Rehabilitation strategies to improve physical functioning in patients with musculoskeletal diseases
Giesen, F.J. van der
Citation
Giesen, F. J. van der. (2010, June 1). Rehabilitation strategies to improve physical functioning in patients with musculoskeletal diseases. Retrieved from https://hdl.handle.net/1887/15578
Version: Corrected Publisher’s Version
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A multidisciplinary hand clinic for patients with rheumatic diseases:
a pilot study
J Hand Ther 2007; 20:251-61
F.J. van der Giesen R.G.H.H. Nelissen P.M. Rozing J.H. Arendzen
Z. de Jong R. Wolterbeek T.P.M. Vliet Vlieland
Abstract
Objective To describe the characteristics, management strategies and outcomes of patients with rheumatic diseases and complex hand function problems referred to a multidisciplinary hand clinic.
Methods Assessments (baseline and after 3 months of followup) included sociodemographic and disease characteristics and various hand function measures.
Results The most frequently mentioned impairments and limitations of the 69 patients enrolled in the study pertained to grip, pain, grip strength, and shaking hands. Fifty-six patients received a treatment advice; conservative therapy (n=39), surgery (n=12), or a combination of both (n=5). In 38 of 56 patients (68%) the recommended treatment was performed, and 33 completed the followup assessment. On average, patients improved, with an increase in grip strength and the Michigan Hand Outcomes Questionnaire scores reached statistical significance.
Conclusion Two-thirds of patients with rheumatic conditions visiting a multidisciplinary hand clinic reportedly followed the treatment advice (recommendations), with an overall trend toward a beneficial effect on hand function. To further determine the added value of a structured, multidisciplinary approach a controlled comparison with other treatment strategies is needed.
Introduction
Hand function problems are common in patients with rheumatic diseases. It is estimated that the hands and wrists are affected in 80-90% of the patients with rheumatoid arthritis (RA)1, whereas the hand is the most frequent site of involvement in osteoarthritis (OA)2. Involvement of the hand is also common in patients with psoriatic arthritis3, scleroderma4 and systemic lupus erythematosus (SLE)5. The importance of hand function in rheumatic conditions is underlined by the fact that the ‘fine hand use’ domain is included in the recently developed preliminary International Classification of Functioning, Disability and Health (ICF)6 Core Sets for both RA and OA7,8 . The ICF is aimed at providing a unified and standard language and framework for the description of health and health-related states (Figure 1). Although the importance of hand function problems in rheumatic diseases is generally acknowledged, there is little evidence on how and when to use conservative or surgical interventions to optimize hand function9. This lack of knowledge can be partly explained by the complexity of hand function problems in many patients. Limitations in hand function during activities of daily living (ADL) are often accompanied by a combination of multiple impairments on the level of the ICF level of body functions or body structures, such as pain, stiffness, joint swelling, limited range of motion (ROM), joint destruction, or deformities. Moreover, personal and environmental factors may play an important role in the occurrence and impact of hand function problems.
Figure 1. The model of the International Classification of Functioning, Disability and Health (ICF). This model shows the relationship between the different ICF components. Each component consists of chapters and each chapter consists of categories. The patient perceived problems can be located within the component ‘Body functions and Body structures’ and ‘Activities’ and ‘Participation’.
To assist in the management of patients with complex, challenging hand function problems, multidisciplinary hand clinics have been established over the last decade. To date, the characteristics and outcomes of patients with rheumatic diseases who are being evaluated in such clinics are not known. Therefore, our aim was to describe the clinical profile, management strategies and outcomes of patients with rheumatic diseases who were referred to a multidisciplinary clinic for complex hand function problems. The description of the organization of the clinic can be used for comparison by clinicians involved with this patient group, such as hand therapists, occupational therapists, physical therapists, surgeons, rheumatologists, and rehabilitation specialists. Moreover, the systematic evaluation of complex hand function problems and their outcomes after comprehensive treatment will help to set the agenda for future research in this area.
Health condition (disorder or disease)
Environmental Factors
Personal Factors
Participation Body functions
and Structures
Activities
Patients and Methods
Study design
This observational study was conducted at the day patient clinic of the Department of Rheumatology of the Leiden University Medical Center in the Netherlands. This clinic is a tertiary referral center and offers multidisciplinary team care for patients with rheumatic diseases10, including two specific multidisciplinary programs: a vocational rehabilitation program11 and a multidisciplinary hand clinic. All 69 consecutive patients referred to the multidisciplinary hand clinic between January 2002 and April 2004 were enrolled in the present study. The Medical Ethical Committee of the Leiden University Medical Center approved the study, and all patients gave written informed consent.
