion in different joints and hands by generalized estimating equations.

RESULTS

Among 3,623 participants (mean age: 64.4 years; women: 58.1%), prevalence of SH, effusion and PDS were 85.5%, 87.3% and 1.5%, respectively. Prevalence of SH, effusion and PDS increased with age, was higher in the right hand than in the left hand and was more common in proximal than in distal hand joints. SH and effusion often occurred in multiple joints (P < 0.001). SH in one joint was strongly associated with presence of SH in the same joint of the opposite hand (odds ratio [OR]= 6.60, 95% confidence interval [CI]: 6.19-7.03) followed by SH in other joints in the same row, (OR=5.70, 95%CI: 5.32-6.11), and then other joints in the same ray of the same hand (OR=1.49, 95%CI: 1.39-1.60). Similar patterns were observed for effusion.

CONCLUSION

Hand synovial abnormalities are common among older people, often affect multiple hand joints and present a unique pattern. These findings suggest both systemic and mechanical factors play roles in their occurrence.

A Pilot Study of an Innovative Hand Exoskeleton: Nuada Glove

The human hand is a crucial anatomical structure, and its complexity enables humans to grasp tools essential for daily life activities. Consequently, hand disabilities have a negative and profound impact on people's autonomy in performing everyday tasks. The Nuada Glove (Nuada, Braga, Portugal) is a wearable exoskeleton robotic device designed to assist individuals with hand impairments or weakness in regaining hand function, particularly in grasping movements. This pilot study aims to evaluate its impact on improving hand function in first-time users with hand disabilities and to assess its usability. A total of 63 participants with hand disabilities were asked to complete a series of exercises that simulated various human grasping motions, initially without any assistance and then with the Nuada Glove. Of the participants, 98% exhibited measurable improvement in hand function in at least one exercise. This pilot study, conducted in a controlled environment, clearly demonstrated the benefits of the Nuada Glove and its ease of use. Future studies should expand from this one to assess the use of the Nuada Glove in a real-world environment with continuous use.

Arthralgia in female Masters weightlifters

BACKGROUND

Arthralgia or joint pain is a heterogeneous condition including organic and nonorganic joint pain. It is common in older populations, particularly in females. There is evidence that menopausal changes are associated with increased prevalence of arthralgia. While physical activities have been recommended to mitigate osteoarthritis (OA) and arthralgia, sport participation also carries risk factors due to excessive loading of some joints and possible injuries. The aim was to evaluate the association of training patterns, prior injuries, and severity of menopausal symptoms with arthralgia in female Masters weightlifters.

METHODS

Competitive female Masters weightlifters (n=868, 30-78 years) from 30 countries completed an online survey including joint pain for different anatomical sites, weightlifting training and performance, sport history, and menopausal symptoms. Logistic regression models were used to estimate the association of training patterns, prior sport participation, and menopausal symptom severity with arthralgia separately for shoulders, spine, hips, knees, ankles, elbows, and hands.

RESULTS

Arthralgia was most reported in knees (38.8%), shoulders (29.8%), hands/wrists (28.8%), and hips (24.9%). The prevalence of arthralgia was 51.5% in pre-menopausal women, 62.4% in women post natural menopause and 73.3% in women post medical or surgical menopause. Lifting heavier weights was associated with arthralgia in hips (OR=1.05, p=0.03), knees (OR=1.06, p=0.01), and hands/wrists (OR=1.05, p=0.04), but prior strength training was protective for arthralgia in the shoulders (OR=0.66, p=0.02). Prior injuries and psychological menopausal symptom severity were associated with an increased risk for arthralgia (p<0.01).

CONCLUSIONS

Arthralgia was common in competitive female weightlifters. Training frequency was not associated with arthralgia, but lifting heavier weights relative to age and body mass was. Prior injuries and menopausal symptoms were associated with arthralgia, but prior strength training was protective of arthralgia in the shoulders. Athletes, coaches and sports medicine professionals should be aware that prevalence of polyarthralgia increases in post-menopausal athletes.

Biopsychosocial, work-related, and environmental factors affecting work participation in people with Osteoarthritis: a systematic review

PURPOSE

Osteoarthritis (OA) causes pain and disability, with onset often during working age. Joint pain is associated with functional difficulties and may lead to work instability. The aims of this systematic review are to identify: the impact of OA on work participation; and biopsychosocial and work-related factors associated with absenteeism, presenteeism, work transitions, work impairment, work accommodations, and premature work loss.

METHODS

Four databases were searched, including Medline. The Joanna Briggs Institute Critical Appraisal tools were used for quality assessment, with narrative synthesis to pool findings due to heterogeneity of study designs and work outcomes.

RESULTS

Nineteen studies met quality criteria (eight cohort; 11 cross-sectional): nine included OA of any joint(s), five knee-only, four knee and/or hip, and one knee, hip, and hand OA. All were conducted in high income countries. Absenteeism due to OA was low. Presenteeism rates were four times greater than absenteeism. Performing physically intensive work was associated with absenteeism, presenteeism, and premature work loss due to OA. Moderate-to-severe joint pain and pain interference were associated with presenteeism, work transition, and premature work loss. A smaller number of studies found that comorbidities were associated with absenteeism and work transitions. Two studies reported low co-worker support was associated with work transitions and premature work loss.

CONCLUSIONS

Physically intensive work, moderate-to-severe joint pain, co-morbidities, and low co-worker support potentially affects work participation in OA. Further research, using longitudinal study designs and examining the links between OA and biopsychosocial factors e.g., workplace accommodations, is needed to identify targets for interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2019 CRD42019133343 .

Association of the anti-thyroid peroxidase antibody with chronic hand pain in older adults in the Third National Health and Nutrition Examination Survey: a cross-sectional study

Background

Autoimmune thyroid disease (AITD) is the commonest autoimmune disease. Although viewed as a classic form of single-organ autoimmunity, AITD is increasingly associated with non-thyroid sequelae including musculoskeletal manifestations and chronic pain syndromes. However, large population-based studies are needed.

Objectives

To examine the relationships between chronic hand pain and the AITD autoantibodies, anti-thyroid peroxidase antibody (TPOAb), and anti-thyroglobulin antibody (TgAb), in the Third National Health and Nutrition Examination Survey (NHANES III).

Design

This is a cross-sectional study.

Methods

We examined data from NHANES III on 4820 persons aged 60 years or older with respect to hand pain and its association with TPOAb and TgAb. Log-binomial regressions were fit to examine the associations between the anti-thyroid autoantibodies and hand pain.

Results

Positive TPOAb was associated with a higher prevalence of hand pain than negative TPOAb [prevalence ratio (PR) = 1.158, p = 0.048] in the unadjusted model. This association was no longer significant after controlling for age, body mass index, gender, and diabetes (p = 0.313). When positive TPOAb was considered as a categorical variable with four levels, the highest quartile was associated with hand pain in the unadjusted (PR = 1.489, p = 0.005) and adjusted models (PR = 1.325, p = 0.042). There was no significant association between TgAb and hand pain when covariates were controlled for.

Conclusion

TPOAb may be associated with the presence of chronic hand pain in persons aged over 60 years, especially at higher serum levels.

