Hand Therapy >
Volume 14, Number 1 >
Pp. 2-9
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Pulvertaft Hand Centre, Derby Hospitals NHS Trust, Derby, UK
Correspondence: Barbara J Davenport, Derbyshire County PCT, Physiotherapy Department, Cavendish Hospital, Manchester Road, Buxton SK17 6TE, UK. Email: davenport.barbara{at}gmail.com
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Methods. A survey design was selected using a self-completed questionnaire as the data collection tool. The questionnaire was designed by the author and distributed to therapists by post to a range of therapy departments and to delegates attending a hand therapy course.
Results. A total of 115 out of 330 therapists (35%) responded with a completed questionnaire and the majority of the sample (97%) treated OA of the first CMC joint. Therapists used a variety of treatments for OA of the first CMC joint and the severity of the OA influenced the treatments used. Advice on activities of daily living, ergonomic advice, splints and exercise were the most commonly used treatment modalities. Therapists varied greatly in how effective they felt the different treatment modalities were in treating OA of the first CMC joint and how strong they felt the evidence base was to support their use. Most therapists used outcome measures, but many different ones were in use. Few therapists were aware of a classification system to grade the severity of OA of the first CMC joint.
Conclusions. There is a need for further research into the conservative management of this condition in order to establish the most effective treatments for each stage of the disease process.
Key Words: Osteoarthritis • carpometacarpal joint • survey • hand therapy
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The natural history of OA of the first CMC joint is thought by some to be one of progressive degenerative change.6 Jackson et al.7 suggest that in CMC joint OA, the progression is unique to both the joint and the individual. In both clinical practice and in research, OA severity is often graded in order to establish the stage of the disease. This grading frequently takes the form of a severity scale of mild, moderate and severe, which is based on a combination of patient-reported symptoms and, where possible, radiological changes. The Eaton and Littler classification system8 is currently the only validated way to grade OA severity affecting the CMC joint and is based solely on radiological evidence. It is recognized however that there is often a discrepancy between severity of OA, as seen on X-ray, and symptom severity as described by the patient.9
Management of OA consists of surgical and conservative measures. Where the OA is less advanced, conservative options tend to be favoured. Livesey et al.10 argue that surgery is only indicated if conservative management fails. Chard et al.11 undertook a systematic review of the literature and concluded that the majority of the research into OA was on medication (59.1%) or surgery (25.6%) with little on conservative management, despite the latter being the preferred option with patients. In light of this lack of research, the Pulvertaft Hand Centre (Derby Hospitals NHS Foundation Trust) planned research projects investigating exercise regimens and splinting for OA of the first CMC joint. It became clear that there was little information available investigating current therapy management of the condition and this study was designed to address this deficiency.
Study aim and objectives
This study aimed to investigate the current treatment techniques used by UK therapists in the conservative management of OA of the first CMC joint and to ascertain their perceptions on the effectiveness of and strength of evidence for the various treatment techniques. The objectives of this study were to:
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Sample
A convenience sample was used and the questionnaire was distributed in two ways. 150 were included within the course information given to all attendees at a hand therapy course organized by the Pulvertaft Hand Centre. It was made clear that completing the questionnaire was voluntary and completed responses could be left in a box at the end of the course. This course is designed for physiotherapists and occupational therapists of any grade and is generally attended by therapists with a special interest in hand therapy. The therapists attending are mainly, but not exclusively, from the UK. As this sample did not represent the general therapist population, in order to attract responses from a wider sample of therapists, including those who may not have a special interest in hands, a postal questionnaire was used. A total of 180 questionnaires, with a stamped addressed return envelope, were distributed by post to all therapy managers or senior therapists from a database held by the Pulvertaft Hand Centre. This included a variety of hospitals, clinics and private practices within the UK.
Data collection tool
This study investigated a research topic not previously studied; therefore a new questionnaire had to be designed. To ensure content validity of the questionnaire, the items in the questionnaire were discussed with several experienced hand therapists working in the Pulvertaft Hand Centre and modified accordingly. Construct validity and reliability were not evaluated as this was not practical given the limited scope of this study.