The multidisciplinary hand clinic
The multidisciplinary hand clinic serves patients with rheumatic diseases and complex hand function problems, defined as a problem in hand function that cannot be solved by a single intervention or a single health professional. Referrals were made by rheumatologists and orthopedic surgeons. At referral, radiographs of hands and wrist were ordered, except when recent radiographs (less than six months) were available. The multidisciplinary team involved an orthopedic surgeon, a rehabilitation specialist, a rheumatologist, an occupational therapist and a physical therapist.
Patients visited the hospital twice for assessment and treatment advice (recommendations). At the initial visit a standardized, comprehensive analysis of hand function was made by a physical therapist, who was the coordinator of the team, a rheumatologist and an occupational therapist, in succession. As part of the occupational assessment a video was made of the patient performing specific ADL within the framework of the Sequential Occupational Dexterity Assessment (SODA)12, recording hand function problems.
At the second visit, the coordinator, with the entire multidisciplinary team and the patient present, reviewed a synopsis of the clinical assessments, including the video and the radiographs. The orthopedic surgeon and rehabilitation specialist undertook additional history and physical examination, and subsequently a multidisciplinary treatment plan was proposed and discussed with the patient. Treatment could consist of conservative or surgical therapy or a combination of both. If an intervention was instituted, a followup appointment for a formal assessment after 3 months was scheduled.
Clinical assessments
A rheumatologist, a trained physical therapist (FJvdG), and 5 trained occupational therapists performed all clinical assessments in connection with the hand function clinic. The principal investigator (FJvdG) trained all evaluating occupational therapists in the performance of the clinical measurements, i.e., the joint count, the SODA and the measurements of grip strength and joint ROM. Training sessions for calibration were repeated with every occupational therapist every three months.
Sociodemographic and disease characteristics and general health status
Sociodemographic data included gender, age, paid employment, and status of living (living alone or living with spouse and/or family). In addition, the rheumatologic diagnosis and the disease duration in years were recorded.
General health status was measured by means of the RAND (Research and Development) 36-Item Health Survey13, which includes 35 items covering eight dimensions of health status (physical functioning, social functioning, role limitations caused by physical health problems, role limitations caused by emotional health problems, pain, mental health, vitality, and general health perception) and one item assessing changes in perceived health over the last 12 months. Each dimension generates a score from 0 to 100, with higher scores indicating better health. The RAND can be converted to two summary scales: the physical and mental component summary scales. The RAND includes the same items as the Medical Outcomes Study Short-Form (SF36) and although the scoring procedures are somewhat different, the effects of these on final scores are minimal14.
We chose the RAND because this questionnaire was validated in a Dutch population13. Joint swelling and deformities
Based on a 28 joint count15, joint swelling of the metacarpophalangeal joints (MCP; 10 joints), the proximal interphalangeal joints (PIP; 8 joints) and the interphalangeal joints of the thumbs (IP; 2 joints) was assessed in a yes/no format for every joint, with the total joint swelling score for the hands ranging from 0 to 20. The presence of deformities (Boutonnière deformity, swan neck deformity and/or ulnar deviation of MCP joints) was listed on a binary scale for each finger or thumb. In addition, the presence of tendon ruptures and Heberden nodules or RA nodules was recorded.
Assistive devices and splint usage
Possession of assistive devices or splints for hand, finger, or wrist function was noted.
For that purpose, the assessor read out a list of 27 frequently used assistive devices and asked with each device whether the patient had the device and if so, whether it was used on regular basis.
Primary hand function problems
The patient’s individual problems and challenges regarding hand function were obtained by means of a semistructured interview. All impairments, limitations, or restrictions were categorized and labelled afterward according to the ICF6 (See ICF Appendix). Furthermore, patients were asked to rank the three limitations and/or problems that were most troubling to them. At the followup assessment, patients were asked to rate the changes regarding their main problem by means of a 5-point Likert-scale (1 = much improved, 2 = improved, 3 = not changed, 4 = worsened, 5 = much worsened).
