ObjectivesTo evaluate whether occupational therapy, provided in the period between referral and surgical consultation, might delay or reduce the need of surgery in thumb carpometacarpal joint (CMCJ) osteoarthritis and to explore predictors for CMCJ surgery.MethodsThis multicentre randomised controlled trial included patients referred for surgical consultation due to CMCJ osteoarthritis. An occupational therapy group received hand osteoarthritis education, assistive devices, CMCJ orthoses and exercises. A control group received only hand osteoarthritis information. Primary outcome was the proportion of patients that had received CMCJ surgery after 2 years. We examined the primary outcome and predictors for surgery with regression models, and time to surgery with the log-rank test and cox regression analyses.ResultsOf 221 patients screened for eligibility, 180 were randomised. Information on the primary outcome was collected from medical records for all included patients. Surgery was performed on 22 patients (24%) that had received occupational therapy and 29 (32%) control patients (OR 0.56, 95% CI 0.26 to 1.21; p=0.14). Median time to surgery was 350 days (IQR 210–540) in the occupational therapy group and 296 days (IQR 188–428) in the control group (p=0.13). Previous non-pharmacological treatment (OR 2.72, 95% CI 1.14 to 6.50) and higher motivation for surgery (OR 1.25, 95% CI 1.09 to 1.43) were significant predictors for CMCJ surgery.ConclusionsOccupational therapy showed a small non-significant tendency to delay and reduce the need for surgery in CMCJ osteoarthritis. Previous non-pharmacological treatment and higher motivation for surgery were significant predictors for surgery.

Background Osteoarthritis (OA) in the thumb carpometacarpal joint (CMCJ) is a prevalent disease which may lead to structural damage, severe pain and functional limitations. Evidence-based treatment recommendations state that all patients with hand OA should be offered non-pharmacological treatment. Surgery should be considered only when other treatment has proven insufficient in relieving pain. The purpose of this study was to investigate prior treatment and characteristics of patients referred to specialist health care surgical consultation due to CMCJ OA. The study includes exploring differences in pain and function between referred and non-referred hand, between men and women, and between patients with and without OA affection of other finger joints than CMCJ. Methods Patients in this cross-sectional study reported prior non-pharmacological treatment for CMCJ OA. Patient demographics, disease and functional variables were assessed based on hand radiographs, patient-reported and observer-based outcome measures. Differences in pain and function between referred and non-referred hand, men and women, and between patients with and without additional affection of finger joints other than CMCJ, were analysed using Paired-samples T-tests, Wilcoxon Signed Rank, or Chi-Square tests. Results One hundred and eighty patients were included. The mean age was 63 years and 79% were women. Only 21% reported having received non-pharmacological treatment before referral to surgical consultation. The results show a statistically significant worse function for referred hands, women and involvement of additional interphalangeal joints. Most patients reported no pain or mild pain in their referred hand. Conclusions The results of this study show a non-pharmacological treatment gap in OA care. Most patients report no pain or mild pain, and that they had not received non-pharmacological treatment prior to being referred to CMCJ OA surgical consultation . The results furthermore show that CMCJ OA negatively affects all aspects of function. Strategies need to be developed to improve OA care, including educating general practitioners in evidence-based treatment recommendations and in the assessment of hand pain, and encourage the routine referral of patients with symptomatic hand OA to occupational therapy before considering surgery.

Objective. To assess the short-term effects of multimodal occupational therapy on pain and hand function in patients referred for surgical consultation due to first carpometacarpal (CMC1) joint osteoarthritis (OA).Methods. In this randomized controlled trial, patients with CMC1 joint OA referred for surgical consultation at 3 rheumatology departments were randomized to 3 months multimodal occupational therapy (including patient education, hand exercises, orthoses, and assistive devices) or usual treatment (OA information). Pain was measured on a numeric rating scale from 0 to 10 (0 = no pain). Function included grip and pinch strength (Newtons), range-of-motion (palmar and CMC1 joint abduction [ ]; flexion deficit in digits 2-5 [mm]), and self-reported Measure of Activity Performance of the Hand (MAP-Hand; range 1-4, 1 = no activity limitation) and short version of the Disability of the Arm, Shoulder, and Hand (QuickDASH; range 0-100, 0 = no disability). Between-group difference was assessed with follow-up values as dependent variables and group as an independent variable, adjusted for baseline values and time to follow-up.Results. Among 180 patients (mean AE SD age 63 AE 8 years; 81% women), 170 completed the short-term followup assessment (3-4 months after baseline). Compared to usual treatment, occupational therapy yielded significantly improved pain at rest (−1.4 [95% confidence interval (95% CI) −0.7, −2.0]; P < 0.001), pain following grip strength (−1.1 [−0.5, −1.7]; P = 0.001), grip strength (23.4 [95% CI 7.5, 39.3]; P = 0.004), MAP-Hand score (−0.18 [95% CI −0.09, −0.28]; P = 0.001), and QuickDASH score (−8.1 [95% CI −4.6, −11.5]; P < 0.001).Conclusion. The multimodal occupational therapy intervention had significant short-term effects on pain, grip strength, and hand function in patients with CMC1 joint OA.ClinicalTrials.gov identifier: NCT01794754.

BackgroundIn the absence of disease-modifying interventions for hand osteoarthritis (OA), occupational therapy (OT) comprising patient education, hand exercises, assistive devices and orthoses are considered as core treatments, whereas surgery are recommended for those with severe carpometacarpal (CMC1) OA. However, even though CMC1 surgery may reduce pain and improve function, the risk of adverse effects is high, and randomized controlled trials comparing surgery with non-surgical interventions are warranted.This multicentre randomized controlled trial aims to address the following questions:Does OT in the period before surgical consultation reduce the need for surgery in CMC1-OA?What are patients’ motivation and reasons for wanting CMC1-surgery?Are there differences between departments of rheumatology concerning the degree of CMC1-OA, pain and functional limitations in patients who are referred for surgical consultation for CMC1 surgery?Is the Measure of Activity Performance of the Hand a reliable measure in patients with CMC1-OA?Do patients with CMC1-OA with and without affection of the distal and proximal interphalangeal finger joints differ with regard to symptoms and function?Do the degree of CMC1-OA, symptoms and functional limitations significantly predict improvement after 2 years following OT or CMC1-surgery?Is OT more cost-effective than surgery in the management of CMC1-OA?Methods/DesignAll persons referred for surgical consultation due to their CMC1-OA at one of three Norwegian departments of rheumatology are invited to participate. Those who agree attend a clinical assessment and report their symptoms, function and motivation for surgery in validated outcome measures, before they are randomly selected to receive OT in the period before surgical consultation (estimated n = 180). The primary outcome will be the number of participants in each group who have received surgical treatment after 2 years. Secondary and tertiary outcomes are pain, function and satisfaction with care over the 2-year trial period. Outcomes will be collected at baseline, 4, 18 and 24 months. The main analysis will be on an intention-to-treat basis, using logistic regression, comparing the number of participants in each group who have received surgical treatment after 2 years.DiscussionThe findings will improve the evidence-based management of HOA.Trial registration identifier NCT01794754. First registrated February 15th 2013.

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