Osteoarthritis Of The Hand
DEFINITION
• Osteoarthritis is a pathology associated with inflammation in the joints of the body. In the case of hand osteoarthritis, the arthritis and inflammation most commonly associated with a loss of carpal, MC, or phalanges glenoid cartilage leading to hand pain.
Osteoarthritis
• Osteoarthritis is a term derived from the Greek word“osteo”meaning “of the bone,”“arthro”meaning“joint,”and“itis”meaning inflammation even though the amount of inflammation present in the joint can range from excessive to little or no inflammation.
SYNONYMS:
• Hand arthritis
• Hand degenerative joint disease
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| Osteoarthritis |
ETIOLOGY:
( What Causes Hand Osteoarthritis? )
• The wearing down of the hyaline cartilage leads to an inflammatory response. There is thickening and sclerosis of the subchondral bone and development of osteophytes or bone spurs. This leads to a narrowing of the joint space, loss of shock absorption, and ultimately pain.
• Daily wear and tear in combination with various injuries sustained throughout life is the most common cause of the breakdown of healthy tissue.
• Degeneration of the cartilage and resultant arthritis can also be the result of other factors such as trauma or joint injury.
• At a cellular level, as a person ages, the number of proteoglycans in the articular cartilage decreases. Proteoglycans are hydrophilic and work within cartilage to bind water. With the reduction of proteoglycans comes a decrease in water content within the cartilage and a corresponding loss of cartilage resilience. With the decreases in cartilage resilience, collagen fibers of the cartilage become susceptible to degradation and injury.The breakdown of collagen and other cartilage tissue isreleased into the surround joint space. Inflammation results as the body attempts to respond to the influx of byproducts from cartilage injury.
• As the cartilage degrades,the jointspace narrows and ligaments become more lax. In response to the laxity, new bone outgrowths,called spurs or osteophytes,can form on the margins of the joints in an attempt to improve the congruence and passive stability of the articular cartilage surfaces.
• Primary osteoarthritis refers to joint degradation resulting from aging and tissue degeneration.
• Secondary osteoarthritis refers to joint degradation and tissue degeneration that results from factors other than aging such as obesity, trauma, and congenital disorders.
Osteoarthritis
EPIDEMIOLOGY AND
DEMOGRAPHICS:
• Adults in the US over 60 years of age:
58% had Heberden’s nodes.
29.9% had Bouchard’s nodes.
18.2% had first CMC deformities.
• Symptomatic hand osteoarthritis occurs in 8% to 15% of the elderly.
• Symptomatic osteoarthritis occurs in the following:
5.4% to 35% at the DIP joints (especially the second)
4.7% to 18% at the PIP joints (especially the third)
1.9% to 21% at the first CMC joints (adults 40 years of age and older)
• 30% of all joints affected by osteoarthritis are joints in the hand, as follows:
21% in the first CMC joint
35% in the second DIP joint
18% in the third PIP joint
• Individuals over 55 years old are the most prone to hand osteoarthritis.
• Women (24% of those over 60 years of age) have a higher prevalence than men (10.3% of 60-year-olds).
• Usually the osteoarthritis is found more in the dominant hand.
Osteoarthritis
MECHANISM OF INJURY:
• Osteoarthritis is a pathology of overuse. The mechanism of injury is therefore the result of repetitive motions that stress the hand and finger joints. The more cycles of an activity that the hand sees, the more likely the result will be anatomical damage.
• Daily use of the hand/fingers
• Excessive use/strain of the hand/ fingers
• Injuries, such as fracture and strains/sprains, that cause inflammation and scar tissue in the hand or fingers.
COMMON SIGNS AND SYMPTOMS:
( What are the first signs of arthritis in your hand ? )
• Deformities(Heberden’s nodes,Bouchard’s nodes)
• Pain in the hand or fingers
• Stiffness in the hand or fingers
• Cracking or deep crunching in the hand or finger joints
• Inflammation and thickening of the hand or finger joints
• The American College of Rheumatology’s criteria for hand osteoarthritis includes pain, ache, and stiffness,plus at least three of the following:
Bony thickening at the third DIP joint.
Bone thickening at the second and third PIP joints.
Bone thickening at the first CMC joint.
Bony thickening of at least two DIP joints.
Swelling of at least three MCP joints.
Deformity of at least 1 of the 10 aforementioned joints.
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| Osteoarthritis |
AGGRAVATING ACTIVITIES
• Inactivity allows the inflammation to“pool” and increase pressure leading to discomfort and loss of availablemovement.Inactivity leads to stiffness.
• Reaching overhead.
• Throwing, lifting,reaching behind.
• Weight-bearing activities such as crawling or making a bed.