Range of motion
The ROM of the wrist (sum of palmar and dorsal flexion) and finger joints (palmar flexion) was assessed with a goniometer according to the method of the American Academy of Orthopedic Surgeons16. For the thumb, palmar flexion of the MCP and IP joints ROM were summed. All scores regarding wrist and finger joint ROM were calculated separately for the left and right as well as averaged for the left and right.
Grip strength
Grip strength was measured with a Jamar dynamometer17. Patients were sitting on a chair with shoulders and wrist in neutral position and the elbow in 90° flexion. They were asked to squeeze the dynamometer as hard as possible and were vocally encouraged. Patients performed the test twice with each hand; the higher score was recorded. The score was calculated separately for the left and right as well as averaged over the left and right.
Pain and stiffness
Hand pain during rest and motion and hand stiffness were measured by means of a 10-cm horizontal visual analog scale for the left and right hand separately, with the left anchor representing no pain or no stiffness at all and the right anchor the maximal pain or stiffness, respectively. An average score over the left and right was calculated.
Hand function
Hand function was assessed by means of the SODA12, the hand and finger function domain of the Dutch Arthritis Impact Measurement Scales (D-AIMS2)18 and the Michigan Hand Outcomes Questionnaire (MHQ)19.
With the SODA, the patient performed 12 standardized tasks, some bimanual and some one-handed, representing all major grips such as pinch grip, cylindrical grip, and writing grip. The assessor scored whether it was possible to perform the task in the standardized way, the effort that the activity took and the pain the patients experienced when performing the task. The combination of the possibility to perform the tasks and the effort formed the SODA score, ranging from 0 to 108, with a higher number representing better hand function. The pain patients experienced when performing the tasks formed the SODA pain score, ranging from 0 to 12, with a higher score indicating more pain. The SODA has been shown to be reliable, valid and responsive to clinical changes in patients with RA12,20,21.
The DAIMS2 is a questionnaire specifically designed to assess health status in subjects with RA. It consists of 12 domains, of which only the domain ‘hand and finger function’ was used in this study. The domain consists of five questions, with the final score ranging from 0 to 10, with higher scores indicating worse hand function.
The MHQ is a 37-item questionnaire covering six domains: overall hand function, ADL, pain, work performance, aesthetics and patients satisfaction with hand function. The latter four of these domains were scored for the right and left hand separately. The total score (average of all domains) ranges from 0 to 100, with higher scores indicating better hand function. A Dutch version has previously been validated in 22 patients with various hand conditions, including nine RA patients22.
Statistical analysis
Data are presented as medians with ranges or interquartile ranges or means with standard deviation for continuous data, and numbers and percentages for categorical data.
Comparisons of the baseline characteristics between the group of patients who underwent treatment and were available for followup and the group of patients who were not available for followup were done by means of the Mann-Whitney test or chi-square test where appropriate.
Mean differences between baseline and followup scores of clinical outcome measures of hand function were calculated with the 95% confidence interval. In addition, the Wilcoxon rank test was used to compare baseline and followup data. In case of treatment of one hand, and the availability of separate scores for the right and left hand, additional change scores and Wilcoxon rank tests were computed for the treated hand only. Change scores of patients who underwent conservative therapy, surgical therapy or a combination were compared by means of a one-way analysis of covariance (ANCOVA), with baseline scores used as the covariates. For all analyses, the level of significance was set at 0.05, and all tests were two sided. All analyses were performed using the Statistical Package for Social Sciences (SPSS) version 11.0 (SPSS inc. Chicago, IL)
Results
All 69 consecutive patients referred to the multidisciplinary hand clinic between January 2002 and April 2004 participated in the study. The sociodemographic and disease characteristics of the total group (n=69) are presented in Table 1. In addition, Table 1 shows the baseline characteristics of the group of patients who underwent treatment and were available for followup separately (n=33).