The questionnaire consisted of closed questions with some open questions where more detailed information was required. Therapists were asked to state whether they used a number of listed treatments (exercise, splinting, ergonomics, advice on activities of daily living [ADL], acupuncture, heat, electrotherapy, injection) in their management of mild, moderate and severe OA. They were also asked to describe what other treatments they used within their practice. For the purpose of the questionnaire, mild OA was defined as intermittent pain on use of the hand and a positive grind test, moderate OA was defined as pain on normal use, reduced grip strength and a prominent metacarpal base and severe OA was defined as stiffness in the joint, adduction and hyperextension deformity and subluxation of the metacarpal base. These definitions were established by consensus opinion among therapists working in the Pulvertaft Hand Centre. A 10-cm visual analogue scale (VAS) was used to quantify how effective therapists perceived treatments to be in mild, moderate and severe OA and how strong therapists felt the evidence was to support the use of the previously stated treatments.
Data analysis
The majority of the data collected were nominal with continuous data collected regarding the perceived effectiveness and strength of evidence for the various interventions. Continuous data were assessed for normality and as these did not follow a normal distribution, medians and interquartile ranges (IQRs) are presented.
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Respondents had been qualified for between two and 38 years (mean = 13.3) and had between one and 34 years (mean = 7.3) experience in hand therapy. A total of 68 of the 115 responses were completed by senior I therapists.
Treatment and referrals
A total of 112 respondents (97%) treated OA of the first CMC joint in their department. Three respondents did not treat this condition and were excluded from the remaining data analysis.
About 72% of therapists received referrals from hand surgeons, 70% from rheumatologists, 66% from general practitioners and 60% from orthopaedic surgeons. Referrals were also received from other sources such as plastic surgeons, occupational health PTs and OTs.
Grading of OA severity
A total of 24% (n = 27) of respondents stated that they were aware of a classification system for grading OA severity. Of these 21 were either aware of the Eaton and Littler classification system or stated grades 1–4, which are used in this system. The other six stated a variety of other non-standardized classification systems.
Treatment of OA of the first CMC joint
The most widely used treatments for all grades of OA were exercise, splints, ergonomic advice and ADL advice (Figure 1).
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Ergonomic advice was frequently used by therapists with little variation between grades of OA severity: mild OA, n = 75 (67%); moderate OA, n = 75 (67%); severe OA, n = 64 (57%). Therapists who commented on the type of advice given stated that they advised patients on modification of activities and work stations and gave joint protection advice.
ADL advice was the most commonly used treatment modality in all grades of OA with little difference between the grades: mild OA, n = 100 (89%); moderate OA, n = 104 (93%); severe OA, n = 99 (88%). Therapists stated that they gave a range of advice (joint protection, avoidance of aggravating activities, equipment advice and activity modification).
Acupuncture was one of the least used modalities: mild OA, n = 19 (17%); moderate OA, n = 30 (27%); severe OA, n = 27 (24%).
A variety of heat treatments (wax, pre-exercise heat, contrast bathing) were used or recommended by therapists for use at home. Heat was used less often in mild OA: mild OA, n = 49 (44%); moderate OA, n = 61 (54%); severe OA, n = 57 (51%).
Electrotherapy was one of the least used modalities. It was most commonly used in moderate OA: mild OA, n = 25 (22%); moderate OA, n = 35 (31%); severe OA, n = 22 (20%) and a wide variety of modalities were in use (laser, ultrasound, pulsed shortwave diathermy [PSWD], interferential and transcutaneous electrical nerve stimulation [TENS]).
Injections were used by 29 therapists (26%) in mild OA and by 50 (45%) in both moderate and severe OA. Three therapists gave the injections themselves, the rest were given by medical practitioners.
Other modalities used by therapists for the management of OA were hand groups, manual therapy, frictions, strapping, ice and education.
