Background
Musculoskeletal hand pain is common in middle and old age, reported by between 12% and 30% of adults aged 50 years and over in the United Kingdom [
1,
2]. Most will self-manage without regular recourse to formal health services [
3] but primary care is likely to play an important role in the initial and ongoing assessment for many, with one Dutch study estimating an annual incidence of new general practitioner consultations for hand complaints of between 4 and 12 per 1000 registered patients over the age of 50 years [
4]. Previous studies suggest that in older people osteoarthritis is likely to be the most common diagnosis, with other specific conditions (for example, tenosynovitis, carpal tunnel syndrome) important but less common [
2,
5]. However, the clinical assessment must fulfil a range of other functions in addition to diagnosis, such as evaluating the nature and severity of the problem and its impact on the patient, predicting its likely future course, and selecting appropriate management. Given the multiple purposes of assessment, the relatively large spectrum of unspecified health problems presenting to general practice [
6], and the often highly time-constrained setting [
7], which questions and assessments are most useful remains unclear. There are many valid and reliable self-report measures for assessing the hand [
8‐
10]. Hand assessment has also been included in examination schedules for the musculoskeletal system in general (Gait Arms Legs and Spine (GALS) schedule [
11] and the Regional Examination of the Musculoskeletal System (REMS) for medical students [
12]), and for the diagnosis, classification and assessment of specific hand disorders (the Southampton examination schedule [
13] and the Sequential Occupational Dexterity Assessment (SODA) [
14]). Despite the high prevalence of hand problems in older adults within primary care, little has been done to determine the best way to assess the hand, with the exception of Recht and colleagues [
15]. In order to address the lack of literature in this area we conducted a consensus study involving UK health care practitioners from a variety of professional backgrounds with a role in the assessment and management of hand problems. As a range of health practitioners have expertise in hand assessment, and many of these work within secondary care settings, a variety of professional groups from a range of work settings were included in the consensus study. The specific aim of this study was to identify the clinical questions and assessments regarded by Health Care Practitioners as important when assessing undifferentiated hand pain or hand problems in adults aged 50 years and over and presenting to primary care. It is envisaged that the questions and assessments arising from this study and subsequent work could be used by any of the Health Care Practitioners involved in the care of the patient in primary care.
Results
From the twenty-six HCPs who were approached, twenty-two agreed to participate. Response to each stage of the Delphi study is illustrated in table
1.
Table 1
Response to each stage of the Delphi study
Agreed to participate | 13 | 4 | 3 | 2 |
Completed round 1 | 7 | 4 | 3 | 2 |
Completed round 2 | 5 | 3 | 3 | 2 |
Completed round 3 | 4 | 3 | 2 | 2 |
Sixteen participants (73%) responded to Round 1 (table
1) generating a total of 156 questions and 143 assessments (table
2).
Table 2
Summary of results from each Delphi round
Questions
| | | |
Case scenario 1 | 130 | 75 | 24 |
Case scenario 2 | 13 | 9 | 1 |
Case scenario 3 | 13 | 10 | 0 |
Total
|
156
|
94
|
25
|
Assessments
| | | |
Case scenario 1 | 123 | 47 | 17 |
Case scenario 2 | 11 | 5 | 1 |
Case scenario 3 | 9 | 3 | 1 |
Total
|
143
|
55
|
19
|
Thirteen (81%) of the sixteen participants who were mailed responded to Round 2 (table
1). Using the decision rule, 9 or more of the participants rated 94 questions and 55 assessments as being "most important" (table
2).
Responses from those taking part in Round 2 were subject to a small amount of missing data: of the 299 items, 12 were not rated by all thirteen participants. However, had complete data been achieved for these items, the outcome of Round 2 would not have been affected.
Eleven (85%) of the thirteen participants who were mailed responded to Round 3 (table
1). Using the decision rule, 7 or more of the participants agreed that 25 questions and 19 assessments should be included in the evaluation (table
2). These final questions and assessments are presented in table
3.
Table 3
Summary of the items retained from the Delphi process.