Table 1. Characteristics of 69 patients with rheumatic diseases referred to a multidisciplinary hand clinic (Total group)
Total group Evaluated group
n=69 n=33
Sex (m/f) 15/54 5/28
Age, years; med (range) 60.0 (21-84) 57.3 (21-80)
Paid employment; no. (%) 14 (20) 7 (21)
Living alone; no. (%) 17 (25) 7 (21)
Diagnosis; no. (%)
Rheumatoid arthritis 55 (80) 28 (85)
Osteoarthritis 5 (7) 1 (3)
Psoriatic arthritis 4 (6) 2 (6)
Systemic lupus erythematosus 3 (4) 1 (3)
Mixed connective tissue disease 1 (1) 1 (3)
Spondylarthropathy 1 (1) 0 (0)
Disease duration, years; med (range) 15.1 (0.2-51.0) 17.1 (0.2-43.0) RAND-36 (0-100), med (range)
Mental component summary scale, n=60 68.9 (15.1-100.0) 71.2 (23.8-94.0) Physical component summary scale, n=60 37.4 (4.3-87.5) 38.1 (16.9-87.5) Joint swelling (MCP + PIP + IP, 0-20); med (range) 2 (0-14) 2 (0-14)
Boutonnière deformity; no. (%) 31 (45) 15 (46)
Swan neck deformity; no. (%) 32 (46) 16 (49)
Ulnar deviation; no. (%) 35 (51) 12 (36)
Tendon ruptures; no. (%) 21 (30) 7 (21)
Heberden nodules; no. (%) 2 (3) 1 (3)
RA nodules; no. (%) 6 (9) 4 (12)
No. of assistive devices in possession; med (range) 6 (0-13) 6 (0-13) Splint possession; no. (%)
Wrist splint(s) 31 (45) 16 (49)
Thumb (CMC) splint 1 (1) 1 (3)
Swan neck splint(s) 14 (20) 6 (18)
MCP = metacarpophalangeal joint; PIP = proximal interphalangeal joint; IP = interphalangeal joint;
CMC = carpometacarpal joint. Characteristics of the 33 patients in whom the advised treatment was executed and who were available for followup (Evaluated group) are presented separately.
With respect to the characteristics of the total group, the majority of the population was female, with most of the patients having RA and a considerable disease duration (median 15.1 years). The median number of swollen MCP, PIP or IP joints per subject was 2 (range 0-14). Fifty (73%) patients had one or more deformities. Thirty-one (45%) patients had one or more boutonnière deformities (median number of boutonnière deformities per subject:
1 [range 1-5]), 32 (46%) patients had one ore more swan neck deformities (median number of swan neck deformities per subject: 3 [range 1-8]) and ulnar deviation in one or more finger was present in 35 patients (51%) (median number of fingers with ulnar deviation per subject: 7 [range 1-8]). Tendon ruptures, Heberden nodules and RA nodules were present in 21 (30%), 2 (3%), and 6 (9%) patients, respectively. Among the patients who had deformities, the median number of boutonnière deformities was 1 (range 1-5), the median number of swan neck deformities was 3 (range 1-8) and the median number of fingers with ulnar deviation was 7 (range 1 -8). A tendon rupture was present in 21 of the 69 patients (30%).
Thirty-one patients (45%) had wrist splints and 14 patients (20%) had finger splints.
Sixty-two patients (90%) used one or more of the listed assistive devices related to hand function. Assistive devices that were most frequently used were: an extended water tap (n=42, 61%), an enlarged pen grip (n=30, 44%) and an elongated shoe horn (n=30, 44%).
A comparison of the baseline characteristics of the group of patients who underwent treatment and was available for followup and the group who did not undergo treatment, showed no significant differences. An exception was the proportion of patients with one or more digits with ulnar deviation, which was significantly lower in the group of patients with treatment and followup (chi-square test; P =0.02).
Table 2 shows the problems patients were facing from their own perspective as categorized according to the ICF6 (See ICF Appendix). With respect to the domain denoted as Body functions and structures, patients clearly distinguished two types of problems, with the following common descriptions: 1) grip: the ability to position the fingers and thumb around an object with the intention to pick up, grab or hold that object; and 2) grip strength: the ability to apply force to an object while using a specific grip. Within the domain Body functions and structures, impaired grip (n=48, 70%), pain in the hand and/or wrist (n=40, 58%) and reduced grip strength (n=24, 35%) were the problems most frequently mentioned. The items that were most frequently perceived as a problem in the domain Activities and participation were: shaking hands (n=21, 30%), cleaning activities (n=20, 30%), and participation in leisure activities (n=19, 28%).
With respect to comparisons of problems between patients who underwent treatment and were available for followup versus the patients who did not undergo treatment, proportions of patients were only different with respect to the activity ‘buying groceries’
(P =0.03, chi-square test).
The treatment advices are presented in Table 3. Of the 69 patients referred to the multidisciplinary hand clinic, 9 (13%) were reassured, 4 (6%) received treatment advice that was not specifically related to the hands (e.g. local treatment for shoulder or elbow), and 56 (81%) received a hand-related treatment advice.