Strength of evidence base for treatments
Therapists rated the strength of evidence for a range of interventions on a 10-cm VAS ranging from 0 (no evidence) to 10 (strong evidence base). This question investigated their perception of the amount of evidence to support the interventions; it did not distinguish between quantity, quality or lack of supporting evidence (Table 2).
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Perceived effectiveness of treatments
Therapists were asked to rate how effective they felt interventions were on a 10-cm VAS; with 0 being not effective and 10 being very effective (Table 3).
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Measuring outcome of interventions
About 89% (n = 100) of respondents used a subjective outcome measure; 78% (n = 87) used some form of pain measure; 14% (n = 16) used the Disability of Arm, Shoulder and Hand (DASH)12 questionnaire, 49% (n = 55) used a subjective functional measure and 15% (n = 17) used patient feedback. There were a variety of other measures used and several therapists used a combination of outcome measures.
About 84% (n = 94) of respondents used an objective outcome measure. The most commonly used were strength measurement (82%, n = 92) and ROM (62%, n = 69). There were a further 26 different objective measures used and many therapists used a variety of measures.
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This survey revealed that patients with OA of the first CMC joint are referred from a variety of sources including GPs. Therefore, therapists have a vital role, not only in managing symptoms, but also ensuring appropriate referral for further input from secondary care.
Although respondents vary treatments depending on the severity of the disease, only 24% of therapists were aware of any system for grading OA of the CMC joint, those that were aware of one mainly knew of the Eaton and Littler system.8 Although this is the only validated method of grading this condition, it is radiologically based and has limitations. X-rays are not universally available to therapists and this may reduce the clinical usage of the Eaton and Littler system. Further research is needed to establish a system of grading OA of the first CMC joint that is valid and reliable and easy to use both in clinical practice and research. This would facilitate the selection of the most appropriate treatments for the patient and enable research to be conducted into the efficacy of treatments.
There were many different treatments being used by therapists; ADL and ergonomic advice was used by the majority of therapists and they described a wide range of advice given to patients, largely related to activity modification. Therapists also scored these interventions highly for their perceived effectiveness and their strength of evidence base. Literature searches did not reveal studies directly investigating their use in this condition, but this survey has shown that there is clearly consensus among respondents that these interventions are effective. Research has been undertaken investigating the effectiveness of education programmes and joint protection techniques in OA generally and these have been shown to be beneficial in managing symptoms.13,14 However, this research did not specifically consider OA of the first CMC joint. The Royal College of Physicians15 produced guidelines for the National Institute for Clinical Excellence (NICE) and they recommended that education, joint protection and pacing advice should form part of the management of OA but also noted there was little supporting evidence for this from the research.
Although exercise of a variety of types was commonly used by therapists, NICE guidelines state that there is a large amount of good quality evidence to support the use of exercise in OA of the knee but limited evidence in hand OA. They conclude that expert opinion suggests that it is beneficial and recommend its use for OA in all joints and for all grades of OA. There was insufficient evidence to suggest any particular type of exercise. This study showed that exercise was used more commonly in mild OA. The NICE guidelines would suggest that until any further research is undertaken, then exercise of any type should be used in the management of all grades of OA.
Splints of many different types were in widespread use in this sample. The use of splinting is supported by the research including a systematic review that concludes that splinting reduces pain in OA of the first CMC joint.13,16,17 There remains a debate regarding which splints are most effective and for what stage of disease and this problem is highlighted by the NICE guidelines. They also highlight a lack of well-designed trials into splinting for OA of the CMC joint but conclude that they can help with pain and function.
Heat is regularly used by therapists in this sample and is widely advocated in the management of OA despite there being little evidence to support its use. However, it is cheap, safe and can be self-administered.18 NICE guidelines recommend the use of heat and ice. This recommendation is based on expert consensus because of a paucity of research.