The Effect of Acupuncture on Hand and Wrist Pain Intensity, Functional Status, and Quality of Life in Adults: A Systematic Review

Objective: This systematic review examined the effects of acupuncture on hand-and-wrist pain intensity, functional status, quality of life, and incidence of adverse effects in adults. Methods: Searches of 6 databases and previous reviews for randomized controlled trials (RCTs) were performed. Each outcome was analyzed for participant conditions, interventions, controls, and follow-up times determined a priori. Active controls were excluded. Follow-up periods were based on Cochrane 5.1.0 guidelines. The results were tabulated and described narratively. Results: In the 10 included RCTs (622 participants), 6 had a low risk of bias. For cryotherapy-induced pain, 1 trial showed significant pain reduction post treatment. For rheumatoid arthritis, 1 trial shown significant pain reduction and function improvements post treatment and short-term. For carpal tunnel syndrome, 1 trial showed significant pain reduction and functional improvements intermediate-term, while 3 trials suggested no significant difference. For tenosynovitis, 1 trial showed significant pain reduction and function improvements short-term. For poststroke impairments, 1 trial showed significant function improvements post treatment and at short-term, while another trial suggested no significant difference. No significant improvements were noted for trapezio-metacarpal joint osteoarthritis. In 2 trials, adverse effects occurred in patients with carpal tunnel syndrome; yet acupuncture appeared to be relatively safe. Conclusions: Acupuncture may be effective and safe for short-term pain reduction and functional improvement in hand-and-wrist conditions. Clinicians should interpret the results with caution due to small sample sizes and clinical heterogeneity. Future research is warranted.

New Trends in Injection-Based Therapy for Thumb-Base Osteoarthritis: Where Are We and where Are We Going?

Thumb-base osteoarthritis (TBOA) is a common condition, mostly affecting post-menopausal women, often inducing a significant impact on quality of life and hand functionality. Despite its high prevalence and disability, the therapeutic options in TBOA are still limited and few have been investigated. Among the pharmacological strategies for TBOA management, it would be worthwhile to mention the injection-based therapy. Unfortunately, its efficacy is still the subject of debate. Indeed, the 2018 update of the European League Against Rheumatism (EULAR) recommendations for the management of hand osteoarthritis (OA) stated that intra-articular (IA) injections of glucocorticoids should not generally be used, but may be considered in patients with painful interphalangeal joints, without any specific mention to the TBOA localization and to other widely used injections agents, such as hyaluronic acid (HA) and platelet-rich plasma (PRP). Even American College of Rheumatology (ACR) experts conditionally recommended against IA HA injections in patients with TBOA, while they conditionally encouraged IA glucocorticoids. However, the recommendations from international scientific societies don’t often reflect the clinical practice of physicians who routinely take care of TBOA patients; indeed, corticosteroid injections are a mainstay of therapy in OA, especially for patients with pain refractory to oral treatments and HA is considered as a safe and effective treatment. The discrepancy with the literature data is due to the great heterogeneity of the clinical trials published in this field: indeed, the studies differ for methodology and protocol design, outcome measures, treatment (different formulations of HA, steroids, PRP, and schedules) and times of follow-up. For these reasons, the current review will provide deep insight into the injection-based therapy for TBOA, with particular attention to the different employed agents, the variety of the schedule treatments, the most common injection techniques, and the obtained results in terms of efficacy and safety. In depth, we will discuss the available literature on corticosteroids and HA injections for TBOA and the emerging role of PRP and other injection agents for this condition. We will consider in our analysis not only randomized controlled trials (RCTs) but also recent pilot or retrospective studies trying to step forward to identify satisfactory management strategies for TBOA.

Accuracy of an algorithm to identify rheumatoid arthritis in the Longitudinal Ageing Study Amsterdam population: a validation study

Objective: In view of global ageing and the scarcity of knowledge about disease determinants in older individuals with rheumatoid arthritis (RA), an algorithm with optimal diagnostic accuracy was developed to identify RA patients in the Longitudinal Ageing Study Amsterdam (LASA).Method: Four case ascertainment algorithms were constructed and assessed for validity in LASA, an ongoing cohort study (≥ 55 years) representing the general older population of the Netherlands. Data sources used to identify the diagnosis RA were: self-reported morbidity, specialist diagnosis, and medication. A validation subsample of LASA participants was taken to verify RA diagnosis by a standard procedure using a checklist.Results: Data from 272/300 (91%) participants were verified. Four algorithms were developed: 'treatment', 'diagnosis', 'treatment or diagnosis', and 'treatment and diagnosis'. The algorithm 'treatment and diagnosis' showed the best measurement properties: specificity 100%, positive predictive value 100%, and area under the receiver operating characteristics curve 0.72. Applying this algorithm in the LASA sample (mean age 71 years) revealed a prevalence of RA of 1.0% (19/1908 participants).Conclusion: An algorithm for RA identification in the LASA population was developed, with high diagnostic accuracy. It provides an accurate tool to identify older adults with RA in LASA and, after validation, may be applicable in other large population-based studies.

Injection Techniques for Common Chronic Pain Conditions of the Hand: A Comprehensive Review

INTRODUCTION

This compilation presents a comprehensive review of the literature on common chronic pain conditions of the hand. It briefly presents these common conditions with their biological background, diagnosis, and common management options. It then presents and compares the latest literature available for injection techniques to treat these diagnoses and compares the available evidence.

METHODS

A comprehensive literature review was performed in MEDLINE, PubMed, and Cochrane databases from 1996 to 2019 using the terms "hand pain", "injection techniques", "steroid injection", "chronic pain", "osteoarthritis", "rheumatoid arthritis", "carpal tunnel syndrome", "De Quervain's tenosynovitis", "ganglion cyst", "gout", "Raynaud's", and "stenosing tenosynovitis".

RESULTS

Hand pain is a common condition with 9.7% prevalence in men and 21.6% in women and can cause significant morbidity and disability. It also carries a significant cost to the individuals and the healthcare system, totaling in $4 billion dollars in 2003. Injection therapy is an alternative when conservative treatment fails. Osteoarthritis is the most common chronic hand pain syndrome and affects about 16% of the population. Its mechanism is largely mechanic, and as such, there is controversy if steroid injections are of benefit. Hyaluronic acid (HA) appears to provide substantial relief of pain and may increase functionality. More studies of HA are required to make a definite judgment on its efficacy. Similarly, steroid ganglion cyst injection may confer little benefit. Carpal tunnel syndrome is a compressive neuropathy, and only temporarily relieved with injection therapy. US-guidance provides significant improvement and, while severe cases may still require surgery, can provide a valuable bridge therapy to surgery when conservative treatment fails. Similar bridging treatments and increased efficacy under US-guidance are effective for stenosing tenosynovitis ("trigger finger"), though, interestingly, inflammatory background is associated with decreased effect in this case. When the etiology of the pain is inflammatory, such as in RA, corticosteroid (CS) injections provide significant pain relief and increased functionality. They do not, however, change the course of disease (unlike DMARDs). Another such example is De-Quervain tenosynovitis that sees good benefit from CS injections, and an increased efficacy with US-guidance, and similarly are CS injections for gout. For Raynaud's phenomenon, Botox injections have encouraging results, but more studies are needed to determine safety and efficacy, as well as the possible difference in effect between primary and secondary Raynaud's.

