Hand OA: benefit of occupational therapy

 Another article on hand arthritis found that short-term use of Occupational Therapy in those with carpal metacarpal osteoarthritis (CMC OA) provided major symptomatic benefit (see hand OA occup therapy helps ArthCareRes2022 in dropbox or DOI 10.1002/acr.2454) 

 

Details: 

-- Norwegian study of 180 patients who had CMC OA of the first carpal metacarpal joint and had been referred for surgical consultation at 3 rheumatology departments were randomized to multimodal Occupational Therapy versus OA information while they were waiting for their surgical appointment

    -- multimodal Occupational Therapy included patient education, exercises (8 exercises for maintaining and increasing joint mobility, grip strength, and stability of the wrist and finger joints, with instructions to exercise at home 3 times/ week), orthoses (both a daytime and nighttime orthosis, commonly a Push Race for the daytime orthosis to increase CMC joint stability, and a custom-made Orfit Classic 2-mm Maxi at night to prevent and correct adduction contracture and subluxation of the thumb), and 5 commonly used assistive devices (bread and vegetable knives with built-up handles, enlarged grip for opening bottles, a key for opening jars, and a self-opening pair of scissors). There was only one individual session of patient education regarding hand OA information, ergonomic principles, and instructions in hand exercises and the use of assistive devices, lasting 30 minutes. There was one visit two weeks later for adjustment of orthoses and exercise program. The rest of the OT program was self-managed at home for the 12-week intervention

    -- control group: written and oral information regarding OA and treatment options, provided by the same 6 occupational therapists who were involved in the intervention group

-- mean age 63, 81% women, median of 5 years of symptoms, 65% with comorbidities, 40% with clinical nodules, radiographic severity by Kellgren/Lawrence scale 3 (i.e. moderately severe OA by xray), 63% took analgesics/anti-inflammatories 

-- baseline hand function: grip strength 185 Newtons (65% of normal strength), pinch strength 32 Newtons (60% of normal strength), abduction of the CMC joint 36°, there was no flexion deficit in digits 2-5 in any patients, self-reported Measure of Activity Performance of the Hand (MAP-Hand, range 1-4, where 1=no activity limitation) was 2, short version of the Disability of the Arm, Shoulder, and Hand (QuickDASH, range 0 to 100, where 0= no disability) QuickDASH score was 36 

--Main outcomes: between group differences in function (grip and pinch strength), range of motion (palmar and thumb CMC joint abduction), flexion deficit in digits 2- 5, and MAP-Hand and QuickDASH scores 

    -- pain was measured on a numeric scale from 0-10, 0=no pain 

 

Results: 

-- adherence to OT intervention: 64% adhered to at least 3 of the 4 components of the intervention, 82% adhered to the exercise program, 68% to the daytime orthosis use, and 54% to the nighttime orthosis use. 69% used at least 3 of the 5 assistive devices. all results by self-report 

-- multimodal Occupational Therapy versus usual treatment (education only), with an effect size of at least 0.8 being considered large, 0.5-0.8 being moderate, and 0.2-0.5 small: 

    -- pain at rest: -1.4 (-0.7 to -2.0), p<0.001 

    -- pain following grip strength: -1.1 (-0.5 to -1.7), p<0.001 

    -- grip strength: 23.4 Newtons (7.5 to 39.3), p=0.004 

    -- MAP-Hand score: -0.18 (-0.09 to -0.28), p=0.001 

    -- QuickDASH score: -8.1 (-4.6 to -11.5), p<0.0001 

-- patients having at least MIC (minimal important change clinically) between OT vs control groups: 

    -- pain at rest: 44% with OT versus 22% of controls, p=0.003 

    -- pain following grip strength: 42% versus 22% (p=0.007) 

    -- QuickDASH: one third versus 7% in the control group,  p<0.001 

    -- grip strength: 40% versus 19%, p=0.006 

    -- pinch strength: 46% versus 29%, p=0.03 

 

