Lending a helpful hand
Published on 29 October 2012
More than 4 million people have osteoarthritis affecting their hands, yet treatment is limited. Jane Tadman reports on two new Arthritis Research UK trials that offer hope.
Study 1: Treating osteoarthritis with a drug traditionally used to treat rheumatoid arthritis
For years a drug that was originally developed to treat malaria has been used in people with rheumatoid arthritis. Hydroxychloroquine, also known as Plaquenil, is a derivation of an anti-malarial medicine and is considered to be the least toxic of the disease-modifying drugs used to treat rheumatoid arthritis. It is also cheap and well-tolerated.
However, for some time, doctors have also been using it off- licence to treat a condition for which there is no ideal pain killer – osteoarthritis, and specifically osteoarthritis of the hand.
Current treatments for hand osteoarthritis such as splinting, pain killers, occupational therapy and physiotherapy provide some relief. And painkillers, although effective, can have side-effects and often people can’t tolerate them.
However, Philip Conaghan, professor of musculoskeletal medicine at the University of Leeds, believes that treating inflammation, in his new £900,000 Arthritis Research UK-funded clinical trial testing hydroxychloroquine in osteoarthritis of the hand, could provide a new relatively safe therapy.
“Osteoarthritis of the hand is generally considered to be less important and less disabling than hip or knee osteoarthritis but a large proportion of those affected report that they have significant difficulties with everyday tasks which have a great impact on their quality of life and general health,” explained Professor Conaghan, who is also chairman of the Arthritis Research UK clinical studies group on osteoarthritis.
“Recent imaging studies have shown that osteoarthritis isn't just ‘wear and tear’ but that inflammation is important too, and we think that by reducing inflammation, pain will also be reduced. We may also slow down structural deterioration of affected joints.”
Although hydroxychloroquine is already used on an anecdotal basis by some doctors to treat osteoarthritic pain, but there’s been no big randomised controlled trial to test its effectiveness.
In Yorkshire, patients will be recruited in Leeds, York, and Harrogate, but over a three-year period up to 250 people from up to 15 rheumatology departments in hospitals and at least 10 GP surgeries around the UK will be recruited onto the trial for one year.
Half will take hydroxychloroquine; the other half will take a placebo drug, and both groups will be allowed to continue with their existing painkillers. Their condition will then be assessed at six and twelve months.
Case study: Jo Robinson
Jo Robinson, aged 64, from Bramhope, near Leeds, has suffered from osteoarthritis in both her hands for the past five years. She has tried various forms of pain relief, and has had surgery on her right hand, which has helped, and she is now able to drive again.
“The fast progression of the arthritis in my hands caused me great concern, and before the surgery I could no longer write well or use keys or the computer,” says Jo. “I still can’t open jam jars as yet, even with the use of a gadget I bought. Squeezing a cloth was a problem and I constantly dropped things. All these things still cause problems but not as badly as before.”
She adds:” I’m very fortunate in that my daughter and two young grandsons live with me, however, I’ have often wondered how those who live alone manage daily chores and simple tasks that they can no longer do without a helping hand.”
Study 2: Treating osteoarthritis using thumb splints and joint protection
Patient power has been driving a new pilot project that will test a splint that could relieve pain, and improve the ability to perform everyday activities, in people whose osteoarthritis is at the base of the thumb.
Thumb base osteoarthritis is not only painful but can also prevent people doing very basic activities because they lose their ability to move their thumb normally and make a pinch grip, making it difficult to hold a pen, do up buttons, pick up a glass or use scissors or clothes pegs.
A small number of patient partners have been involved in a forum set up by occupational therapist Dr Jo Adams alongside Bristol and Keele partners Dr Rachael Gooberman-Hill and Dr Krysia Dziedic to establish people’s views on whether and how splints are worn, and what they’d like to see incorporated to form the basis of a clinical trial. (Nearly 100 people responded to Jo’s appeal in Arthritis Today 157 for their views – evidence both of the need for better treatment, and the level of willingness of patients to take part in research.)
Jo and her team have also sought the views of clinicians have also been sought, to ensure maximum buy-in for the study.
Senior lecturer in occupational therapy at the University of Southampton, Jo Adams has funding of more than £100,000 from Arthritis Research UK over two years to set up the pilot study.
Jo is a leading advocate of the need to involve patients in the design of clinical studies to ensure that questions being addressed are questions that are important and relevant in real -life, rather than leaving the study design entirely up to academics. She is working closely with colleagues at the Arthritis Research UK Primary Care Centre at Keele University who have a similar ethos, and has incorporated the findings of the joint protection study for hand osteoarthritis reported by Arthritis Today in summer 2011.
The aim of the pilot study is to find out if a thumb splint can make a difference to patients’ quality of life, or whether one-to-one consultations with an occupational therapist offering joint protection, education, and exercises are just as effective. It will also test a placebo splint, which patients themselves have also helped design.
One thing to have come out of the patient forum is that people want to wear splints that are soft, don’t look too medical, are easy to put on, and can be worn when they do different everyday tasks they most value; activities such as gardening, for example, to help them with the pain.
“This research combines exciting patient-based focussed developmental work, along tried and tested procedures for examining the effectiveness of routinely-used treatment for thumb base osteoarthritis,” explains Jo. ”There’s currently a lack of evidence for the effectiveness of splints. If we could show they were clinically and cost-effectiveness, then there’d be demonstrable benefit for a large proportion of people with osteoarthritis, as it affects 20 per cent of the population over the age of 55.”
Case study: Avril Appleby-Fleming
Avril Appleby-Fleming was one of the patient partners involved in the forum. Avril, now 65, from Devizes in Wiltshire, was diagnosed with thumb base osteoarthritis five years ago. For her it is a serious problem rather than a painful inconvenience, as she earns a living by being an illustrator, and the condition has played havoc with her ability to produce calligraphic hand-writing.
“I can only draw on good days as on bad days it’s hard to hold a pen,” she explains. “And it’s frustrating as well as painful. I have to ask my husband to open safety lids on jars and bottles, for example.”
Avril has found her thumb splint a boon that helps her to write, do the gardening and even to sleep, but she also swears by joint protection and uses gadgets and self-help techniques suggested by her occupational therapist, and tricks she’s learned herself to help her do her everyday jobs.
“It’s been very empowering to have been involved in using my own experiences to help inform the clinical trial pilot,” she says. “I’ve found that splints and exercises have helped me very much and I’m much better off than I was.”
Around 30 people with thumb base osteoarthritis will be recruited from five centres around the UK when the pilot starts in September 2012.
• Thanks to everyone who responded to Dr Adams’ appeal for people with thumb base osteoarthritis to help with her research.