Twelve of the 56 patients (21%) received advice pertaining to surgical intervention only, 39 of 56 patients (70%) received an advice regarding one or more conservative interventions only (occupational therapy and/or physical therapy and/or pharmacological treatment) and 5 of 56 patients (9%) received advice for a combination of surgical intervention and one or more conservative intervention(s). Of the 44 who received advice pertaining on one or more conservative interventions, the advice included occupational therapy in 33 patients (38 different modalities), physical therapy in 15 patients (16 proposed treatment modalities),
and pharmacological treatment in 15 patients (15 proposed treatment modalities). Totals add up to over 44 beause in some subjects multiple conservative interventions or treatment modalities were recommended.
Table 2. Perceived hand function problems in 69 patients with rheumatic diseases referred to a multidisciplinary hand clinic (Total group) and in 33 patients in whom the advised treatment was executed and who were available for followup (Evaluated group)
Total group (n=69) Evaluated group (n=33) Body functions and Body structures, no. (%)
Impaired grip (s730) 48 (70) 24 (72)
Pain (b280) 40 (58) 18 (55)
Decreased grip strength (b730) 24 (35) 13 (39)
Hand stiffness (b780) 11 (16) 5 (15)
Need for general informationND 5 (7) 2 (6)
Sensibility problems (b265) 3 (4) 1 (3)
Cosmetic problems (b180) 2 (3) 1 (3)
Activities and Participation, no. (%) Self-care
Dressing and undressing (d540) 15 (22) 7 (12)
Using cutlery (d550) 14 (20) 6 (18)
Holding glasses and cups (d560) 12 (17) 6 (18)
Washing and drying themselves (d510) 10 (15) 2 (6)
Using toilet paper (d530) 8 (12) 3 (9)
Domestic life, no. (%)
Cleaning activities (d640) 20 (30) 6 (18)
Preparing meals (d630) 11 (16) 6 (18)
Buying groceries (d620) 10 (15) 8 (24)*
Community, social and civic life, no. (%)
Participation in hobbies (d920) 19 (28) 11 (33)
Participation in sports (d920) 15 (22) 6 (18)
Communication, no. (%)
Shaking hands (d3602) 21 (30) 11 (33)
Writing (d360) 16 (23) 7 (21)
Using keyboard and mouse (d360) 6 (9) 4 (12)
Handling a telephone (d360) 5 (7) 2 (6)
*P <0.05, chi-square test, comparison of patients who underwent treatment and were available for followup (n=33) and patients who did not (n=36); ND = Not definable in ICF. Numbers in parentheses refer to ICF codes.
Table 3. Treatment recommendations to 69 patients with rheumatic diseases referred to a multidisciplinary hand clinic (Total group)
Total group (n=69) Treatment executed group (n=38)
Reassurance only 9 (13)
General advice only 4 (6)
Hand problem related advice 56 (81) 38 (68)
Occupational therapy 33 (48) 21 (64)
Finger and/or wrist splint(s) 21 14
Assistive devices / adjustments 10 4
Ergonomic advice 7 4
Physical therapy 15 (22) 13 (87)
Hand exercises 14 13
Sport advice 2 2
Medication 15 (22) 12 (80)
Injections with corticosteroids 12 9
Adjusting oral medication 3 3
Surgery 17 (25) 11 (65)
Joint fusion 7 5
IP 3 1
MCP 2 2
PIP 6 2
DIP 1 1
Soft tissue correction 5 4
Correction osteotomy boutonnière dig. 1 2 2
Resection arthroplasty CMC 1 1 1
Intrinsic transfer with rerouting tendons 1 0
Intrinsic release dig. 2-5 1 1
Total joint replacement 3 1
MCP 2 1
PIP 1 0
Osteoclasy 1 0
Wrist procedure (Sauvé Kapandji) 1 1
Carpal Tunnel Syndrome release 1 1
Excision of tendon nodules 1 1
Excision of skin nodules 1 1
MCP = metacarpophalangeal joint; PIP = proximal interphalangeal joint; IP = interphalangeal joint; CMC = carpometacarpal joint. Treatment recommendations within the group of patients in whom the treatment was executed are presented separately (Treatment executed group). All results are expressed as numbers (%).