CONCLUSIONS

Chronic hand pain is a prevalent and serious condition and can cause significant morbidity and disability and interferes with independence and activities of daily living. Conservative treatment remains the first line of treatment; however, when first-line treatments fail, steroid injections can usually provide benefit. In some cases, HA or Botox may also be beneficial. US-guidance is increasing in hand injection and almost ubiquitously provides safer, more effective injections. Hand surgery remains the alternative for refractory pain.

Effects of Comorbid Cardiovascular Disease and Diabetes on Hand Osteoarthritis, Pain, and Functional State Transitions: The Johnston County Osteoarthritis Project

OBJECTIVE

The purpose of this study is to examine the course of hand osteoarthritis (HOA) and its relationship with cardiovascular disease (CVD) and diabetes (DM).

METHODS

Data were collected at 3 timepoints from 845 Johnston County Osteoarthritis Project participants (two-thirds women, one-third African Americans, mean age 60 yrs) with and without HOA, CVD, or DM. A diagnosis of radiographic HOA (rHOA) required a Kellgren-Lawrence severity grade of ≥ 2 in at least 3 joints in each hand. A 4-state progressive model included transitions based on rHOA and pain or function as defined using the Australian/Canadian HOA Index (AUSCAN). Markov multistate models estimated HR (aHR) and 95% CI for associations between DM or CVD and specific state transitions, adjusting for baseline and time-varying covariates.

RESULTS

Participants with DM (vs those without DM) were more likely to experience worsening pain with rHOA. Individuals who had or developed CVD (vs those who did not) were significantly less likely to experience symptomatic improvement, regardless of rHOA status. Those with DM or CVD (vs those without these comorbidities) were less likely to experience improvement in function, although this was statistically significant only for those with DM and no rHOA.

CONCLUSION

Overall, having or developing DM and/or CVD reduced the likelihood of symptomatic and functional improvement over time, suggesting an effect of comorbid CVD and DM on the clinical and radiographic course of HOA. Additional studies are needed to confirm these findings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

ISRCTN registry, ISRCTN62513257 . Registered on 17 May 2012.

The Effect of Simulated Total Distal Interphalangeal Joint Stiffness on Grip Strength

Purpose

Production of a functional grip pattern requires the concerted action of numerous structures within the hand. This study quantifies the effect of total distal interphalangeal joint (DIPJ) stiffness to grip strength.

Methods

Fifty (25 men, 25 women, 100 hands) individuals with a mean age of 38 years (range: 17-69 years) were recruited. Exclusion criteria included history of previous upper limb injury, neuropathies, or systemic disease. Custom thermoplastic orthoses were used to splint participants' DIPJ in full extension simulating stiffness. Grip strength before and after splinting was measured using a calibrated Jamar dynamometer. Data were analyzed using paired and independent sample t tests and 2 × 2 repeated-measures analysis of variance with hand dominance and configuration (splinted or unsplinted) as within-subject factors.

Results

Restriction of DIPJ flexion led to a 20% decrease in grip strength (P < .001). There was no significant difference in this decrease between dominant and non-dominant hands. Univariate analysis did not demonstrate any interaction between hand dominance and testing configuration. Post hoc analysis revealed no statistical difference in baseline grip strength between the dominant and non-dominant hands. Furthermore, men had significantly stronger grip strength than women in all configurations (P < .001).

Conclusions

Flexion at the DIPJ contributes significantly to grip strength, and stiffness at this joint greatly limits functional capabilities of the hand. This necessitates the need for targeted rehabilitation in DIPJ injuries to minimize adverse effects on grip strength.

Calcium-Containing Crystals and Osteoarthritis: an Unhealthy Alliance

PURPOSE OF REVIEW

Osteoarthritis (OA) is the most common form of joint disease globally and is associated with significant morbidity and disability. Increasing evidence points to an important inflammatory component in the development and progression of OA. The precise pathways involved in OA inflammatory processes remain to be clarified. Basic calcium phosphate (BCP) and calcium pyrophosphate dihydrate (CPP) crystals can induce inflammation and arthritis and recent studies point to a potential pathogenic role in OA. In the light of this evidence, we explore the relationship and potential mechanistic pathways linking calcium-containing crystals and OA.

RECENT FINDINGS

CPP crystals induce inflammation through the NLRP3 inflammasome while BCP crystals mediate both NLRP3 dependent and independent effects. BCP crystals have been demonstrated to induce key mitogenic and inflammatory pathways and contribute to cartilage degradation. Calcium-containing crystals induce key inflammatory pathways and may represent an attractive novel target in OA, a condition devoid of effective treatments.

[The feasibility of the application of cryotherapy and radonotherapy for the treatment of the patients presenting with osteoarthritis]

Osteoarthritis (OA) is currently considered to be one of the most widespread diseases. Its main clinical symptoms include pain and dysfunction of joints. In the present review of the foreign and domestic literature, the questions of pathogenesis and risk factors underlying the development of osteoarthritis are discussed. The understanding of OA pathogenesis have altered essentially in the recent years which made necessary the search for the novel approaches to the treatment of this pathology. According to the modern views of OA origin and progression, its therapy should be based on the application of the combination of medicamentous and non-medicamentous modalities including, in particular, collective and individual activities focused on the implementation of the programs of therapeutic physical training as an obligatory component of ОА prophylaxis and treatment. The present review gives evidence of the feasibility of the application of the methods of cryotherapy and radonotherapy for the management of the patients suffering from osteoarthritis. It is emphasized that many recent publications report extensive investigations of the clinical and pathogenetic aspects of the application of these methods for the combined regenerative treatment of the patients presenting with gonarthrosis. The influence of cryotherapy and radonotherapy on the neuroendocrine and immune systems is discussed with special reference to the possibility of regulation of the metabolic processes and retardation of inflammation. It is concluded that the introduction of the above methods into the compulsory individual program for the regenerative treatment of patients presenting with osteoarthritis is pathologically substantiated since it greatly contributes to the reduction of pain and retardation of the progress of the disease. The main pharmaceutical preparations for the OA treatment remain to be slow-acting symptomatic medicines possessed of the chondro-protective effect.

Changes in disability in older adults with generalized radiographic osteoarthritis: A complex relationship with physical activity

OBJECTIVE

The aim of the present study was to report on factors associated with changes in disability after 5 years, with a focus on physical activity (PA) in community-dwelling older adults with generalized radiographic osteoarthritis (GROA).

METHODS

Assessment of GROA (hand, knee, hip) and disability (Health Assessment Questionnaire) in the Rotterdam Study (cohort RS-1, N = 7,983; with GROA, n = 821). A good outcome at follow-up was defined as improved or mild disability, and a poor outcome as worsened or severe disability. Factors potentially associated with outcome were demographics, joint complaints, other chronic health problems or limitations (body mass index, number of chronic conditions, cognition), and level of different types of PA. Some of these assessments were repeated in between 1997 and 1999 (RS-3), and between 2002 and 2004 (RS-4).

