Background The 2018 update of the EULAR recommendations for the management of hand osteoarthritis (OA) states that every patient with hand OA should be offered patient education, hand exercises and provision of assistive devices. Orthoses should be considered for symptom relief in patients with thumb carpometacarpal (CMC1) OA. Surgery should only be considered when other treatment modalities have not been sufficiently effective in relieving pain (1).
Objectives The main aim was to evaluate whether occupational therapy in the waiting period prior to surgical consultation can reduce or delay the need for surgery in CMC1 OA. A secondary aim was to explore potential predictors for CMC1 surgery.
Methods This is a multicentre parallel-group randomized controlled trial including patients referred by their general practitioner for surgical consultation due to CMC1 OA at three Norwegian departments of rheumatology. After baseline assessments, participants were randomized into an occupational therapy group or a control group and reassessed after 4, 18 and 24 months. Both groups received written and oral information on hand OA. In addition, the occupational therapy group received a hand exercise program, day and night orthoses, assistive devices and a treatment diary.
Intention-to-treat analyses were conducted fitting multivariate logistic regression analyses to compare the proportion of participants in the two groups who had received CMC1 surgery after two years. Time to surgery was examined in a Kaplan-Meier survival plot, whereas crude and adjusted logistic regression analyses were performed to investigate predictors for CMC1 surgery using a predefined set of covariates of demographic and clinical variables.
Results Of 214 patients screened for eligibility, 180 (84%) were randomized. The mean age was 63 years (SD 7.6) and 79% were women. Eighty-four (93%) participants in the occupational therapy group and 82 (91%) in the control group completed 24 months follow-up assessments. Fifty-eight (64%) participants in the occupation therapy group were categorized as having high treatment adherence. Twenty-two (24%) participants in the occupational therapy group and 31 (34%) in the control group received surgery before the two year follow-up. The odds for receiving surgery were 50 percent lower in the occupational therapy group (p=0.10). Median time to surgery was 349 days (IQR 210 to 540) in the occupational therapy group and 267 days (IQR 181 to 406) in the control group (p=0.07). Previous non-pharmacological treatment (OR 2.70, 95% CI 1.16 to 6.27) and higher motivation for surgery (OR 1.22, 95% CI 1.07 to 1.38) were significant predictors for CMC1 surgery
Conclusion In participants receiving occupational therapy there was a clear, but not statistically significant trend towards reduction and delay in CMC1 surgery as compared to the control group. Previously received non-pharmacological treatment and higher motivation for surgery significantly predicted surgery. The results support that patients with CMC1 OA should be referred to occupational therapy before surgery is considered.
Reference  Kloppenburg M, Kroon FP, Blanco FJ, Doherty M, Dziedzic KS, Greibrokk E, et al. 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Ann Rheum Dis. 2019;78(1):16-24.
Disclosure of Interests: Else Marit H. Gravås: None declared, Nina Østerås: None declared, Randi Nossum: None declared, Ruth Else Mehl Eide: None declared, Åse Klokkeide: None declared, Karin Hoegh Matre: None declared, Monika Olsen: None declared, Øyvor Andreassen: None declared, Ida Kristin Haugen Grant/research support from: ADVANCE research grant from Pfizer, Consultant for: Advisory board Abbvie, Anne Therese Tveter: None declared, Ingvild Kjeken: None declared
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