Hands on approach to osteoarthritis
Published on 01 July 2011
Stiff, painful hands can make everyday life almost impossible. New research is showing how to improve the quality of life for those people who are affected.
Imagine not being able to open a tin, peel or chop vegetables, dry yourself properly after a bath or even pick up a kettle to make a cup of tea; everyday activities that most people take entirely for granted.
Yet for people with osteoarthritis in their hands, the constant pain and stiffness in their fingers or thumb joints make such basic activities extremely difficult. And while it’s generally recognised by the medical profession that rheumatoid arthritis can have severe, painful and deforming effects on the hands, the same recognition is not accorded to people with osteoarthritis.
Sixty-eight year-old Christine Walker from Cheshire has suffered from severe nodal osteoarthritis for the past 15 years.
“A number of times I just wanted to get a knife to my hand and chop off the lumps on my fingers; they were so painful,” she says.
Christine developed knobbly, painful fingers in her 50s while working at Manchester Metropolitan University. “I get red lumps on my fingers like small cysts which are very painful while they are growing, but once they’re calcified they hurt less. But they look horrible and my hands have got progressively stiffer.”
It became increasingly challenging for Christine to hold a pen or a sewing needle, and she found that paint brushes slipped out of her hand. “The kind of things you take for granted became very difficult,” she says.
I wanted to get a knife and chop off the lumps on my fingers…
Sixty-four year-old Penny Hogg from Bramley near Guildford, has had a similar experience. “I have osteoarthritis in both my thumbs, which makes menial tasks very tough,” she says.
“It’s also very painful, especially when I wake up in the morning. I can’t turn the pages of a newspaper, dry myself with a towel after a bath; I can’t write very well – it looks like a spider has crawled across the page – and my thumbs go numb when I’m cold. Carrying heavy shopping bags is a problem; I can’t put gloves on –or dry spoons! I just about cope, but it’s no fun at all. If you don’t have the use of your hands, you’re stuck.”
Osteoarthritis of the hand is a big problem, which until fairly recently has not been addressed by researchers. According to a recent study at the Arthritis Research UK Primary Care Centre at Keele University, more than 12 per cent of people over the age of 50 have severe hand-related disability. Of these, 38 per cent had seen their GP but only three per cent had seen an occupational therapist (OT); therapists who help people with daily living by giving practical advice on aids and equipment. The research also showed that many people with hand osteoarthritis who went to their GP had been told that nothing could be done, so they never went back.
Unlike replacement surgery of the larger joints in the body such as the hip or knee, surgery to replace joints in the hand is not widely performed in people with osteoarthritis. And until recently the standard approach to treating osteoarthritis in the hand was taking pain medication.
What can be done?
So what can be done to help people with osteoarthritis of the hand? Joint protection and exercise are two very practical options, and evidence has shown that both approaches used together can be helpful.
Krysia Dziedzic, an academic physiotherapist and professor of musculoskeletal therapies at the Arthritis Research UK Primary Care Centre at Keele – and a longstanding expert in hand osteoarthritis – is involved in two Arthritis Research UK-funded clinical trials into finding more practical ways of improving treatment. The first, which has recently been completed, aimed to find out which of the two treatments, joint protection or hand exercises, worked better than advice leaflets. The second, about to start, will look at the effectiveness of thumb splinting.
A real mine of information
In the SMOotH study (which was presented at a major European rheumatology conference, EULAR, in London in June) Professor Dziedzic and OT colleagues recruited 257 people with hand osteoarthritis to test the effectiveness of joint protection and exercises, both delivered by an OT. Education – which involved giving some patients an educational leaflet – was also assessed.
The hand exercises were based on what OTs currently use in their NHS treatments and involved strengthening and mobilising exercises. Joint protection was all about group work, where participants were shown gadgets to use to help them prepare a simple meal and techniques to help them cope with everyday activities. They were then encouraged to go out and buy those gadgets which worked best for them.
Christine Walker took part in the SMOotH trial at Leighton Hospital. “It showed me some very practical ways of coping, and was a real mine of information,” she says. “I thought I knew every single modern piece of equipment and aid but I had my eyes opened! The group was a great source of information, with tips from other people, too.”
I’d struggled with potato peelers and tin openers but found there were much better ones available. We were shown how to squeeze out a dish cloth, how to hold a kettle with two hands and take the top off a hot-water bottle and shown gadgets that release the vacuums in jars. It was really practical information of interest to people like me and it made an enormous difference.”
Christine also found the education arm of the trial useful too. “I learned that osteoarthritis is all about wear and repair, not wear and tear; something I hadn’t thought about. It gave me insight into what was going on under the skin.”
The results of the trial are yet to be published but the findings are important, as they show that simple joint protection approaches can be effective.
Joint protection gives people some control over their pain…
It’s easy for people to pick up joint protection techniques that help them, and this approach very quickly gives people some control over their pain and gives them a feeling of confidence that they can do something about it,” Professor Dziedzic explains. “Joint protection is easier to adapt into their everyday lives than activity or exercise.”
Building on these results, Professor Dziedzic is now liaising with Dr Jo Adams, senior lecturer and professional lead in OT at Southampton University, on a two-year pilot trial of 30 patients whose osteoarthritis affects specifically their thumbs.
The pilot aims to find out if as well as offering one-to-one consultations with OTs providing joint protection and exercise, a thumb splint can make a difference. The findings will be used to design a full trial. Use of a placebo splint will help to establish whether it is the splint itself that is effective or the whole procedure of providing a splint.
Patients will take part in forums to discuss their experiences and impact of osteoarthritis of the hand and also their treatment preferences. They will also be asked to give their input into the best type of splint to be used.
“We found that 90 per cent of the people in the SMOotH trial had some problems with their thumbs, and we know that 20 per cent of the population aged over 50 have osteoarthritis of the thumb – it’s one of the most common sites of osteo-arthritis and pain, yet again, rarely considered by researchers,” says Professor Dziedzic.
“We want to be able to produce an evidence-based package of the best occupational therapy care for patients.”
Christine Walker agrees: “If GPs and nurses could give out the tips we learned in the trial to their patients during their consultations it would be hugely helpful, and enable people to manage most of things they want to do.”
Surgical options for hand osteoarthritis
Thumb joint: The commonest form of surgery option for hand osteoarthritis is a trapeziectomy, also known as an excision arthroplasty, which has an excellent outcome. Surgery involves the removal of the thumb joint, replacing it with an augmented ligament reconstruction. The thumb joint can also be replaced but there are no long-term results available; or fused, again, results are not particularly good.
Knuckle joints: Replacement is a good option, fusion much less so.
Middle finger joint: Fusion is a good option. Replacement is also possible, but although this approach removes pain, it does not provide extra movement.
Finger tip joints: These cannot be replaced; only fused, leading to some restriction in movement.