Non-pharmacological treatment gap preceding surgical consultation in thumb carpometacarpal osteoarthritis - a cross-sectional study

Osteoarthritis of the hand (HOA) is a highly prevalent disease that can potentially lead to pain, joint stiffness, reduced pinch and grip strength, impaired activity performance and can have a negative effect on work and quality of life [1‐3]. In the Framingham cohort, radiographic HOA in at least one joint was observed in 44% of the women and 38% of the men between 40 and 84 years, while 14 and 7% of women and men, respectively, had symptomatic HOA in at least one joint. The thumb carpometacarpal joint (CMCJ) is one of the most commonly affected joints, and the observed prevalence of radiographic osteoarthritis (OA) in the CMCJ was 33% for women and 30% for men in the same study [4]. The thumb has a prominent role in hand functioning. Whether CMCJ OA is associated with more pain and disability than OA in other finger joints is a debated point [5‐7].

There is currently no cure for OA. Non-pharmacological interventions, which include assistive devices, orthoses, hand exercise and patient education, are recommended as a core treatment for all patients with HOA. Surgery should only be considered for patients with structural abnormalities when other treatment modalities have not been sufficiently effective in relieving pain [8, 9]. Results from studies of hip and knee OA indicate that there is a treatment gap in OA care, as many patients do not receive recommended conservative treatment before being referred to orthopaedic surgery [10]. Little is, however, known about functional limitations and about the treatment received by patients with HOA before being referred to CMCJ OA surgical consultation. Studies have been carried out that compare HOA patients with and without CMCJ OA [5, 6]. There is, however, a lack of research that compares the symptoms and functional limitations in patients with isolated CMCJ OA with patients with a combination of CMCJ OA and OA in the interphalangeal joints (IPJ) of the hand.

The aim of this study was to investigate prior treatment and characteristics of patients referred to surgical consultation in specialist health care due to CMCJ OA. The study explores differences in pain and function between the referred and non-referred hand, between men and women, and between patients with and without OA affection (clinical nodes and pain) of finger joints besides CMCJ.

One hundred and eighty patients were included in the study (Table 1). The mean (SD) age was 63 (7.6) years and 142 (79%) were women. Eighty-three (46%) used analgesics, 63 (35%) used a Non Steroid Anti Inflammatory Drug (NSAIDs), 31 (17%) used a combination of analgesics and NSAIDs and 15 (8%) used Glucosamine. Self-reported comorbidities were present in 104 (64%) of the patients. Forty-four patients (24%) reported co- or pre-existing comorbidities or injuries of the hand, of which three (2%) reported current carpal tunnel syndrome. Additionally, 15 (8%) reported previous carpal tunnel syndrome surgery. Median (IQR) symptom duration was 5 (2 to 10) years. Only 37 (21%) self-reported having consulted an occupational therapist or physiotherapist before being referred to surgical consultation. These patients had statistically significant more pain at rest, lower max grip strength, less range of motion in IPJs and MCPJs, less thumb palmar abduction and also had longer symptom duration in years compared to patients with no prior non-pharmacological treatment. Nineteen (11%) had previously consulted a rheumatologist. There were no statistically significant differences between the patients of the three hospitals, except for a slightly higher proportion of women from St. Olav’s Hospital, Trondheim. Most patients (n = 101, 56%) were referred for unilateral surgery, 53 (29%) for left hand and 48 (27%) for right hand surgery, whereas 79 (44%) were referred for bilateral surgery. Sixty-three (35%) patients also had OA affection in IPJs in addition to CMCJ OA.

All of the patients in this study were referred to specialist health care surgical consultation due to CMCJ OA. Most of these patients reported no pain or mild pain in the referred hand. Only a minority had received the recommended first-line non-pharmacological treatment, the remainder being referred directly to surgical consultation by their GP. The results furthermore show that unilateral referral patients consistently reported better function in the non-referred hand, and that there were only minor differences between left and right hand in bilateral referral patients. Gender differences include women having poorer scores than men in most aspects of function. Patients with both CMCJ OA and IPJ OA furthermore reported more severe symptoms and functional limitations than those with isolated CMCJ OA.