The exercise therapy involved strengthening exercises and ROM exercises tailored to the individual needs. Patients in this category performed strengthening and ROM exercises 3 times a day. Strengthening exercises consisted of 3 sets of 10 repetitions (10-second
contractions) for each muscle group during each session. ROM exercises included 5 sets of 10 repetitions (placing the joint 30 seconds in the limited position of the joint). Occupational therapy comprised, apart from the provision of assistive devices and splints, instruction on joint protection and energy conservation, training of motor functions, and ADL (summarized as ergonomic advice) according to individual needs.
Thirty-eight of the 56 patients (68%) who received a hand-related treatment advice followed through with the advice. The proportions of proposed interventions that were accepted by the patients were in the same range for both occupational therapy (21/33, 64%) and surgery (11/17, 65%), with the proportional rates being somewhat higher for physical therapy (13/15, 87%) and medication (12/15, 80%). Thirty-three of the 38 patients who accepted the treatment (87%) completed the followup. The 5 patients unavailable for followup either declined further participation (n=3) or were not able to come to the hospital due to serious comorbidity (n=2).
Thirty-three of the 38 patients who had treatment were available for followup at three months. Table 4 shows that in general, patients showed a trend towards improvement according to all outcome measures, except for ROM, hand pain during rest and hand stiffness. The improvements of the total score of the MHQ and grip strength reached statistical significance (P <0.005 and P =0.01, respectively).
Seventeen of the 33 patients (52%) who completed the followup stated that their most important hand function problem had improved (n=13) or much improved (n=4). In 11 patients (33%) the problem remained unchanged, whereas in 5 patients (15%) the problem had worsened.
Table 4. Baseline measures of hand function in 69 patients visiting a multidisciplinary hand clinic (median, IQR) and baseline and followup measures of hand function (median, IQR) and mean difference between baseline and followup (95% Confidence Interval) in 33 patients with rheumatic diseases who underwent local treatment for hand function problems
Outcome measure
Baseline Total group (n=69)
Baseline Evaluated group (n=33)
Followup Evaluated group (n=33)
Mean difference‡ (95% CI)
Thumb palmar flexion (MCP + IP), degr. 100 (28) 98 (21) 95 (29) -2 (-9 ; 6)
MCP palmar flexion, degr. 98 (22) 98 (16) 93 (14) 0 (-3 ; 2)
PIP palmar flexion, degr. 90 (24) 90 (23) 90 (25) 0 (-3 ; 3)
Wrist palmar flexion + dorsal flexion, degr. 85 (79) 98 (74) 79 (66) -2 (-7 ; 2)
Grip strength, kg. 6.5 (10.5) 8.0 (10.3) 12.0 (10.3) 2.8 (0.7 ; 5.0) ¥*
Hand pain moving (VAS, 0-100 mm) 33 (44) 30 (41) 21 (37) 5 (-13 ; 3)
Hand pain rest (VAS, 0-100 mm) 10 (34) 5 (20) 5 (24) 1 (-7 ; 4)
Hand stiffness (VAS, 0-100 mm) 20 (34) 16 (33) 20 (23) 0 (-7 ; 7)
SODA total (0-108) 75.0 (39.0) 75.0 (37.0) 88 (45.0) 4.7 (-0.7 ; 10.2)
SODA pain (0-12) 2.5 (4.0) 2.0 (4.0) 2.0 (5.0) 0.7 (-1.5 ; 0.1)
MHQ total (0-100) 49.3 (17.0) 49.2 (17.0) 56.2 (20.5) 7.4 (4.1 ; 10.8)*
D-AIMS hand and finger function (0-10) 5.0 (4.0) 4.3 (3.0) 3.5 (3.6) 0.5 (-1.0 ; 0.1) IQR = Interquartile range; MCP = metacarpophalangeal joint; PIP = proximal interphalangeal joint;
IP = interphalangeal joint; VAS = Visual Analogue Scale; SODA = Sequential Occupational Dexterity Assess- ment; MHQ = Michigan Hand Outcomes Questionnaire; D-AIMS = Dutch Arthritis Impact Measurement Scales;
CI = Confidence interval. ¥= data of the treated side; ‡ positive value = improvement *P <0.05 (Wilcoxon signed- rank test).
There were no significant differences in effectiveness regarding any of the outcome measures among the 8 patients who underwent surgical intervention, the 22 patients who
underwent conservative treatment only, or the 3 patients who had a combination of surgery and conservative treatment (ANCOVA; results not shown).