Corticosteroid injections were not used frequently by therapists in this sample but they did rate the perceived evidence base and effectiveness higher than many other interventions (Tables 2 and 3). This discrepancy could be because the treatment is outside the scope of practice of many therapists, especially OTs and therefore they do not consider it as part of their treatment package. There is a small amount of evidence to support the use of intra-articular corticosteroid injections in OA of the first CMC joint but the effects seem to be short term.15,19,20
Although not widely used, there was a variety of electrotherapy modalities used among this sample population. Electrotherapy was perceived to have the lowest strength of evidence base and be least effective, which may affect its frequency of use. This is a treatment used by few OTs, who made up half this sample, something that may have skewed the results. A randomized controlled trial conducted by Brosseau et al.21 found no benefit of laser therapy over placebo in the treatment of OA of the hand. Minor and Sanford18 reviewed the use of electrotherapy in OA and concluded that shortwave diathermy and ultrasound had no benefit over placebo. They found some evidence to support the use of TENS in patients with rheumatoid arthritis but not in patients with OA. The NICE guidelines concluded that there was evidence to support the use of TENS for pain relief in OA of the knee but that ultrasound was not effective in OA of the hip and knee: there was no evidence investigating their use in hand OA. They also concluded that there was insufficient evidence to make recommendations about PEME (Pulsed Electromagnetic Energy). Reviewing the literature would suggest that while there is a lack of available quality evidence to support the use of electrotherapy there is only evidence that one modality (ultrasound) is not effective, and this is in hip and knee OA. There is clearly a need for further well-designed trials into these modalities to establish their effectiveness.
Therapists use acupuncture to treat a variety of complaints and this study found that it was used in the treatment of OA of the first CMC joint. As with injections and electrotherapy, it is outside the scope of many therapists and this may have affected how frequently it was used. A literature search revealed little evidence investigating its role in OA of the first CMC joint specifically but some evidence to supports its use in the management of OA in general.22,23 The NICE guidelines concluded that there was a lot of evidence available but with mixed results. They concluded that it appeared to give short- to medium-term pain relief in some patients.
In the management of mild OA, therapists tended to favour the more active treatments with the patient engaged in self management of the problem through exercise, utilization of ADL advice and using splints. The pain-relieving modalities (acupuncture, heat, electrotherapy and injections) were less commonly used. This perhaps would be expected as these treatment modalities aim to prevent the progression of OA as well as managing the current symptoms. Exercise aims to improve joint nutrition and cartilage repair, increase bone mineralization, increase the strength of the soft tissues, reduce pain and anxiety, and improve function;13,18,24,25 splinting aims to protect the joint and thus relieve pain and improve function17 and ergonomic/ADL advice aims to maximize function while minimizing discomfort and disease progression.26
In moderate OA, the treatments used continued to include splints and ADL advice but also include pain-relieving modalities such as acupuncture, heat, electrotherapy and injections. This may reflect the increasing severity of symptoms requiring further treatments to effectively manage the condition, or it could be that therapists feel the treatments are more effective in moderate OA than mild OA and therefore use them more frequently.
The use of most interventions diminished in severe OA, particularly exercise. It would be expected that the severity of the OA will be reflected in the symptoms and the author's personal experience has demonstrated this to be so. It may be that conservative management is not appropriate in severe OA and patients would benefit more from surgery. More research is required investigating the effects of interventions related to disease severity in order to establish if this is correct.
There was a wide range of responses seen for the perceived evidence base for and efficacy of interventions suggesting a lack of consensus among therapists. The interventions felt to be more effective and having a stronger evidence base tended to be used more frequently by therapists. This suggests that therapists do use treatments they feel are effective and supported by evidence.
This study demonstrated that the outcome measures currently used range from standardized valid and reliable tools, such as the DASH questionnaire, to individual observations. While therapists should have the option to use the most appropriate outcome tool, the widespread use of the same tool by all therapists would make comparison of interventions easier.
There were limitations with this study: The questionnaire was distributed to a large sample with a known interest in hands and reflects a representative sample of hand therapists but the results cannot be generalized to the wider population of therapists. There was a lower return rate (35%) than Drummond27 states can be expected (40.6%) and this limits the ability to generalize the findings. The reasons for this are not clear, although the questionnaire was quite long and this may have reduced return rates.
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Appendix 1 Search terms and databases used for the literature search
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