What’s The Best Way To Treat Osteoarthritis Of The Hand? Do The Europeans Know Something We Don’t?
By Nathan Wei
Symptomatic osteoarthritis (OA) of the hand affects 20% of those people older than 55 years and has the potential for significantly affecting activities of daily living. Interference with grip and fine precision pinch and dissatisfaction with cosmetic appearance are major concerns.
Current evidence for the management of hand OA is currently based on either expert opinion or what appears to be effective for OA affecting other joints. However, the small size and accessibility of hand joints allow a different range of interventions than in large joint OA.
The European League Against Rheumatism (EULAR) is the American equivalent of the American College of Rheumatology. They formulated guidelines for OA of the hand at their annual meeting in June 2006.
The 11 recommendations were as follows:
– Optimal management of hand OA requires a combination of nonpharmacologic and pharmacologic (non drug and drug) treatment modalities individualized for each patient.
– Therapy of hand OA should be individualized based on the localization of OA; risk factors (age, sex, adverse mechanical factors); type of OA (nodal, erosive, traumatic); presence of inflammation; severity of structural change; level of pain, disability and restriction of quality of life; comorbidity (other concurrent diseases) and comedication (other concurrent medicines) (including OA at other sites); and patient wishes and expectations.
– All patients with hand OA should receive education concerning joint protection (how to avoid adverse mechanical factors) together with an exercise regimen (involving both range of motion and strengthening exercises).
– Local application of heat (with paraffin wax or hot pack), especially before exercise, and ultrasound are helpful.
– Splints are recommended for thumb base OA, as well as orthoses to prevent or correct lateral angulation and flexion deformity.
– Local treatments are preferred over systemic treatments, especially for mild to moderate pain and when only a few joints are involved. Topical non-steroidal anti-inflammatory drugs (NSAIDs) and capsaicin are safe and effective.
– Because of its efficacy and safety, paracetamol (up to 4 g/day) is the oral analgesic of first choice. It is the preferred long-term oral analgesic for patients who respond. (Paracetamol is an analgesic similar to acetaminophen).
– In patients who respond inadequately to paracetamol, oral NSAIDs should be used at the lowest effective dose and for the shortest duration, and the patient’s requirements and response to therapy should be reevaluated periodically. Patients with increased gastrointestinal risk should use nonselective NSAIDs (eg., regular anti-inflammatory drugs like ibuprofen or naproxen) plus a gastroprotective (medicine to protect the stomach lining) agent or a selective Cox-2 inhibitor (eg., drugs like Celelbrex). In patients with increased cardiovascular risk, Cox-2 specific inhibitors are contraindicated, and nonselective NSAIDs should be used with caution.
– Symptomatic Slow-Acting Drugs for Osteoarthritis (eg, glucoasamine, chondroitin sulphate, avocado soybean unsaponifiables, diacerhein, intra-articular hyaluronan) may offer symptomatic relief with low toxicity, but effect sizes are small, suitable patients are not defined, and clinically relevant structure modification and pharmacoeconomic benefits have not been established.
– Intra-articular injection of long-acting corticosteroid (cortisone shots) is effective for painful flares of OA, especially at the trapeziometacarpal joint.
– Surgery, such as interposition arthroplasty, osteotomy, or arthrodesis, is effective for severe thumb base OA and should be considered in patients with marked pain and/or disability after failure of conservative treatments.
While these guidelines are useful, they are by no means comprehensive nor are they hard and fast rules.
In our clinic we have found many other types of therapy to be helpful. For instance, compressive driving gloves worn inside out so the seams are on the outside at night are helpful for reducing morning stiffness.
We advocate the regular use of therapeutic paraffin baths.
Steroid injections are very useful but should be done using ultrasound guidance to ensure accuracy.
Symptomatic OA at the base of the thumb that does not respond to injection with glucocorticoids can be treated arthroscopically with debridement followed by an injection of a viscosupplement. (Wei N, Delauter SK, Beard SJ. Arthroscopic debridement and viscosupplementation: a minimally invasive treatment for symptomatic osteoarthritis involving the base of the thumb. J Clin Rheum. 2002 Jun;8(3):125-9.
Finally, the role of the hand therapist is key in maintaining functionality in patients.
Nathan Wei, MD, FACP, FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland (http://www.aocm.org). He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine and consultant to the National Institutes of Health. For more info: Arthritis Treatment