Thumb base osteoarthritis (CMC1-OA) is a common subset of hand OA. The prevalence of symptomatic CMC1-OA is 2% in men and 7% in women, whereas radiographic CMC1-OA is present in 30% of men and 33% of women (Eaton et al., 2022; Haugen et al., 2011). Symptoms and functional consequences of CMC1-OA include pain, stiffness, reduced grip strength and hand function, and impaired activity performance, work ability and quality of life (Kwok et al., 2014). In the absence of disease-modifying interventions, non-pharmacological approaches, such as patient education, hand exercises and assistive devices, are recommended as first-line treatment for CMC1-OA, whereas surgery should be considered when other treatment modalities have not been sufficiently effective in relieving pain and improving function (Kloppenburg et al., 2019). A significant short-term effect of non-pharmacological interventions on pain and hand function has been shown in patients with CMC1-OA (Tveter, Østerås, et al., 2020). Surgical procedures most frequently comprise trapeziectomy with or without ligament reconstruction and tendon interposition or trapeziometacarpal arthrodesis (Vermeulen et al., 2011); however, there are no high-quality randomised controlled trials (RCTs) comparing surgery to non-surgical interventions for CMC1-OA. Also, studies assessing the long-term effects of non-pharmacological treatment and surgery in this patient group are lacking. The purpose of this study was to explore long-term changes in pain and hand function over a 2-year period using data from an RCT in patients with CMC1-OA receiving occupational therapy (OT group) or brief information (control group) in the waiting period prior to surgical consultation. The results presented are secondary analyses from a multicentre RCT where the main aim was to evaluate whether OT might delay or reduce the need of surgery in patients with CMC1-OA (Gravås et al., 2019). Patients were included in three departments of rheumatology in Norway in the period between 2013 and 2015. The study protocol and main results are previously published (Gravås et al., 2019; Kjeken et al., 2016). The trial was approved by the Norwegian Regional Ethical Committee (2012/2265/REK sør-øst C). Sample size was calculated based on the primary outcome, which was the proportion of patients undergoing surgery in the two groups, with a total of 180 patients required to detect a 20% difference (Gravås et al., 2019; Kjeken et al., 2016). Patients were referred for surgical consultation in specialist healthcare based on an initial symptomatic diagnosis of CMC1-OA provided by their general practitioner. They were considered eligible for inclusion in the study if they could speak Norwegian and had no cognitive deficits. All participants gave a written informed consent before taking part in the study. Those who agreed to participate completed a questionnaire before they were scheduled for a baseline assessment at the hospital. Patients were randomised 1:1 to an OT intervention (n = 90) or control group (n = 90) in the period prior to surgical consultation using a computer-generated randomisation list and concealed opaque envelopes at each recruitment site (Gravås et al., 2019; Kjeken et al., 2016). Patients in the OT group met an experienced occupational therapist for a single session, consisting of patient education, hand exercises, orthoses, and provision of five commonly used assistive devices, and were instructed to perform eight specific hand exercises 3 days per week in the following 3 months. The OT group also met for a control consultation after 2 weeks for adjustment of orthoses and hand exercises. The control group received an information sheet, which could be considered as usual care. Both groups were reassessed at 4, 18, and 24 months. The decision on surgery was based on the surgical consultation, which took place immediately after the 4-months assessment. The 18- and 24-month timepoints were chosen as most patients scheduled for surgery would have undergone surgery by these timepoints (Gravås et al., 2019). The demographic and clinical variables collected at baseline included gender, age, education level, years with symptoms, and referred hand. Pain at rest in the referred hand (mean for both hands for those with bilateral referral) was assessed using an 11-point numeric rating scale (NRS, 0 = no pain, 10 = worst possible pain). Hand function was self-reported by the Measure of Activity Performance of the Hand (MAP-Hand) containing 18 items scored on a 4-point scale from 1 (no activity problems) to 4 (unable to perform). If complete answers were given for ≥15 of the 18 items, a total mean score between 1 and 4 was calculated (Tveter, Nossum, et al., 2020). The questionnaire is shown to have acceptable reliability and validity in patients with CMC1-OA, with a smallest detectable change of 0.6 points at the individual level and 0.3 at the group level (Tveter, Nossum, et al., 2020). Only patients with complete data (pain/function) at all timepoints were included in the analyses. Radiographs were taken prior to the surgical consultation to confirm the diagnosis. The long-term within- and between-group differences in pain and hand function were assessed using repeated measure ANOVA. p-value was set to <0.05. Of the 180 included patients, 163 had complete data and were included in the analyses of pain, while 162 were included in the analyses of hand function. There were no between-group differences in demographic or clinical variables at baseline. Mean age was 63 (SD 8) years, 129 (79%) were female, and 54 (33%) had higher