RESULTS

A total of 309 older adults with GROA and valid measures on RS-3 and RS-4 showed mild to moderate disability, with minor increases over 5 years (follow-up N = 287 RS-3 to RS-4). PA levels decreased with increasing disability, especially in sport and walking. PA was univariately associated with a better outcome at follow-up but when adjusted for other factors (higher age, having knee pain and stiffness, and having more than two other chronic conditions) was associated with negative changes in general and lower limb disability, although not with upper limb disability.

CONCLUSIONS

This was the first study to report that community-dwelling older adults with GROA show moderate levels of disability, and that reduced levels of disability are associated with higher levels of PA, but when adjusted for other confounders this association is lost. Further research is needed to study the complex relationships between PA and other determinants of disability.

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

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

Evidence-Based Medicine: Thumb Basal Joint Arthritis

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Assess the patient's history, clinical examination, and radiographic findings to diagnose and stage basilar joint arthritis. 2. Recall the cause and epidemiology of the condition. 3. Formulate a management plan including nonoperative management, and evaluate the candidacy for surgical treatment. 4. Understand the rationale for the various surgical options available (including rehabilitation), their potential complications, and the evidence related to outcomes.

SUMMARY

This article has been prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It is designed for clinicians to analyze and structure their care of a patient with arthritis of the trapeziometacarpal joint.

Single-arm open-label study of Durolane (NASHA nonanimal hyaluronic acid) for the treatment of osteoarthritis of the thumb

Introduction

Osteoarthritis of the trapeziometacarpal (TMC) joint of the thumb – also known as rhizarthrosis – is painful and has a significant impact on quality of life. Intra-articular injection of hyaluronic acid may potentially meet the need for effective, minimally invasive intervention in patients not responding adequately to initial treatment. We aimed to confirm the safety and effectiveness of viscosupplementation with Durolane (NASHA nonanimal hyaluronic acid) in rhizarthrosis.

Patients and methods

This was a prospective, single-arm, multicenter, open-label study with a 6-month follow-up period. Eligible patients had Eaton–Littler grade II–III rhizarthrosis in one TMC joint with pain and visual analog scale (VAS) pain score ≥4 (scale: 0–10). A single injection of NASHA was administered to the affected TMC joint. The primary effectiveness variable was change from baseline in VAS pain score.

Results

Thirty-five patients (mean age 60.8 years; 85.7% female) received NASHA and completed the study. The least-squares mean change from baseline in VAS pain score over 6 months was −2.00, a reduction of 27.8% (p<0.001). The reduction in pain exceeded 25% as early as month 1 (26.5%), and gradual improvement was observed throughout the 6-month follow-up period. Secondary effectiveness parameters included QuickDASH (shortened version of Disabilities of the Arm, Shoulder, and Hand [DASH]), Kapandji thumb opposition test, radial abduction, metacarpophalangeal (MCP) joint flexion, and pinch (clamp) strength. Most of these measurements showed statistically significant improvements from baseline over 6 months. Five adverse events (injection site reactions) were reported in four patients (11.4%), and there were no serious or allergic reactions.

Conclusion

This study suggests that viscosupplementation using NASHA is effective and well tolerated in treating the symptoms of rhizarthrosis.

Influence of upper limb disability, manual dexterity and fine motor skill on general self-efficacy in institutionalized elderly with osteoarthritis

STUDY DESIGN

Descriptive, cross-sectional.

INTRODUCTION

The impact of upper limb (UL) disability, dexterity and fine motor skill on self-efficacy in older adults with osteoarthritis (OA) is not well known yet.

PURPOSES OF THE STUDY

To evaluate the self-efficacy and its relationship with UL function/disability in institutionalized OA.

METHODS

Institutionalized adults (n = 45) over the age of 65 years with OA were evaluated in a single session, to determine pinch strength, active range of motion of the hand and UL disability and functionality. They were classified as self-efficacious or not based on their general self-efficacy level. The influence on self-efficacy on upper limb function was statistically analyzed using bivariate and multivariate regression analyses.

RESULTS

Self-effective older adults showed significantly lower scores in disability and higher scores in pinch strength, dexterity and motion of thumb than those who were classified as non-self-effective. Self-efficacy was associated with pinch strength (p ≤ 0.038), disability (p < 0.001) and dexterity (p ≤ 0.048). Multiple regression analyses showed that disability explained almost 40% of the variability of self-efficacy.

CONCLUSIONS

Older adults classified as non-self-effective have higher UL disability and less pinch strength, manual dexterity and thumb motion than those who are self-effective, suggesting a relationship between impairment and perceived ability.

Prevalence of hand osteoarthritis and its relationship to hand pain and grip strength in Japan: The third survey of the ROAD study

OBJECTIVES

To examine the prevalence and pattern of hand osteoarthritis (HOA), and determine its relationship with grip strength and hand pain.

METHODS

Among the participants of the third survey of the Research on Osteoarthritis/Osteoporosis Against Disability (ROAD) study, 507 Japanese men and 1028 Japanese women were included. Radiographs of both hands were graded for osteoarthritis (OA) using the modified Kellgren-Lawrence (KL) scale. HOA was defined as the presence of at least one affected joint. The absence or presence of subchondral erosion was also scored.

RESULTS

The prevalence of HOA (KL grade ≥2) was 89.9% in men and 92.3% in women (p = 0.11), and it was significantly associated with age. OA in the distal interphalangeal (DIP) joint was the highest overall. After adjusting for age, sex, body mass index, and the residing area, both severity (KL grade ≥3) and erosion were significantly related to low grip strength and hand pain. With regard to the joint groups, severe OA in the DIP and first carpometacarpal joints were related to hand pain.

CONCLUSION

This study showed a high prevalence of radiographic HOA and a significant relationship between hand pain and the severity of HOA, in addition to erosion.

Evaluation of jar lid design characteristics by older women with hand use limitations

The study evaluated several lid design characteristics (diameter, height, top shape, side shape, and surface texture) by means of controlled laboratory testing with older women with hand function limitations. A subjective evaluation process was applied to examine main effects and interactions of lid design characteristics on usability, determined by participants' perceptions of effort and discomfort. Results showed that lid height was the most important design characteristic associated with usability. For 42 mm diameter lids, designs perceived as best were ones with taller height, hexagonal top shape, and convex side shape. For 28 mm diameter lids, the best designs were ones with taller height and hexagonal top shape. Additionally, when the smaller lid's side shape was flat, a serrate surface texture provided some advantages, particularly for subjects with more severe hand dysfunction. This information could be used by package designers to improve jar lid usability for a growing sector of consumers.

Musculoskeletal Hand Symptoms and Functional Limitation in Community-Dwelling Adults Aged 50 Years and Over: Results from a Cross-Sectional Study

Introduction:

Hand pain and problems are common in community-dwelling adults aged 50 years and over. As the population ages, the absolute number of people with these issues is likely to increase. Debilitating hand problems affect at least 12% of the older population in the United Kingdom, but fewer than 1 in 30 people with this degree of disability consult an occupational therapist.

Method:

This paper describes a new analysis of a population study using data from surveys and a nested clinical cohort. Demographic characteristics, and the nature, severity, and frequency of symptoms and functional limitation in 1,811 adults aged 50 years and over with disabling hand problems are described, and the potential need for healthcare estimated.