Within the surgically treated group and in the group of patients who underwent a combination of surgery and conservative treatment, none of the differences between baseline and followup reached statistical significance. The conservatively treated group demonstrated significant improvements of the SODA total score, SODA pain score and the MHQ total score (Wilcoxon signed-rank test; results not shown).
Discussion
This cross-sectional study concerning a multidisciplinary hand clinic shows that the most frequently mentioned impairments, limitations and restrictions of patients with rheumatic diseases and hand function problems pertain to grip, pain, grip strength, and shaking hands. Management recommendations, including conservative and surgical treatment, are followed by nearly two-thirds of the patients. On average, patients who are treated improve significantly with respect to grip strength and overall hand function as measured by a questionnaire (MHQ).
Our description of hand function problems perceived by patients with rheumatic diseases is in line with the growing interest in describing impairments and limitations from a specific patient groups’ perspective. An illustration of an instrument developed for describing these issues is the development of ICF based core sets for a large number of conditions, including rheumatic diseases23. Although it is conceivable that there are many similarities among the problems perceived by patients with various conditions, disease-specific impairments may also result in disease-specific problems in daily life. Insight into the problems perceived by specific patient groups may facilitate the setting of patient-oriented treatment goals and the institution of appropriate and satisfying interventions. So far, the literature on specific hand function problems encountered by patients with rheumatic diseases in daily living is scanty. Overall, among the studies included in systematic reviews on hand surgery24, hand exercises25, occupational therapy26, or splints and orthoses in RA27, a wide range of measures concerning hand function is used, hampering direct comparison. Our findings concerning the patient perceived importance of loss of grip, hand and/or wrist pain and reduced grip strength are in concordance with the study by Chung et al.28. That study focused on underlying reasons for choosing hand surgery. Chung and colleagues studied 61 patients with RA and MCP joint extensor lag and/or ulnar deviation. Study participants had to choose whether they wanted to receive either MCP joint arthroplasty or not. It appeared that, after controlling for age and gender, hand function and hand pain were found to be significantly associated with the choice for surgery. In that study, aesthetics was not associated with choosing surgery. The latter is in line with our observation that, despite the large proportion of patients having one or more deformities, cosmetics was not a frequently mentioned problem in our population. With respect to hand function, the present study showed that on the ICF level of body functions and structures, patients clearly perceive ‘the ability to position the fingers and thumb around an object with the intention to pick up, grab or hold that object’ (grip) as different from ‘applying force to an object while using a specific grip’ (grip strength). In addition, with respect to ADL, in our group of patients, shaking hands was a relatively frequently mentioned problem. To date, this activity has however, not been included in common questionnaires on hand function, such as the D-AIMS hand function dimension and the MHQ. All of the above-mentioned findings suggest that the development of more patient-oriented questionnaires regarding hand function problems is warranted.
With respect to the advised interventions, in our study, 17 of the 56 patients who received treatment advice were advised to undergo surgery. As there are no data available from similar multidisciplinary services, we can not compare the frequency of surgical or conservative advices with other clinics.
Sixty-eight percent of the patients who received advice directly aimed at the hands followed the advice and underwent treatment, whereas 32% of the patients did not follow the advice. The proportions of conservative and surgical recommendations that were accepted or declined were in the same range. Thus, far little data are available regarding decision making in management of rheumatic hand function problems. In the above- mentioned study by Chung et al.,33 of the 61 patients (54%) elected to undergo MCP joint arthroplasty surgery and 28 patients (46%) chose not to have surgery for MCP extensor lag and/or ulnar deviation. Other studies on medical decision making in arthritis principally pertain to total joint arthroplasty for disabling hip or knee arthritis. In two studies by Hawker et al.29,30, the proportions of patients willing to consider such a procedure were 33.5% and 10%, respectively. Proportions of patients following treatment recommendations have to be interpreted with care. Decision making by the patient is a complex process, involving the gathering of information on available choices, needs, risks and benefits and then the systematic weighing or analyzing of alternatives31. Future studies, aimed to investigate individual considerations for either following or not following treatment recommendations could provide more insight into patients’ decision making in case of rheumatic disease related hand function problems.