General questions: |
Do you have problems with one or both hands? |
Do you have any previous history of the same type of problem? |
When did your symptoms start? |
How did your symptoms start-were there any identifiable incidents? |
Have you ever had surgery or injuries to your hands? If so when and what? |
Are your symptoms getting worse, better or about the same since they started? |
How is your general health? |
Do you have any illnesses e.g. diabetes, heart condition or arthritis? |
Do you have any problems anywhere else with your joints or muscles? |
Are you on any medication or having any other medical treatment at the moment? |
Are you right or left handed? |
What have you done so far to get relief? |
Have you had to take time off work or stop work because of your symptoms? |
Specific symptom questions:
|
Where do you have the pain? |
When does the pain occur-at night, with usage, at rest or does it hurt all the time? |
What makes it better/worse? |
Does pain limit your activities? |
Do you experience any thumb pain during activity, e.g. writing, carrying a plate, or turning a key in a lock? |
Do you experience stiffness? |
Have you noticed any swelling in your hand or puffiness in your fingers? |
Do you have any altered sensation (e.g. pins and needles, tingling or numbness) in any part of your hand? |
Do you think your strength has decreased? |
Function questions:
|
What are you not able to do now that you were able to do before the onset of this problem? |
What is involved with your job? |
Other questions:
|
Have you had any neck, shoulder or elbow problems-now or in the past? |
Examinations:
|
Observation of upper limb/hand posture/use of hand |
Observation of swelling |
Observation of muscle wasting |
Observation of skin condition: colour/pallour/discolouration/cyanosis/redness/Raynaud's |
Observation of overall pattern of deformity at rest |
Observation of deformity on use-what doesn't work properly |
Observation of wrist deformity-subluxed carpus, radial or ulnar deviation, supinated or pronated carpus |
Observation of MCP joint deformity-subluxed, radial/ulnar drift, hyperextension |
Observation of PIP joint deformity-flexion contracture, hyperextension or lateral deformity, swan neck, Boutonierre |
Palpation of swelling |
Palpation of pain/tenderness |
Palpation of CMC joint/thumb base for pain |
Assessment of neck |
Specific tests:
|
Phalen's test (carpal tunnel syndrome) |
Evaluation of range of movement:
|
Ability to make a full fist |
Ability to flatten hand onto a flat surface |
Evaluation of muscle power:
|
Power grip strength |
Evaluation of sensation:
|
Light touch/threshold testing (e.g. monofilaments/general map) |
Assessment of function:
|
Broad hand function-activities of daily living |
Discussion
In this postal Delphi study, a sample of UK HCPs identified a pool of 156 questions and 143 assessments relevant to the evaluation of hand problems in primary care. By the third round, participants agreed on the importance of 25 questions and 19 assessments.
There are many sources of expert advice and guidance on the clinical assessment of musculoskeletal conditions in general and specified single musculoskeletal diagnoses [
29‐
31], but fewer that focus on undifferentiated hand problems as they might present to primary care. Nevertheless, some relatively direct comparisons are possible with the Gait Arms Legs and Spine (GALS) schedule [
11], the Regional Examination of the Musculoskeletal System (REMS) for medical students [
12], and the Southampton examination schedule for diagnosis of specific upper limb musculoskeletal disorders [
13,
32]. These existing schedules were not considered during the development of the framework for the Delphi rounds as the hand assessment component was either concerned mainly with observation and palpation, or the focus was on diagnostic classification and screening, and as such, we did not wish to replicate work which had already been done. Although previous studies suggest that in older people osteoarthritis is likely to be the most common condition, we wanted Delphi participants to think more broadly-about undifferentiated hand problems in primary care-rather than biasing participants towards a particular diagnostic group, which using these schedules within the development of the framework may have done. There were however similarities between the findings from this Delphi study and the hand assessment component of the GALS [
11], the REMS [
12], and the Southampton schedule [
13,
32]. In particular, the emphasis on observation of gross movement (for example, ability to make a full fist) in contrast to instrumented measurement of movement at individual joints was evident in both the GALS and this Delphi study. However, the assessment of joint nodes and bony enlargements, whilst included in the GALS, REMS and the Southampton schedule, was omitted by the Delphi participants. Presence of these features is indicative of hand OA; a condition that is generally considered by HCPs to be an inevitable part of ageing and as such, more limited in treatment options and less serious than inflammatory arthropathies [
33,
34]. The final examinations agreed by the Delphi participants (observation and palpation of swelling, palpation of pain/tenderness and observation of deformity) appear to be targeted at identifying more serious but treatable diseases such as inflammatory arthritis.