Findings:

Moderate or severe functional limitation within the previous week was commonly reported. Irrespective of age and gender, weakness was the most frequently reported severe symptom (n = 470, 27%). Most problems occurred in activities requiring strength (such as opening a jar: n = 945, 52%). More females reported difficulty with tasks requiring strength (such as opening a jar: f: 59%; m: 38%), and more males reported difficulty with dexterous activities (such as picking up coins: m: 24%; f: 17%).

Conclusion:

The results from this study have implications for current and future management of hand problems in the community, highlighting a potential role for occupational therapy.

The role of imaging in early hip OA

Hip osteoarthritis (OA) is characterized by cartilage degradation, subchondral bone sclerosis and osteophyte formation. Nowadays, OA is thought to develop via different etiologies that all lead to a similar form of end stage joint degradation. One of these subtypes is related to an abnormal shaped hip joint, like acetabular dysplasia and a cam deformity. These bony abnormalities are highly predictive for development of hip OA, but they are likely to already be present from childhood. This suggests that these deformations induce OA changes in the hip, well before extensive hip degradation becomes present three to four decades later. Accurate detection and successful characterization of these early OA events might lead to better treatment options for hip OA besides nowadays available invasive joint replacement surgery. However, current diagnostic imaging techniques like radiographs or plain magnetic resonance imaging (MRI), are not sensitive enough to detect these subtle early OA changes. Nor are they able to disentangle intertwined and overlapping cascades from different OA subtypes, and neither can they predict OA progression. New and more sensitive imaging techniques might enable us to detect first OA changes on a cellular level, providing us with new opportunities for early intervention. In this respect, shape analysis using radiography, MRI, computed tomography (CT), single photon emission computed tomography (SPECT)/CT, and positron emission tomography (PET) might prove promising techniques and be more suited to detect early pathological changes in the hip joint. A broad application of these techniques might give us more understanding what can be considered physiological adaptation of the hip, or when early OA really starts. With a more clear definition of early OA, more homogenous patient populations can be selected and help with the development of new disease modifying OA interventions.

Preference of lid design characteristics by older adults with limited hand function

INTRODUCTION

Although opening jars is problematic for older adults, little is known about the best interface design for jar lids.

PURPOSE OF THE STUDY

To evaluate preferences in current and new lids for persons self-reporting difficulty with opening jars.

METHODS

Participants were twenty-six older females with hand pain. Preference ratings were obtained for twenty-four current and forty-two new lid designs of different sizes, shapes, and textures.

RESULTS

Current lids with taller heights, larger diameters, and textured sides were preferred. Texture compensated for limitations of shorter and smaller diameter lids. Preferred characteristics in new smaller diameter lids included taller height, non-circular top shapes, and concave side shapes. Taller height, regardless of shape, was preferred for new medium diameter lids. Least preferred for small and medium lids was the short height, traditional circular shape.

CONCLUSIONS

The preferences of jar lids made by elderly females with hand pain support the recommendations commonly suggested by clinicians to increase the height, diameter, texture, and shape of jars, especially for lids smaller than 40 mm.

Night-time immobilization of the distal interphalangeal joint reduces pain and extension deformity in hand osteoarthritis

Objective. DIP joint OA is common but has few cost-effective, evidence-based interventions. Pain and deformity [radial or ulnar deviation of the joint or loss of full extension (extension lag)] frequently lead to functional and cosmetic issues. We investigated whether splinting the DIP joint would improve pain, function and deformity.

Methods. A prospective, radiologist-blinded, non-randomized, internally controlled trial of custom splinting of the DIP joint was carried out. Twenty-six subjects with painful, deforming DIP joint hand OA gave written, informed consent. One intervention joint and one control joint were nominated. A custom gutter splint was worn nightly for 3 months on the intervention joint, with clinical and radiological assessment at baseline, 3 and 6 months. Differences in the change were compared by the Wilcoxon signed rank test.

Results. The median average pain at baseline was similar in the intervention (6/10) and control joints (5/10). Average pain (primary outcome measure) and worst pain in the intervention joint were significantly lower at 3 months compared with baseline (P = 0.002, P = 0.02). Differences between intervention and control joint average pain reached significance at 6 months (P = 0.049). Extension lag deformity was significantly improved in intervention joints at 3 months and in splinted joints compared with matched contralateral joints (P = 0.016).

Conclusion. Short-term night-time DIP joint splinting is a safe, simple treatment modality that reduces DIP joint pain and improves extension of the digit, and does not appear to give rise to non-compliance, increased stiffness or joint restriction.

Trial registration: clinical trials.gov, http://clinicaltrials.gov, NCT01249391.

Cross-sectional and longitudinal associations between radiographic features and measures of pain and physical function in hand osteoarthritis

OBJECTIVE

Previous longitudinal studies have shown no associations between increasing amount of radiographic hand osteoarthritis (OA) and levels of hand pain/disability. In this longitudinal study, we aimed to study whether radiographic hand OA was related to pain/disability in cross-sectional and longitudinal settings focusing on joint-specific analyses.

METHODS

We included 190 patients (173 women, mean (standard deviation, SD) age 61.5 (5.7) years) from the Oslo hand OA cohort, of whom 112 had 7-year follow-up data. Finger joints were scored for radiographic OA according to the Kellgren-Lawrence scale and Osteoarthritis Research Society International (OARSI) atlas. Pain and function were assessed by clinical examination (joint tenderness), grip strength and the Australian/Canadian (AUSCAN) questionnaire. Associations between radiographic hand OA and tenderness in the same joint were examined by logistic regression analyses with Generalized Estimating Equations, whereas associations between overall amount of radiographic OA and hand pain/disability were assessed by linear regression (adjusted for age and sex).

RESULTS

A dose-dependent association was found between the severity of radiographic OA and tenderness in the same joint. Joints that progressed into severe radiographic OA during follow-up had the highest odds of developing tenderness (OR = 11, 95% confidence interval (CI) 4.0-33). Incident erosions seemed to be the most important individual feature associated with incident tenderness (OR = 6.2, 95% CI 3.2-12). Weak associations were found between the amount of radiographic hand OA and overall hand pain/disability.

CONCLUSION

Radiographic hand OA is associated with tenderness in the same joint, and erosive development strongly predicts future joint tenderness independent of other radiographic features.