Concerning the effectiveness of treatment in those patients who received an intervention, our study showed that on average, patients showed a trend towards improvement regarding a number of measures of hand function, some of the results reaching statistical significance. These results may indicate that patients with complex problems could benefit from a multidisciplinary approach. A limitation of our study is that it involved only a relatively small number of patients, with various rheumatic conditions and a variety of impairments underlying limitations in ADL. Moreover, the comparison of effectiveness among the three groups of patients receiving surgical therapy, conservative therapy, or a combination involves very small numbers per group so that it is difficult to draw conclusions about the effectiveness of the three intervention strategies separately.
Although the occupational therapists involved in the study were trained by an experienced assessor at various time points, it remains unclear to what extent interobserver and intraobserver variability had an impact on the clinical outcomes of the study. Moreover, as the study was embedded in regular clinical care, patients who were not treated did not undergo a followup assessment. To get a clear picture of the added value of a multidisciplinary approach for complex hand function problems in comparison with alternative treatment strategies, a controlled trial should be performed, with adequate followup of all participants.
Our results are difficult to compare with other studies, as this study pertains to various treatment strategies including combinations of interventions in a considerable proportion of patients. A comparison with other studies is, apart from variability regarding the interventions, also hampered by variability with respect to the outcome measures used in trials concerning interventions for hand function problems24-27. To solve this problem, the development of a core set specifically for hand function problems in patients with arthritis, appears to be a useful initiative. Indeed, the development of ICF based core sets related to specific parts of the body has been advocated before32. With the development of such a core set, the contents of existing hand function questionnaires, and the experiences of expert health professionals and patients would have to be taken into account.
With respect to indications for treatment, it remains to be established which patients would profit most from conservative or surgical therapy, or a combination of both.
Concerning the issue of indications, attitudes of clinicians as well as patients toward outcomes of treatment are of utmost importance. One study evaluated the attitudes of hand surgeons and rheumatologists toward the effectiveness of rheumatoid hand surgery9. In that study, the outcomes of MCP joint arthroplasty, small joint synovectomy, extensor synovectomy, resection of the distal ulna, wrist fusion, and soft tissue reconstruction for boutonnière and swan neck deformities were perceived as more effective by surgeons than by rheumatologists9.
Understanding the considerations of patients to accept treatment recommendations, which is an essential part of counseling patients with complex hand function problem, is an area which deserves additional research. Moreover, the added value of a multidisciplinary approach needs to be further examined. For that purpose, a controlled trial in which the outcomes of patients referred to a multidisciplinary hand clinic are compared with those of alternative treatment approaches is needed. A focus on specific diagnoses and interventions is advocated. Additional area for research includes standardization of indications for surgical and conservative treatment and the development of a core set of outcome measures.
Conclusion
In patients with rheumatic diseases visiting a multidisciplinary hand clinic for complex hand function problems, impaired hand function, pain, and shaking hands were the most frequently mentioned problems. About two-thirds of the patients followed the conservative and/or surgical treatment advices (recommendations), resulting in an improvement of hand function in the majority of patients.
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ICF Appendix. Overview of the linking of the patient perceived problems in hand function to the ICF components
‘Body functions and Body structures’ and ‘Activities and Participation’
Patient perceived problems ICF Chapters (in italics) and Categories second level of the ICF ICF Category Codes second level Body functions and Body structures
Mental functions (Chapter 1) b110-b199
Cosmetic problems Specific mental functions b180
Sensory functions and pain (Chapter 2) b210-b299
Sensibility problems Touch function b265
Pain Pain b280
Neuromusculoskeletal and movement- related functions (Chapter 7)
b710-b799
Decreased grip strength Muscle power functions b730
Hand stiffness Sensations related to muscles and movement functions b780 Need for general information Not definable in ICF
Structures related to movement (Chapter 7) s710-s799
Impaired grip Structure of the upper extremity s730
Activities and Participation
Communication Communication (Chapter 3) d310-d399
Shaking hands Using communication devices and techniques d360
Writing Using communication devices and techniques d360
Using keyboard and mouse Using communication devices and techniques d360
Personal care Self-care (Chapter 5) d510-d599
Washing and drying themselves Washing oneself d510
Using toilet paper Toileting d530
Dressing and undressing Dressing d540
Using cutlery Eating d550
Holding glasses and cups Drinking d560
Household tasks Domestic life (Chapter 6) d610-d669
Buying groceries Acquisition of foods and services d620
Preparing meals Preparing meals d630
Cleaning activities Doing house work d640
Spending free time Community, social and civic life (Chapter 9) d910-d999
Participation in hobbies Recreation and leisure d920
Participation in sports Recreation and leisure d920