education (university/college). The median symptom duration was 5 years (IQR 2–10). Seventy (43%) patients had complaints from both hands, 45 (28%) for the right hand only, and 48 (29%) for the left hand only. Of the 163 patients, 22 underwent surgery in the OT group and 28 in the control group. Both the control and OT groups showed a significant within-group reduction in pain (p < 0.001) and improvement in hand function (p < 0.001) over the four time points. There was a significant between-group difference in pain (p = 0.004) but not in hand function (p = 0.069), with the OT group reporting less pain than the control group (Figure 1). The largest between-group difference was found at 4 months, where the OT group had significantly less pain (p < 0.001) and better hand function (p = 0.001) compared to the control group. Between-group difference in pain at rest (a) and hand function (b) over a 2-year period, divided into control and intervention groups. When dividing into subgroups, we found no significant difference over time in pain or hand function between those undergoing surgery or not in neither the OT group (pain: p = 0.35; function: p = 0.24) nor the control group (pain: p = 0.072; function: p = 0.27). However, at the time of the surgical consultation (approx. 4 months), those later undergoing surgery in the control group reported significantly higher pain at rest and poorer hand function than the other groups (p < 0.001) (Figure 2). Between-group difference in pain at rest (a) and hand function (b) over a 2-year period. The control group is marked in light grey and the intervention group in black. Those who underwent surgery are marked with dotted lines, while those who did not are marked with solid lines. Both the OT and the control groups had significant reduction in pain and improvement in hand function over 24 months, with significant between-group differences for pain in favour of the OT group. In general, these results support current treatment recommendations, stating that non-pharmacological interventions should be the first-line treatment for patients with hand OA (Kloppenburg et al., 2019). The largest between-group difference was found immediately after the 3-month intervention period, highlighting that future studies should explore how the positive effect of OT can be prolonged, for example, through support of digital technology. When comparing groups receiving OT only, OT and surgery, brief information only, and brief information and surgery, patients receiving brief information and surgery had significantly more pain and poorer function at 4 months compared to the other groups, whereas no difference was found between the four groups at 24 months. In patients who received surgery after having received OT, pain and function did not change between 4 and 24 months, suggesting that surgery did not provide additional improvement in this group. While there is growing evidence for the effect of the recommended non-pharmacological interventions for people with hand OA, there are yet no high-quality studies comparing the (cost-)effectiveness of CMC-surgery with no surgery, non-pharmacological, or pharmacological interventions (Kloppenburg et al., 2019). In order to provide personalised and evidence-based interventions, more knowledge is needed on the most optimal timing, order, dose, and combination of interventions, and if patients should be stratified to different pathways based on medical, psychological and personal factors. In summary, the results of this study show that both the OT and the control groups had significant improvement in pain and hand function over time, with a significant between-group difference for pain in favour of the OT group. No additional benefit from surgery on pain and hand function was found in patients who first underwent multimodal occupational therapy. The results should however be interpreted with caution as these are secondary analyses. RCTs where surgery is compared head-to-head with other interventions are needed to establish evidence-based pathways for people with hand OA. The authors have made substantial contributions to the concept or design of the work (Ingvild Kjeken, Nina Østerås, Randi Nossum, Ruth Else Mehl Eide, Åse Klokkeide, Karin Hoegh Matre, Monika Olsen), the acquisition of data (Randi Nossum, Ruth Else Mehl Eide, Åse Klokkeide, Karin Hoegh Matre, Monika Olsen), analysis (Anne Therese Tveter, Ingvild Kjeken, Nina Østerås) and interpretation of data (Anne Therese Tveter, Ingvild Kjeken, Nina Østerås). All authors have contributed to the drafting and critical revision of the work (Anne Therese Tveter, Ingvild Kjeken, Nina Østerås, Randi Nossum, Ruth Else Mehl Eide, Åse Klokkeide, Karin Hoegh Matre, Monika Olsen), and final approval (Anne Therese Tveter, Ingvild Kjeken, Nina Østerås, Randi Nossum, Ruth Else Mehl Eide, Åse Klokkeide, Karin Hoegh Matre, Monika Olsen). Anne Therese Tveter is the guarantor, accepting full responsibility for the work. We would like to acknowledge our patient research partner for her contribution throughout the project. This work was supported by the South-Eastern Norway Regional Health Authority (2015109) and the Norwegian Research Council (328657). The funding authorities had otherwise no involvement in the study. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sector. None of the authors have any financial or personal conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.
No takes yet. Share an insight, caveat, or question.
Tveter et al. (2024) studied this question.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: