Understanding and treating hand osteoarthritis: a challenge

Osteoarthritis of the hand is a condition prevalent in elderly men and women, and causes significant pain and limitations in daily function. International guidelines recommend that non-pharmacological treatment protocols should be composed multidisciplinary and should focus on different dimensions, e.g. education, improvement of impairments (grip strength and joint mobility), the use of assistive devices and improvement of coping skills. However, there is no evidence on the optimal mixture of treatment components. A multidisciplinary and multidimensional treatment program according to the recommendations of current international guidelines was developed following a systematic approach. The program contained an individual intake, four weekly nurse and occupational therapist-led group sessions and a booster session after six months. Treatment components of the program were self-management, daily home exercises to enhance joint mobility and grip strength, and education about ergonomic principles. 151 patients with osteoarthritis of the hand were randomized to determine the efficacy of the newly developed treatment program compared to a single educational session. Outcomes focused primarily on limitations in activities, along with pain and joint stiffness. At 3 months no significant and no relevant differences were observed between the experimental and control group in any of the outcome measures. In both groups about one-third of patients were classified as responder. Therefore, it was concluded that there is insufficient evidence to confirm a clinically relevant treatment effect on the short term. In addition, one year after the treatment program we found no evidence for the efficacy of a single booster session after a multidisciplinary treatment program on pain and limitations in activities. These negative findings could possibly be due to the broad range of impairments and limitations evoked by osteoarthritis of the hand, and may not be treatable with a standardized program. One of the main results of the thesis is that although our treatment program was developed following a systematic, thorough approach, it was found to be not effective in improving pain and limitations in activities, being the predominant problems of patients with hand OA. The second aim of this PhD study was to gain more insight into factors contributing to the burden of hand OA. In several cross sectional studies it was found that, patients with hand OA experience lowered health related quality of life compared with a Dutch reference population. Joint stiffness and grip strenght were found to be the main determinants of pain whereas pain is the main determinant of limitations in activities Patients with more signs and symptoms of the thumb base joints showed a significant higher disease burden than patients without signs and symptoms in this joint area. In clinical practice we recommend to focus on presence of joint stiffness, limited grip strength, and signs and symptoms in the thumb base joints. Interventions aimed at adequate pain control (such as splints and medication) may be important treatment options.