Guidance on the management of pain in older people

This guidance document reviews the epidemiology and management of pain in older people via a literature review of published research. The aim of this document is to inform health professionals in any care setting who work with older adults on best practice for the management of pain and to identify where there are gaps in the evidence that require further research. The assessment of pain in older people has not been covered within this guidance and can be found in a separate document (http://www.britishpainsociety.org/pub_professional.htm#assessmentpop). Substantial differences in the population, methods and definitions used in published research makes it difficult to compare across studies and impossible to determine the definitive prevalence of pain in older people. There are inconsistencies within the literature as to whether or not pain increases or decreases in this age group, and whether this is influenced by gender. There is, however, some evidence that the prevalence of pain is higher within residential care settings. The three most common sites of pain in older people are the back; leg/knee or hip and 'other' joints. In common with the working-age population, the attitudes and beliefs of older people influence all aspects of their pain experience. Stoicism is particularly evident within this cohort of people. Evidence from the literature search suggests that paracetamol should be considered as first-line treatment for the management of both acute and persistent pain, particularly that which is of musculoskeletal origin, due to its demonstrated efficacy and good safety profile. There are few absolute contraindications and relative cautions to prescribing paracetamol. It is, however, important that the maximum daily dose (4 g/24 h) is not exceeded. Non-selective non-steroidal anti-inflammatory drugs (NSAIDs) should be used with caution in older people after other safer treatments have not provided sufficient pain relief. The lowest dose should be provided, for the shortest duration. For older adults, an NSAID or cyclooxygenase-2 (COX-2) selective inhibitor should be co-prescribed with a proton pump inhibitor (PPI), and the one with the lowest acquisition cost should be chosen. All older people taking NSAIDs should be routinely monitored for gastrointestinal, renal and cardiovascular side effects, and drug–drug and drug–disease interactions. Opioid therapy may be considered for patients with moderate or severe pain, particularly if the pain is causing functional impairment or is reducing their quality of life. However, this must be individualised and carefully monitored. Opioid side effects including nausea and vomiting should be anticipated and suitable prophylaxis considered. Appropriate laxative therapy, such as the combination of a stool softener and a stimulant laxative, should be prescribed throughout treatment for all older people who are prescribed opioid therapy. Tricyclic antidepressants and anti-epileptic drugs have demonstrated efficacy in several types of neuropathic pain. But, tolerability and adverse effects limit their use in an older population. Intra-articular corticosteroid injections in osteoarthritis of the knee are effective in relieving pain in the short term, with little risk of complications and/or joint damage. Intra-articular hyaluronic acid is effective and free of systemic adverse effects. It should be considered in patients who are intolerant to systemic therapy. Intra-articular hyaluronic acid appears to have a slower onset of action than intra-articular steroids, but the effects seem to last longer. The current evidence for the use of epidural steroid injections in the management of sciatica is conflicting and, until further larger studies become available, no firm recommendations can be made. There is, however, a limited body of evidence to support the use of epidural injections in spinal stenosis. The literature review suggests that assistive devices are widely used and that the ownership of devices increases with age. Such devices enable older people with chronic pain to live in the community. However, they do not necessarily reduce pain and can increase pain if used incorrectly. Increasing activity by way of exercise should be considered. This should involve strengthening, flexibility, endurance and balance, along with a programme of education. Patient preference should be given serious consideration. A number of complementary therapies have been found to have some efficacy among the older population, including acupuncture, transcutaneous electrical nerve stimulation (TENS) and massage. Such approaches can affect pain and anxiety and are worth further investigation. Some psychological approaches have been found to be useful for the older population, including guided imagery, biofeedback training and relaxation. There is also some evidence supporting the use of cognitive behavioural therapy (CBT) among nursing home populations, but of course these approaches require training and time. There are many areas that require further research, including pharmacological management where approaches are often tested in younger populations and then translated across. Prevalence studies need consistency in terms of age, diagnosis and terminology, and further work needs to be done on evaluating non-pharmacological approaches.

Quantitative sensory testing in painful hand osteoarthritis demonstrates features of peripheral sensitisation

Hand osteoarthritis (HOA) is a prevalent condition for which treatments are based on analgesia and physical therapies. Our primary objective was to evaluate pain perception in participants with HOA by assessing the characteristics of nodal involvement, pain threshold in each hand joint, and radiological severity. We hypothesised that inflammation in hand osteoarthritis joints enhances sensitivity and firing of peripheral nociceptors, thereby causing chronic pain. Participants with proximal and distal interphalangeal (PIP and DIP) joint HOA and non-OA controls were recruited. Clinical parameters of joint involvement were measured including clinical nodes, VAS (visual analogue score) for pain (0-100 mm scale), HAQ (health assessment questionnaire), and Kellgren-Lawrence scores for radiological severity and pain threshold measurement were performed. The mean VAS in HOA participants was 59.3 mm ± 8.19 compared with 4.0 mm ± 1.89 in the control group (P < 0.0001). Quantitative sensory testing (QST) demonstrated lower pain thresholds in DIP/PIP joints and other subgroups in the OA group including the thumb, metacarpophalangeal (MCPs), joints, and wrists (P < 0.008) but not in controls (P = 0.348). Our data demonstrate that HOA subjects are sensitised to pain due to increased firing of peripheral nociceptors. Future work to evaluate mechanisms of peripheral sensitisation warrants further investigation.

Self-management strategies to support performance of daily activities in hand osteoarthritis

AIMS

The main aim of this study was to explore self-management strategies in persons with hand osteoarthritis (HOA).

METHODS

Self-management strategies were explored in semi-structured interviews, in which 125 participants described strategies, use of devices or equipment, and advice they would give to people with HOA concerning how to manage their daily life.

RESULTS

The participants made a total of 483 statements, which were classified into 27 discrete strategies, and thereafter grouped into 13 broader strategies within three categories: general behavioural strategies, HOA-specific behavioural strategies, and cognitive strategies. The broad strategy "activity accommodations" specifically addressed performance of daily activities in people with HOA, comprising "use assistive devices", "adapt tools, materials or working techniques", "practise activity pacing" and "stop or avoid certain activities", of which the two first were the most frequently stated by participants.

CONCLUSIONS

People with HOA use a wide variety of self-management strategies to support performance of daily activities, in which use of assistive devices and activity adaptation are the most frequently reported strategies. Patient-recommended self-management strategies should be included in written information material and patient education programmes, which should be developed in cooperation with patient representatives and made available for patients soon after they are diagnosed.

Factors associated with the severity and progression of self-reported hand pain and functional difficulty in community-dwelling older adults: a systematic review

BACKGROUND

Hand problems are common in older adults and cause significant pain and disruption to everyday living. The aim of this systematic review was to summarize evidence on the factors associated with the severity and progression of self-reported hand pain and functional difficulty in population-based studies of older adults.

METHODS

MEDLINE, EMBASE, CINAL, BNI, AMED, HMIC, PsycINFO and ISI Web of Knowledge were searched up to January 2011 for relevant articles. The search strategy combined text words for hand, pain, function and epidemiological study. Inclusion criteria were applied and articles in the review assessed for quality using the QUality In Prognosis Studies (QUIPS) assessment tool. Data extraction included: author, year of publication, study location, participant inclusion criteria, risk factor and outcome measurement, and association with hand pain and/or function.

RESULTS

Seven articles from five studies met the inclusion criteria from 5,679 citations. All studies were cross-sectional and provided no information on progression of hand pain and function over time. Factors associated with limited hand function were older age, female gender, manual occupation, neck or shoulder pain, clinical and radiographic osteoarthritis, weaker hand strength, hand pain, history of Parkinson's disease, stroke, diabetes or rheumatoid arthritis, and illness perceptions (namely, frustration, impact and symptom count). Key factors associated with hand pain severity were age, impact, frustration, patient expectation of a long disease time course and self-reported diagnosis of the cause of the hand problem.