EASING ACTIVITIES
• Rest
• Gentle motions of the hand and finger joints
• Gentle stretching and exercise, heat,massage, antiinflammatory medications,non-weight–bearing activities, and leg elevation
• Generally speaking,these activities lead to decreased wear and tear, increased joint lubrication, and loss of stiffness and inflammation associated with this condition.
24-HOUR SYMPTOM PATTERN
• Stiffness in the morning (first 10 to 15 minutes)
• Better after a warm shower and taking medication
• Can worsen with excessive movement
• Stiffens again in the evening.
PAST HISTORY FOR THE REGION
• Jobs or recreational activities that require excessive use/strain of the hand (dancing, walking, running, jumping,etc)
• Abnormal amount of damage from injuries.
PHYSICAL EXAMINATION:
(What does hand arthritis feel like ? )
• Joint thickening (bony changes and inflammation)
• Loss of hand/finger ROM
• Localized pain and loss of joint mobility
• Crepitus with movement
IMPORTANT OBJECTIVE TESTS
• The standard test for differentiating hand or finger osteoarthritis is x-ray. MRIs may be warranted if soft tissue damage is suspected.
• No one specific clinical test has proved reliable in differentiating hand or finger osteoarthritis.
- Common clinical assessments are as follows:
( How to test for arthritis in hands ? )
Palpation: Composite compression test (through the MCP joints) and specific joint compression
Alignment assessment
AROM and PROM
Joint mobility
Strength tests (grip and pinch dynamometers).
DIFFERENTIAL
DIAGNOSIS:
• Hand/finger sprain/strain
• Tendonitis (de Quervain’s syndrome)
• RA
• Trigger finger
• Reflex sympathetic dystrophy
• Complex regional pain syndrome
• Cervical radiculopathy.
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| Osteoarthritis |
CONTRIBUTING FACTORS
• Uncontrolled risk factors that contribute or predispose an individual to hand osteoarthritis pathology are as follows:
Gender (females more than males)
Age (increase 2% per year after age 40 years)
Genetics
• Modifiable risk factors that contribute or predispose an individual to continue or to progress to hand osteoarthritis are as follows:
Weight
Work or recreational activities
Repetitive or significant traumatic injuries to the hip
Poor health (smoking, long-term use of steroids).
TREATMENT
SURGICAL OPTION:
( Hand arthritis treatment )
- Fusion (arthrodesis).
REHABILITATION
• Rehabilitation regimes should address the following:
Education regarding correct use of ice/heat at home
Give home exercise program/ADL training
Body mechanics and joint protection (use of assistive devices) training with ADLs
Manual therapy (soft tissue mobilization, joint mobilization)
Modalities: Heat, paraffin, ultrasound,electrical stimulation,tape/splints
• Initial exercises used to promote healing are as follows:
Therapeutic exercises: ROM, isometrics (for painful joints), and progressive resistive exercises (for minimal to nonpainful joints)
Agility exercises
• Manual therapy (soft tissue mobilization, joint mobilization) can improve joint mobility and joint arthrokinematics and decrease pain.
• Massage can decrease pain by relaxing muscular tension, improving circulation, and increasing endorphin release.
• Exercise should be used to do the following:
Decrease muscular and joint stiffness
Improve joint alignment by increasing muscular support
Improve functional mobility
Create a sense of control over the symptoms and the condition.
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| Osteoarthritis |
PROGNOSIS
• Long-term prognosis for a patient with hand osteoarthritis depends on the extent of wear and tear and the ability to reduce the joint strain placed on the joint (posture, activity, etc).
• For the most part, hand osteoarthritis is a degenerative condition. At earlier stages of the pathology,rehabilitation aimed at reducing the load placed on the joint can potentially slow or halt the progression of degeneration.
• For patients who are further along in the degenerative process, outcomes will be less favorable because cartilage has only a limited ability to repair itself.
SIGNS AND SYMPTOMS
INDICATING REFERRAL
TO PHYSICIAN:
• Unrelenting pain
• Unusual responses to therapy
• Neurological symptoms
• Signs of infection, reflex sympathetic dystrophy, or complex regional pain syndrome.
SUGGESTED READINGS:
1- Dillon CF, Hirsch R, Rasch EK, Gu Q. Symptomatic hand osteoarthritisin the United States: prevalence and functional impairment estimates from the third U.S.National Health and Nutrition Examination Survey, 1991–1994.
2- Am J Phys Med Rehabil. 2007;86(1):12–21.
3- Dugan SA. Exercise for health and wellness at midlife and beyond: balancing benefits and risks. Phys Med Rehabil Clin N Am. 2007;18(3):555–575.
4- Glass GG. Osteoarthritis. Dis Mon.2006;52(9):343–362.
5-Rogers MW. The effects of strength training among persons with hand osteoarthritis: a two-year follow-up study. J Hand Ther.2007;20(3):244–249. quiz 250.2006;14(9):953–957.