Limited comparisons can be made between the results from this Delphi study and national guidelines for the assessment of OA published after this study was undertaken [
35]. Although these are not specific to the assessment of the hand they do suggest that the assessment of OA ought to be 'holistic' including consideration of activities of daily living, hobbies and occupation. Indeed, items relating to all of these categories were generated in the Delphi study but not retained in the final selection by the Delphi participants. Generally, Delphi participants chose more items related to symptoms (pain, stiffness, swelling, altered sensation and weakness) than function. The Delphi participants agreed that only one question and three assessments relating to hand function should be retained at the end of the study. Standardised hand function tests were excluded in the second round in favour of assessment of broad hand function. This may be due to a genuine lack of agreement about the relative importance of the many different functional questions and tests available. It may also reflect what previous authors have noted: namely, that for busy clinicians, time constraints and lack of knowledge about hand function tests may preclude the use of a standardised test of hand function [
36,
37].
In the absence of empirical evidence, this study has provided an indication of current opinion on the most important questions and assessments for evaluating the hand in primary care. The Delphi technique used in this study achieved its aim of generating a comprehensive list of questions and assessments and filtering them into a core of essential items. Delphi participants were chosen purposively to represent the main professional groups involved in musculoskeletal hand assessment, although others of the same professional background may not necessarily share the views of the individuals who participated in this study. A good response rate was achieved for each round, exceeding the 70% recommended [
38]. Although attrition occurred at each stage of the Delphi study, the final number of participants satisfied the need to have 10 or more participants to achieve good reliability [
16]. Response rates for this study are comparable to others [
18,
39‐
42].
Although the Delphi is a useful tool for identifying consensus, it is not without its limitations. While the intention of this study was to identify the important components of the assessment of hand problems in older adults within primary care, the HCPs approached and recruited to the study were not all specifically involved in the delivery of front line care. These participants were purposively selected as the majority of health practitioners with experience and specialist skills in assessing the hand tend to be employed in a secondary care setting. Inclusion of other HCPs with specialist hand assessment skills working in secondary care, such as hand surgeons, may have provided a different perspective from that of the other participants on the Delphi panel. Evidence suggests, that whilst the prevalence of hand problems within primary care is high, consultation with HCPs is low [
3], suggesting that front line HCPs may be likely to have less experience of assessing hands than their secondary care counterparts. The high prevalence of inflammatory athropathies in secondary care settings is reflected in the outcome of this Delphi study. For example, items relating to examination of deformity were primarily concerned with the deformities that would occur with inflammatory arthritis.
Despite attempts to minimise attrition, participants dropped out at each stage of the study. Attrition was greatest amongst the OTs, particularly between the point of agreeing to participate in the study and returning the first round of the Delphi questionnaire. However, after this, the rate of attrition amongst the OTs was generally comparable to the other professional groups, with the exception of the GPs, for whom there was no attrition. The early attrition could therefore be considered as a reflection of recruitment rates.
The sample size could be considered a limitation of this study, although for Delphi studies where the purpose of the study is focussed and the participants are from similar backgrounds, it is recommended that 15-20 participants should be recruited [
17]. Studies with 20 or fewer participants have the advantage of being more successful than larger studies in reducing attrition rates [
28].
Future work will establish the reliability, feasibility and value of using these questions and assessments identified for older adults with hand problems in a primary care setting. Specifically, the relative contribution of these questions and assessments in evaluating the nature and severity of hand problems, assisting diagnosis, indicating appropriate management, and predicting future outcome requires further investigation.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
All authors contributed to the conception and design, execution, analysis and interpretation of data, were involved in drafting and critically revising the article, and read and approved the final version.