CONCLUSIONS

Both demographic and clinical factors were found to be related to self-reported hand pain severity and functional difficulty in older adults; however, the results were derived from a small number of studies, with no information on progression of hand pain and functional difficulty over time.

Muscle activation during hand dexterity tasks in women with hand osteoarthritis and control subjects

STUDY DESIGN

Descriptive cross-sectional study.

INTRODUCTION

Hand osteoarthritis (OA) is a condition that results in hand pain and disability. It is important to understand how muscle function impairments contribute to impaired dexterity.

PURPOSE OF THE STUDY

To compare muscle activation in women with and without hand OA and determine if the activation relates to measures of impairment and disability.

METHODS

Electromyography (EMG) was recorded from four muscles of the hand/forearm while subjects threaded (assembly) and unthreaded (disassembly) a small bolt. The groups were compared on the integrated EMG (IEMG) of four muscles using two-way repeated-measures analyses of covariance for the assembly and disassembly tasks.

RESULTS

No differences were found in muscle activation between groups when IEMG values were normalized by time (p>0.05).

CONCLUSIONS

Patients with OA have some indicators of altered muscle function. It is unclear whether these are adaptive or predisposing changes. When controlling for the time to perform a task, there were no significant IEMG differences between women with hand OA and control subjects.

LEVEL OF EVIDENCE

2b.

Determinants of incident and persistent finger joint pain during a five-year followup among female dentists and teachers

OBJECTIVE

To investigate the association of radiographic finger osteoarthritis (OA), hand use, and lifestyle factors with incident and persistent finger joint pain among female dentists and teachers.

METHODS

Random samples of female dentists (n = 295) and teachers (n = 248) ages 45-63 years were examined by radiography for the presence of finger joint OA. Body weight was measured. Information on finger joint pain during the past 30 days, height, smoking, and leisure-time hand activity was collected by questionnaire. Five years later, 482 women (89%; 65% still active occupationally) responded to a survey on finger joint pain.

RESULTS

The incidence and persistence of finger joint pain were higher among the subjects with OA compared to those without OA. The relative risk (RR) of incident pain in the first through the third fingers was 1.8 (95% confidence interval [95% CI] 1.2-2.7) in the right hand and the RR in the left hand was 3.0 (95% CI 2.0-4.6), allowing for age, occupation, and lifestyle factors. The corresponding figures for the fourth and fifth fingers were RR 2.3 (95% CI 1.4-3.8) in the right and RR 1.9 (95% CI 1.1-3.5) in the left hand. Regarding persistent pain, the RRs varied between 2.4 and 5.4. Body mass index, smoking, or leisure-time hand activity were not associated with pain. The dentists tended to have a higher incidence of pain in the first through the third fingers of the right hand compared with the teachers.

CONCLUSION

Radiographic finger joint OA was a significant determinant of both persistent and incident finger joint pain in a 5-year followup among middle-aged women. Hand use may modify the association between radiographic OA and finger joint pain.

Extended roles of non-physician health professionals and innovative models of care within Europe: results from a web-based survey

BACKGROUND AND OBJECTIVE

Due to the increasing prevalence of rheumatic diseases, extended roles of non-physician health professionals and innovative models of care may be important options in rheumatology in the future. Extended roles have been pioneered in the UK, Canada, USA and Australia and been found to be effective and safe. However, few data are available about mainland Europe, so the aim of this study was to explore the current status of the extended roles undertaken by health professionals within Europe, and the corresponding models of care used.

METHODS

Non-physician health professionals from various European countries were asked to complete a web-based survey using convenience and snowball sampling techniques. Data analysis involved calculating descriptive statistics and frequencies based on the countries where the participants currently worked.

RESULTS

Of the 479 health professionals who filled in the survey, 430 (92%) indicated that they were performing extended roles. Considerable differences between the 27 participating countries existed, in terms of which extended roles and which innovative models of care were being used. Barriers to performing extended roles were cited as the attitude of rheumatologists in all but eight countries, while attitudes of patients were less common barriers. Lack of knowledge, education and educational opportunities were also experienced in several countries.

CONCLUSION

The present study produced the first data on extended roles for non-physician health professionals and corresponding innovative models of care in rheumatology within Europe. We recommend increasing educational opportunities, as well as developing strategies to limit the barriers experienced.

Hand assessment in older adults with musculoskeletal hand problems: a reliability study

BACKGROUND

Musculoskeletal hand pain is common in the general population. This study aims to investigate the inter- and intra-observer reliability of two trained observers conducting a simple clinical interview and physical examination for hand problems in older adults. The reliability of applying the American College of Rheumatology (ACR) criteria for hand osteoarthritis to community-dwelling older adults will also be investigated.

METHODS

Fifty-five participants aged 50 years and over with a current self-reported hand problem and registered with one general practice were recruited from a previous health questionnaire study. Participants underwent a standardised, structured clinical interview and physical examination by two independent trained observers and again by one of these observers a month later. Agreement beyond chance was summarised using Kappa statistics and intra-class correlation coefficients.

RESULTS

Median values for inter- and intra-observer reliability for clinical interview questions were found to be "substantial" and "moderate" respectively [median agreement beyond chance (Kappa) was 0.75 (range: -0.03, 0.93) for inter-observer ratings and 0.57 (range: -0.02, 1.00) for intra-observer ratings]. Inter- and intra-observer reliability for physical examination items was variable, with good reliability observed for some items, such as grip and pinch strength, and poor reliability observed for others, notably assessment of altered sensation, pain on resisted movement and judgements based on observation and palpation of individual features at single joints, such as bony enlargement, nodes and swelling. Moderate agreement was observed both between and within observers when applying the ACR criteria for hand osteoarthritis.

CONCLUSION

Standardised, structured clinical interview is reliable for taking a history in community-dwelling older adults with self reported hand problems. Agreement between and within observers for physical examination items is variable. Low Kappa values may have resulted, in part, from a low prevalence of clinical signs and symptoms in the study participants. The decision to use clinical interview and hand assessment variables in clinical practice or further research in primary care should include consideration of clinical applicability and training alongside reliability. Further investigation is required to determine the relationship between these clinical questions and assessments and the clinical course of hand pain and hand problems in community-dwelling older adults.

The effect of disease site (knee, hip, hand, foot, lower back or neck) on employment reduction due to osteoarthritis

BACKGROUND

Osteoarthritis (OA) has a significant impact on individuals' ability to work. Our goal was to investigate the effects of the site of OA (knee, hip, hand, foot, lower back or neck) on employment reduction due to OA (EROA).

METHODS AND FINDINGS

This study involved a random sample of 6,000 patients with OA selected from the Medical Service Plan database in British Columbia, Canada. A total of 5,491 were alive and had valid addresses, and of these, 2,259 responded (response rate = 41%), from which 2,134 provided usable data. Eligible participants were 19 or older with physician diagnosed OA based on administrative data between 1992 and 2006. Data of 688 residents were used (mean age 62.1 years (27 to 86); 60% women). EROA had three levels: no reduction; reduced hours; and total cessation due to OA. The (log) odds of EROA was regressed on OA sites, adjusting for age, sex, education and comorbidity. Odds ratios (ORs) represented the effect predicting total cessation and reduced hours/total cessation. The strongest effect was found in lower back OA, with OR = 2.08 (95% CI: 1.47, 2.94), followed by neck (OR = 1.59; 95% CI: 1.11, 2.27) and knee (OR = 1.43; 95% CI: 1.02, 2.01). We found an interaction between sex and foot OA (men: OR = 1.94; 95% CI: 1.05, 3.59; women: OR = 0.89; 95% CI = 0.57, 1.39). No significant effect was found for hip OA (OR = 1.33) or hand OA (OR = 1.11). Limitations of this study included a modest response rate, the lack of an OA negative group, the use of administrative databases to identify eligible participants, and the use of patient self-reported data.

