Background

Hand osteoarthritis (OA) is one of the most common degenerative joint disorders seen in the adult population. The prevalence of hand OA increases with age and is more common among women than in men. The distal interphalangeal, proximal interphalangeal, or first carpometacarpal joints of the hand are typically affected (Bijlsma et al., 2011). The common symptoms include activity-related pain, brief periods of joint stiffness in morning or after rest, loss of joint movement, reduced grip strength, joint instability, and joint crepitations. Pain coupled with joint stiffness and reduced grip strength results in activity restriction (Elliott et al., 2007; Stamm et al., 2009). With the global demographic aging trend, the burden of OA is expected to be more in the near future.

Currently, there is no definitive cure for OA, and the treatment goals are to reduce pain and minimize loss of physical function. Pharmacological management is mainly symptomatic, and surgical treatments are recommended only for severe cases of OA. Hence, nonpharmacological approaches play a significant role in managing OA. The recommended nonpharmacological therapies include patient education, weight reduction, and exercises (Fernandes et al., 2013; McAlindon et al., 2014). Even though the current evidence supports the use of exercise interventions for knee and hip OA, these interventions' effects on hand OA remain uncertain.

Hence, there is a need to examine the available evidence on the effectiveness of exercises on hand OA to generate practice recommendations. This summary is based on a Cochrane systematic review, that investigated the effect of exercises on clinical outcomes of patients with hand OA (Osteras et al., 2017).

Objective

The objective of the Cochrane review was to evaluate the benefits and harms of exercise compared with other interventions (including placebo or no interventions) in the management of hand OA (Osteras et al., 2017). Primary outcomes of interest of this review were hand pain and physical function.

Intervention/Methods

Randomized trials comparing the effectiveness of therapeutic exercises versus no exercise or different exercise programs were considered. The studies were included if it had participants 18 years and older with a physician-confirmed diagnosis of hand OA. Studies evaluating postoperative exercise programs were excluded.

The major outcomes considered were hand pain, hand function, joint stiffness, quality of life, and the proportions of adverse events and withdrawals due to adverse events. First assessment after completion of the exercise program was considered as the time point of interest.

The authors searched seven electronic databases-Cochrane Central Register of Controlled Trials, Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Allied and Complementary Medicine Database (AMED), the Physiotherapy Evidence Database (PEDro), and Occupational Therapy Systematic Evaluation of Evidence (OTseeker). Additional records were explored using trial registries, reference lists, gray literature, and conference proceedings. Two authors independently screened the studies, assessed the risk of bias, and evaluated the evidence quality using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach.

Results

Seven studies with a total of 534 participants were included in the review. All seven studies were randomized controlled trials (RCTs) with one small trial being reported as pilot RCT. One study was from Brazil, and two studies each were conducted at the United States, the U.K., and Norway. Participants' mean age ranged from 60 to 81 years, and there was a preponderance of female participants across the studies (66%-100%).

A considerable amount of heterogeneity was found in the content, mode, dosage, and supervision of exercise interventions. Nonetheless, the aims of the interventions were relatively consistent across the studies, which were, to reduce pain, improve grip and pinch strength, and enhance the range of motion. Five studies with 381 participants comparing exercises with no exercises were included in the meta-analysis. Pooled results from five studies showed that the exercises had a small beneficial effect on pain. Four studies with 369 participants demonstrated that exercises improved the hand function among patients with hand OA. Only one study (113 participants) evaluated the effect of exercises on quality of life of patients; however, the effect was uncertain. Four out of five studies, with a cumulative 368 participants, evaluated the effect of exercises on finger joint stiffness and the pooled results demonstrated a small to moderate beneficial effect.

Three studies reported adverse events such as hand pain, joint inflammation, or neck/shoulder pain. Pooled data showed that the likelihood of adverse events or withdrawals were higher in the intervention group, but these effects were uncertain. The medium and long-term follow-up data demonstrated uncertain long-term effect of exercise on hand pain, hand function, and finger joint stiffness.

Conclusions

A total of seven studies were included in the qualitative synthesis and five in the meta-analysis. The exercise interventions varied across the studies. The overall low-level evidence from the review indicates that exercise interventions had beneficial effects on hand pain, hand function, and finger joint stiffness among patients with hand OA. Owing to small and moderate effect sizes, a clinically meaningful change may be debated. The effects of the exercise interventions did not seem to sustain over long periods. Adverse events were only a few, indicating good tolerance for the exercise interventions. The review's extremal validity is restricted due to the limited number of studies, and hence the results should be generalized with caution.

Implications for Practice

The findings of the review may be utilized by orthopaedic nurses caring for patients with hand OA. The exercise interventions are found to be safe and are associated with very few side effects. The interventions could be considered for pain reduction, improvement of hand function, and easing the joint stiffness. However, in view of the small effect, a clinically relevant change may not be apparent. The long-term effects of exercise interventions also remain uncertain. Additional randomized trials could be undertaken to determine what constitutes an "optimal exercise intervention" and evaluate the long-term effects of exercise intervention on the clinical outcome of patients with hand OA.

References