Pain is the predominant symptom that leads patients with OA to contact their GP [23], and the main indication for CMCJ surgery is to reduce pain and increase function [9]. There is, however, growing evidence that non-pharmacological interventions such as patient education, hand exercises, orthoses and assistive devices reduce pain and improve function in HOA patients [24‐26]. Complications, repeated surgery and substantial periods of time off work are furthermore frequently reported after CMCJ surgery [27, 28]. Accordingly, the European League Against Rheumatism recommendations state that surgery should only be considered for patients with structural abnormalities when other treatment modalities have not been sufficiently effective in relieving pain [29]. Still, the majority of patients in our study reported no pain or mild pain. This may be an indication that GP consultation quality needs to be improved for this patient group. One strategy may be to inform GPs about simple and timesaving procedures, such as using a patient’s pain-level rating to inform the referral to surgical consultation decision.

In line with studies on hip and knee OA [10], only a minority of the patients in our study had consulted an occupational therapist or physiotherapist before surgical consultation. One reason for this may be that many GPs are not sufficiently up to date on treatment recommendations and the beneficial effects of non-pharmacological interventions. GPs therefore refer patients to the treatment they are familiar with, namely surgery, a hypothesis supported by findings from qualitative studies. Patients with HOA reported, in these studies, a lack of support and information on management of their condition and that other non-pharmacological treatments were rarely offered or tried before referral to surgical consultation [30‐32]. Other studies indicate that increased workload and lack of time and experience are key barriers to GPs engaging in optimal OA care [33, 34]. A strategy that has been proven to be effective in improving the quality of care is the implementation of a primary care-based OA model [35]. This includes an enhanced OA consultation by a GP, follow-up consultations with an OA trained nurse and access to a broader multidisciplinary team including occupational therapists and physiotherapists [36, 37]. Another approach is to build alliances with patient organisations and use social media to enhance and disseminate knowledge about disease consequences and effective self-management strategies for those with HOA. Educated patients can inform GPs about and request available and effective treatment options. This can break the vicious circle of patients not consulting health professionals, thereby concealing their problems and the lack of treatment services and disparities between the services offered to different patient groups [30].

As expected, unilateral referral patients in this study reported consistently worse function in their referred hand, and women had lower hand strength and more functional limitations than men. The gender differences are in line with previous studies of HOA patients [38], rheumatoid arthritis patients [39] and in the general population [40, 41]. The association between muscle weakness and functional limitations [38, 42] is well known. Strengthening exercises have, however, been found to improve hand function in HOA patients [25]. Women display lower muscle strength than men [43], and the functional consequences of muscle weakness therefore have a greater affect upon women. This emphasises that women with HOA should focus on exercises that improve strength and hand function.

Although results are somewhat ambiguous, previous research has shown that CMCJ OA and IPJ OA functional limitations are comparable [6] and that the ailment of patients with IPJ OA increase when they also suffer from CMCJ OA [5]. The current study suggests that additional IPJ OA involvement in patients with CMCJ OA worsens symptoms and functional limitations, indicating that involvement of more joints in the hand will cause more functional limitations, regardless of initial joint involvement. Future studies should explore whether there is a linear relationship between number of joints and degree of disability, with the increased number of affected joints leading to increasingly limited function regardless of the joint(s) involved, or if there are certain patterns of involvement that are more disabling than others.

Our findings in general support the hypothesis that there is a treatment gap in OA care [44, 45]. Dziedzic and colleagues suggest that the quality of this care can be improved by taking factors outside the joint into consideration and by introducing a biopsychosocial model as an alternative to the medical approach. They furthermore suggest that occupational therapists play a crucial role in the care of HOA patients. Occupational therapists have been trained in approaches that take into consideration psychological, social, and environmental needs, and in methods to reduce activity limitations and participation restrictions caused by HOA [46]. Encouraging GPs to routinely refer patients with HOA to an occupational therapist as a first-line treatment may, therefore, be one way of ensuring better support for OA patients.

The availability of only referred hand radiographs represents a limitation of this study. This, however, only slightly limited the referred hand/non-referred hand comparison. A further limitation is the cross sectional design, which does not allow cause and effect relationship conclusions to be drawn. It should, however, be kept in mind when comparing pain and function of the referred hand versus non-referred hand, that the patients may also have OA in the non-referred hand. Some patients also had co-existing diseases, which can potentially affect self-reported outcome measurements. The use of analgesics and assistive devices were self-reported. This can have induced a recall bias. The strengths of the study include the large study sample, the thorough clinical and radiographic evaluation combined with patient self-reported data, and that patients were recruited from three different and geographically separate hospitals.