-- adverse events: 8 patients reported discomfort using the daytime and/or nighttime orthosis (5 minor, 3 moderate events), 8 reported pain related to some strengthening exercises (2 minor and 6 moderate events), and 3 patients discontinued thumb stabilizing exercise because of pain 

 

Commentary: 

-- hand OA at the first CMC joint is very common (radiological OA in 30% of men and 33% of women in the Framingham Osteoarthritis Study)

-- the previous blog assessed overall hand OA prevalence, incidence, and progression in several US sites, finding that CMC OA was the most common hand arthritis (see http://gmodestmedblogs.blogspot.com/2022/06/hand-osteoarthritis-prevalence.html ); this blog also comments on the substantial disparity between radiologic versus symptomatic OA.  

-- CMC OA also typically has the most pain and functional limitations (especially since it impairs thumb opposition) 

-- several  guidelines reinforce the importance of education and training in ergonomic principles, exercise, activity pacing, and the use of assistive devices as first-line treatment, as in the 2019 recommendations of the EULAR (the European Alliance of Associations for Rheumatology) 

-- the 2-year results from the current Norwegian study found that Occupational Therapy was associated with a small but nonsignificant tendency to delay and reduce the need for surgery in those with CMC OA (24% versus 32% having surgery), and median time to surgery (350 versus 296 days), see https://rmdopen.bmj.com/content/rmdopen/5/2/e001046.full.pdf . This longer study did not have any analysis of specific pain or functional improvement by OT at the two year mark, only the rate and timing of subsequent surgery. Prior other studies have shown some benefit for OT, but these studies had somewhat conflicting results and often included trials that had a relatively high risk of bias

 

--overall, the short-term Norwegian study above found clear benefit for the multimodal Occupational Therapy in decreasing functional impairment from thumb CMC OA, and, per their 2-year study results, some nonstatistically significant decrease in both the need for surgery as well as an increase in time to surgery over a two-year period. 

-- in the intention-to-treat analysis of the current short-term study, there was no significant change from baseline in the control group, but significant improvements in all aspects of pain and hand function (except for flexion deficit) in the Occupational Therapy group 

     -- in the per-protocol analysis, there were similar findings, with the addition of a significant difference in palmar abduction 

 

Limitations: 

-- though this was a randomized controlled trial, there might be a significant placebo effect in those randomized to an active OT intervention versus the more passive education instruction 

-- since the same 6 occupational therapists were involved in the intervention and control groups, there might have been a bias in how the groups were educated and treated

-- this was clearly a very short term study finding dramatic benefit from Occupational Therapy, and it is unclear whether these results would be long-term (or how long?) and might provide enough functional improvement to avoid surgical intervention ultimately

    -- the two-year study noted above did not find a significant change in those getting surgery nor in the timing of surgery but: 

        -- there may have been a bias toward surgery since these patients had to follow up with the surgeon instead of their primary care providers 

        -- even then, there was a non-statistically significant benefit from this nonsurgical intervention, meaning it is likely that some individuals did well without surgery and its attendant potential complications. But it would be very useful to have granular data on the effect of OT on those getting surgery (what was their baseline function/pain, did they adhere well to the OT program, what was their outcome at 3 months and then at 2 years, what was their reason for having the surgery, etc )

-- this group of patients were referred for surgical evaluation, and results may not be generalizable to those not referred with less severe pain 

-- the current study was a secondary analysis of the multicenter parallel group RCT, leading to decreased statistical validity than a primary analysis 

-- it would also be useful to see which of the OT components done had the most effect, so that these could be prioritized in the training 

 

So, there seems to be a clear benefit for short-term multimodal Occupational Therapy in decreasing functional impairment from thumb CMC OA, which suggests that we in primary care should strongly consider referring those patients with painful CMC joints for multimodal Occupational Therapy, prior to surgical referral. as in this study, this therapy can involve minimal intervention (only 1-2 OT appointments) with the rest being home-based interventions: a much less intensive intervention, for example, than engaging in physical therapy for 1 hour/d for 3 days/week for many weeks

geoff

 

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