CONCLUSIONS

After adjusting for socio-demographic variables, comorbidity, and other OA disease sites, we find that OA of the lower back, neck and knee are significant predictors for EROA. Foot OA is only significantly associated with EROA in males. For multi-site combinations, ORs are multiplicative. These findings may be used to guide resource allocation for future development/improvement of vocational rehabilitation programs for site-specific OA.

There is inadequate evidence to determine the effectiveness of nonpharmacological and nonsurgical interventions for hand osteoarthritis: an overview of high-quality systematic reviews

BACKGROUND

Patients with hand osteoarthritis are commonly treated by health care professionals (allied to medicine). Practice should be informed by updated evidence from systematic reviews of randomized controlled trials.

PURPOSE

The purpose of this overview is to summarize the evidence from systematic reviews of the effectiveness of nonpharmacological and nonsurgical interventions for patients with hand osteoarthritis.

DATA SOURCES AND STUDY SELECTION

Systematic reviews published between January 2000 and October 2008 were identified by a comprehensive literature search.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently selected reviews for inclusion, assessed their methodological quality, and extracted and synthesized data according to predefined criteria. Four systematic reviews finally were included. Based on single randomized controlled trials, there is some evidence of the effect of pain relief from topical capsaicin compared with placebo and for favorable functional outcomes for exercise and education compared with osteoarthritis information alone.

LIMITATIONS

In overviews, results are dependent on available systematic reviews. They are important tools to guide choice of interventions and locate areas where more research is needed, but they might not be useful for deciding specifically how interventions should be carried out.

CONCLUSIONS

There currently is insufficient high-quality evidence regarding nonpharmacological and nonsurgical interventions for hand osteoarthritis. Considering the limited research evidence and the prevalence and impact of the disease, there is an urgent need for more trials of nonpharmacological and nonsurgical interventions for hand osteoarthritis.

Diagnosis and management of patients with hand and wrist problems in general practice

OBJECTIVES

1) To describe diagnoses made by general practitioners (GPs) in patients with hand or wrist problems, 2) to describe management, and 3) to determine the association between diagnostic information and two outcomes: persistent symptoms and specialist referral.

METHODS

GPs recruited patients with hand or wrist problems and completed a standardized form recording information about patient history, observations, palpation, and physical tests. Patients were sent a questionnaire at baseline, 3, and 12 months, containing questions on characteristics and symptom severity. Logistic regression analyses were used to determine the association between diagnostic information and the odds of persistent symptoms or specialist referral.

RESULTS

The three most frequently recorded diagnoses were osteoarthritis (17%), tenosynovitis (16%), and nerve entrapment (13%). "Wait and see" (30%) and painkillers (24%) were most often advised. Higher probability of persistent symptoms at both 3 and 12 months was associated with being female, higher age, long baseline symptom duration, and higher baseline pain intensity score; positive DeQuervain test was associated with lower probability of persistent symptoms. Having a recurrent problem was associated with higher odds of specialist referral.

CONCLUSION

In primary care, physical tests and information about physical signs are of importance in diagnosing patients with hand or wrist problems, but provide limited prognostic information.

Do Heberden and Bouchard nodes affect finger dexterity in elderly?

Elderly often have Heberden nodes (HN) and Bouchard nodes (BN) that may affect finger dexterity. The aim of this cross-sectional study was to assess an effect of HN and BN on finger dexterity of the elderly. The nine-hole peg test was used for dexterity measurement in 200 elderly with HN and/or BN. Mean age was 68.6 +/- 5.39 years. Average performance of each hand was compared between elderly with or without nodes. HN and BN were found in 75 right hands (37.5%) and 73 left hands (36.5%). Nodes were found in females more often than males (p < 0.001). Average right hand dexterity in elderly with and without nodes was 21.6 +/- 3.16 and 21.4 +/- 3.16 s. Average left hand dexterity in elderly with and without nodes was 23.3 +/- 3.13 and 23.3 +/- 3.67 s. There was no significant difference between elderly with or without nodes (p >/= 0.05). In conclusion, HN and BN in elderly hands do not affect finger dexterity. Therapist may use the same training program to prevent deterioration of finger dexterity in elderly with or without nodes.

Hand problems in community-dwelling older adults: onset and effect on global physical function over a 3-year period

OBJECTIVE

To determine the impact of the onset of hand problems on global physical functioning in community-dwelling older adults.

METHODS

Three-year follow-up postal survey of a population sample of older adults (50 yrs and over) previously recruited to the North Staffordshire Osteoarthritis Project. Questionnaires at baseline and 3-yr collected data on joint pain in the past 12 months in the hands and lower limbs, and physical functioning [SF-36 subscale (PF-10)]. Onset of hand problems at 3 yrs was determined in two subgroups: (i) those free from hand problems and lower limb pain at baseline (n = 762) and (ii) those free from hand problems but with lower limb pain at baseline (n = 754). Changes in PF-10 scores from baseline to 3 yrs were examined in these two subgroups.

RESULTS

Onset of hand problems was similar in the two subgroups (20.6 and 24.3% in those without and with baseline lower limb pain, respectively). Females had a higher onset than males but age had little influence. Significantly greater mean change in PF-10 scores was seen in those who reported hand problem onset compared with persons who remained free of hand problems; 8.47 vs 4.62 and 4.78 vs 1.08 in those without and with baseline lower limb pain, respectively.

CONCLUSIONS

The development of hand problems has a detrimental effect on global physical functioning even in the absence of concurrent lower limb problems. The assessment and effective treatment of hand problems could prove to be important components of maintaining function in the older adult with joint pain and OA.

Exercise and hand osteoarthritis symptomatology: a controlled crossover trial

STUDY DESIGN

Randomized Clinical Trial.

INTRODUCTION

Hand exercises have been recommended as treatment for hand osteoarthritis (OA) but research evidence is sparse.

PURPOSE OF THE STUDY

To investigate effects of daily 16-week home-based hand exercise among persons with hand OA.

METHODS

Forty-six older adults completed a crossover trial with washout between exercise and sham treatments. The AUSCAN physical function sub-scale served as the primary outcome measure. Other outcomes included pain and stiffness sub-scales, dexterity, and grip & pinch strengths.

RESULTS

Changes in AUSCAN sub-scales did not differ between exercise and sham treatments. No changes in dexterity were seen. Grip and pinch measures modestly improved after exercise but not sham.

CONCLUSIONS

It is possible that our exercise protocol may have been too ambitious for this age group. Future research will further the understanding of the role of hand exercise in hand OA symptomatology.

LEVEL OF EVIDENCE

2b.