Hand osteoarthritis prevalence, incidence, progression

 A recent article assessed the prevalence, incidence, and progression of both radiologic and symptomatic hand osteoarthritis (see hand OA prevalence and progression ArthRheum2022 in dropbox, or https://doi.org/10.1002/art.42076 

 

Details: 

-- 3588 participants were selected from four clinical sites (Memorial Hospital of Rhode Island, Ohio State University, University of Maryland/Johns Hopkins University, and University of Pittsburgh), from February 2004 to May 2006 

-- this cohort was selected initially of individuals at risk of knee OA (though excluding those with end-stage knee OA or inflammatory rheumatic disease), from the Osteoarthritis Initiative 

-- at baseline, posteroanterior radiographs of one or both hands were obtained along with questions about hand symptoms 

-- radiological OA was defined as a Kellgren/Lawrence (K/L) score of at least 2 (this is cutpoint for definition of OA) 

    -- K/L score 1: doubtful joint space narrowing and possible osteophytic lipping 

    -- K/L score 2: definite osteophytes and possible joint space narrowing 

    -- K/L score 3: moderate multiple osteophytes, definite narrowing of joint space and some sclerosis and possibly joint deformity of bone ends 

    -- K/L score 4: large osteophytes, marked narrowing of the joint space, severe sclerosis and definite deformity of bone ends 

-- they did not include OA of the thumb base (eg carpal metacarpal joint, CMC, and the often-associated scaphotrapeziotrapezoid joint, STT), since these joints may have a different etiology (more common in the nondominant hand and associated with hypermobility of the nondominant hand) 

-- study assessments: 

    -- both prevalent and incident OA: at the time of study initiation (prevalent) and over the course of the study (incident), and rates of progression

    -- prevalent symptomatic hand OA: radiographic OA at baseline plus same-sided hand pain 

    -- incident symptomatic hand OA: either radiographic OA at baseline but then new report of symptoms at 48 months, hand pain at baseline but then new reported OA on xray at 48 months, or new onset of both xray and symptoms in the same hand at 48 months 

 

Results: 

-- prevalent hand OA:  by xray in 41.1% (39.8%-43.0%), by symptoms in 12.4% (11.3%-13.5%) 

 

  

 

 

(note: the CMC is the carpometacarpal joint; STT is the scaphotrapeziotrapezoid joint) 

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-- incident hand OA over 48 months: by xray in 5.6% (4.7%-6.7%), by symptoms in 16.9% (15.6%-18.2%) 

 

  

 

 

-- progression rate: over 48 months, 27.3% (25.9%-28.8%) had OA progression, with average increase in hand joint K/L scores of 1.85 (1.78-1.93) [ie, a lot]

 

-- Overall, Black participants had a low risk of both incident and prevalent radiographic and symptomatic hand OA; with aging, women had a larger increase in symptomatic hand OA than men, though men had a higher incidence of radiographic OA 

-- overweight/obesity was associated with an increased prevalence of radiographic hand OA, and knee OA severity was associated with an increased prevalence of radiographic and symptomatic hand OA  

-- there was an association between hand pain and radiographic OA: hand pain at baseline was associated with 33% increased risk of prevalent radiographic OA, a 206% increased risk of incident radiographic OA, and a 66% increased risk of hand OA progression 

-- there was a more complex relationship between xray hand OA and symptoms, varying by the joint involved (their Table 3)

 

Commentary: 

-- this article highlights the high prevalence, subsequent incidence, and progression of hand OA in the population. Almost all of these measurements were more severe in women than men, particularly in younger women. There was also some difference in hand OA distribution: women had more DIP and PIP joint OA and males more MCP joint OA 

-- it is notable that CMC arthritis is so common, affecting 11-33% of people in their 50s-60s (eg see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3249665/ ), had the highest prevalence and incidence of any hand arthritis in this current study, but seems to be pathophysiologically different from the more typical osteoarthritis in the body, being more associated with ligamentous laxity 

    -- that being said, i can personally attest (and have confirmation by many patients) that CMC arthritis is incredibly painful. my personal and patient experiences confirm that steroid injections work remarkably well and often for a long time (my last one was close to 2 years ago), and this injection is a very easy injection to do (mine were self-administered.....)

-- osteoarthritis is a complex disease, with inflammation (lots of proinflammatory mediators including cytokines and chemokines, proteolytic enzymes, but low levels of leukocytes compared to other arthritides). Risk factors include age; past trauma; obesity (even in non-weight bearing joints, as found in the above study of hand OA); genetics (large numbers of genetic loci  associated with different osteoarthridities have been identified); twin studies have found that  familial aggregations are strong particularly for hip OA (60%) and less so for knee (39%): see osteoarthritis genetics CurOpinRheum2010  in dropbox, or DOI: 10.1097/BOR.0b013e3283367a6e); anatomic factors (several of which are clearly genetic); and sex (more hands and knees in women, similar sex distribution for hip) 

    -- there was also a strong association between knee OA and hand OA (symptomatic and radiologic), with a dose-response curve, suggesting some commonality of their pathophysiology. is it the inflammatory state itself? is it a specific array of elevated cytokines that predispose to OA; this study found that another systemic inflammatory disease (obesity) was; some other studies have identified another inflammatory condition (diabetes) with hand OA. All of this suggests that OA can be s systemic disease associated with multiple bodily functions

-- with OA, there is often a discordance between xray findings and symptoms. this was true for knee OA in the NHANES1 (National Health and Nutrition Examination Survey) study: 4% had xray knee pain but only 47% of them had knee pain; knee pain was found in 15% but only 15% of them had knee OA on xray of at least K/L score 2, see https://pubmed.ncbi.nlm.nih.gov/10852280/, or see the knee OA review knee OA review knee arthritis felson nejm 2006 in dropbox or N Engl J Med 2006;354:841-8.)  This current hand study also found a discordance: hand pain by xray and symptoms differed considerably, though hand pain strongly predicted the development of hand OA xray changes, though the reverse was more nuanced as noted above

-- as a maybe related note, a recent blog suggested that inflammation early in musculoskeletal pain may be an important part of the healing process, and that too much anti-inflammatory therapy (meds, ice) might actually be associated (?causally) with prolonged and chronic pain: see http://gmodestmedblogs.blogspot.com/2022/05/acute-pain-anti-inflammatories-lead-to.html

  

Limitations: 

-- this group of people were at high risk of knee OA and may not represent the general population.  

-- no information about the quality of the symptoms in those symptomatic. Were they severely functionally impaired by their OA? Or just a bit bothered? did they take meds? which ones? how often?

So, I bring this article up for a few reasons: 

-- hand arthritis is really common 

-- and, it can be really disabling (straight from the horse’s mouth, as noted above, especially with CMC arthritis)

-- but many hand problems are amenable to splinting or injections (eg CMC arthritis, occasionally smaller joints, trigger fingers, tendinitis). Surgery can be an effective option

-- and this article reinforces an important (i think) clinical point for primary care: this study and other joint OA articles have found a discordance between symptoms and xray findings (ie, a patient with clear OA symptoms but a normal xray may really still have OA and need to be treated for it). i have certainly had many patients with symptomatic knee OA who respond very well to steroid injections. The review of knee OA above (N Engl J Med 2006;354:841-8) suggests not even doing knee films unless there are concerning symptoms (eg knee pain that is nocturnal or is not activity-related)....

geoff

 

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