Journal Article Review March 2017

Journal Article Review    

Do exercises help hand osteoarthritis?

Østerås N et al: Exercise for hand osteoarthritis. Cochrane Database Syst Rev. 2017 Jan 31;1:CD010388

Osteoarthritis in the hand is a common cause of joint pain, stiffness, and loss of function, especially in older individuals. No cure is available, and medications that reduce pain and inflammation often produce side effects that are worse than the arthritic symptoms. Exercise benefits hip and knee arthritis, but its effect on hand arthritis is unclear.

A new Cochrane Review addresses this issue. The authors found 7 randomized, controlled clinical trials that compared exercise to no exercise or compared different exercise regimens. The assessors in most studies were blinded to any treatment received.

Overall, the authors graded the quality of evidence as low because the participants were unblinded and because the studies were imprecise (low numbers of participants and wide confidence intervals for pain, function, and joint stiffness). The authors graded the quality of evidence very low for quality of life, adverse events, and withdrawals secondary to adverse events because the studies addressing these issues were few and the confidence intervals were very wide.

Five studies (381 participants) indicated a 5% reduction in pain for the exercise group compared to the control group. Four studies (369 participants) showed a 6% improvement in hand function for the exercise group over the control group. One study (113 participants) evaluated quality of life and found a .3% improvement for the exercise group over the control group. Four studies (369 participants) indicated a 7% reduction in finger joint stiffness in the exercise group versus the control group.

Three studies reported treatment-related adverse events and withdrawals secondary to adverse events, which were few and not severe. The adverse events were mainly increased finger joint inflammation and pain. Low quality evidence suggested that withdrawals secondary to adverse events were more common in the exercise group than in the control group.

Two studies (220 participants) reported 6-month data. One study (102 participants) provided 12-month data. The exercise regimens varied widely with respect to frequency, content, and duration. Participants exercised 2-3 times weekly in 4 studies, daily in 2 studies, and 3-4 times each day in one study.

Self-reported adherence to the exercise regimens ranged between 78 and 94% in 3 studies. In another study, 67% of participants completed as least 80% of the scheduled 18 sessions.

The authors conclude that the pooled results showed low-quality evidence for exercise producing small benefits on hand pain, stiffness, and function. The effect sizes were small and whether they “represent a clinically important change may be debated.”

COMMENT: Symptoms of osteoarthritis of the hip or knee may be progressive and unrelenting and thereby contributing greatly to a diminished quality of life. Conversely, osteoarthritis in the finger joints is often migratory and transient, causing major symptoms in one or more joints for months and then becoming quiescent. With multiple fingers, each with closely spaced joints, pain and stiffness in several joints does not usually cause the same degree of functional limitation caused by a painful and stiff hip or knee.

The Cochrane Review highlights the dearth of information supportive of exercises providing a marked benefit on hand arthritis symptoms. The problems include that there are only a few studies, many potential biases, small if any effects, and incomplete compliance.

I reassure patients that the painful, stiff joints that they presently note will likely settle down over a few months and that their current discomfort is not going to be lifelong.  I recommend palliating the present symptoms with frequent heat (especially a paraffin bath) and Coban wraps or elasticized digital sleeves. Having a therapist help them with aids or alternative maneuvers for performing daily living activities is also useful.

An occasional cortisone injection may provide months of relief when other remedies have failed, although the DIP joint is hard to inject. Topical non-steroidal anti-inflammatory cream may also help. I save joint fusions or arthroplasties for the rare joint that is unrelentingly painful and causing disability not merely annoyance.