Research Review By Dr. Brynne Stainsby©

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Date Posted:

May 2019

Study Title:

The effectiveness of physical therapies for patients with base of thumb osteoarthritis: Systematic review and meta-analysis

Authors:

Ahern M, Skyllas J, Wajon A & Hush J.

Author's Affiliations:

Department of Health Professions, Faculty of Medicine and Health Sciences; Macquarie University, Australia; Jubilee Sports Physiotherapy, Sydney, Australia; Macquarie Hand Therapy, MQ Health, Macquarie University, Australia.

Publication Information:

Musculoskeletal Science and Practice 2018; 35: 46-54.

Background Information:

Osteoarthritis (OA) is the most common type of arthritis, affecting approximately 10% of men and up to 18% of women over 60 (1-3). Interventions such as self-management, education and physical activity modifications have been shown to reduce pain and improve quality of life in patients with chronic disease, including arthritis (4). For trapeziometacarpal OA (also called ‘base of thumb’ OA), whether treatment is surgical or conservative is typically determined by the severity of symptoms, the patient’s functional abilities and his/her goals. Conservative care typically consists of splinting or orthoses, joint mobilizations, exercises and activity modifications (5, 6). Education regarding pain management, the appropriate use of splints, and advice on modifying daily tasks is also an important component of care for all patients (6, 7).

The purpose of this review was to systematically examine the effectiveness of unimodal and multimodal physical therapies for base of thumb OA.

Pertinent Results:

  • The initial search yielded 239 possible articles, of which 134 were possibly relevant based on their title. Abstracts were then screened, resulting in 27 studies selected for critical appraisal. Five studies were included in the review (5, 8-11).
  • In the included studies, risk of bias was relatively low, however, participant blinding was not possible, and thus three studies had high risk of performance and detection bias (9-11), and one did not specify allocation concealment (8).
  • Data from 198 subjects were included in this review. The mean age of participants was 69 (range 55-90). The majority of subjects were female. The mean duration of pain ranged from 2.9-7.7 years (however three studies did not report on these data [5, 8, 9]).
  • Interventions in this review included joint mobilizations, neurodynamic techniques, exercise, heat, orthoses, passive accessory mobilizations, alone or in combination (referred to collectively as “physical therapy” [PT]). Treatment ranged from 10-20 minutes of manual therapy, typically two to three times per week for durations of two to 26 weeks.
  • Included studies reported pain at rest (visual analogue scale [VAS] from 0-10), pain after pinch (VAS from 0-10 or 0–100) (9,10), pinch strength (5,8-11), grip strength (5,8-10) and self-reported function (Disability of Arm, Shoulder and Hand [DASH] Outcome Measure, Australian/Canadian Osteoarthritis Hand Index [AUSCAN]) (9-11).
  • A multimodal PT program appears to reduce pain intensity by 2.9 (95% CI 2.8-3.0) when data was pooled, and as a single therapy, by 3.1 (95% CI: 2.5-3.8). PT was estimated to increase pinch strength by 0.1 kg (95% CI: 0.0-0.2) when a multimodal approach was used, though this was not clearly demonstrated in the trials of a single therapy. Effect size suggests grip strength may improve with PT, however the precision of this estimate was low and the confidence interval crossed 0 (95% CI: -0.1-0.9). Pooled estimates on the effects of unimodal PT on hand function showed an improvement of 6.8 points on a 100-point scale (95% CI: 1.7-11.9).

Clinical Application & Conclusions:

Though the evidence was very limited, the findings of this review suggest interventions such orthoses, therapeutic exercise, heat, joint mobilizations and neurodynamic techniques may have an effect on pain, strength and possibly function in patients with thumb OA. These improvements are small in magnitude, however. Therefore, it is important to recognize that these changes may not reflect a clinically relevant improvement, however, it is important to consider that the follow-up period was typically four weeks in length, and perhaps a longer follow-up would be more appropriate to demonstrate improvements in a progressive, degenerative condition like OA.

Although the conclusions made are not fully supported by the results, it is still important to recognize the evidence does suggest a possibility of small improvements, and a trial of care may be initiated. Although this review did not report on adverse events (AE), the interventions included in this review have not been shown to cause or be associated with significant AE in other trials, and there is little anatomical plausibility to suggest any would be expected here. Despite this, as always, clinicians should monitor for any adverse responses to care. Patients should be educated that a longer-term plan may be required, and clinicians should consider the role of home-based exercises in order to both empower patients and minimise costs, if appropriate. The repeated use of outcome measures in order to assess for evidence of effectiveness is also indicated.

Study Methods:

For this systematic review and meta-analysis, randomized controlled trials published in English with subjects 18 years of age or older with a confirmed diagnosis (clinical or radiographic) of trapeziometacarpal OA and no other serious comorbidities of the hand or wrist were included. Interventions could include any trial of physical therapy (PT), compared to control or placebo, sham or usual primary care, and outcomes were related to pain, strength or function. Electronic searches of MEDLINE, CINAHL, Embase, AMED, PEDro, Cochrane Database of Systematic Review, and Cochrane Register of Controlled Trials from inception to May 2017 were conducted, with the key words: ‘thumb’, ‘base of thumb’, ‘osteoarthritis’, ‘conservative’, ‘OA’, carpometacarpal joint’, ‘treatment’ and ‘management’. Reference lists of the selected studies were hand searched. Titles and abstracts were screened by two reviewers for inclusion criteria. Finally, full texts of potentially relevant studies were screened by two reviewers, with any discrepancy resolved by consensus with a third reviewer.

Methodological quality was assessed using the Cochrane domain-based risk of bias tool (12). Descriptive analyses were used for clinical and demographic data for each trial. Continuous data were converted to a 0-10 or 0-100 scale if the same outcomes were assessed using different instruments. Effect sizes were calculated using the PEDro confidence interval (13). Comprehensive Meta-Analysis Software was used for all meta-analyses (14).

Study Strengths / Weaknesses:

Strengths:
  • This is the first review on the effects of PT on thumb OA that included only RCTs.
  • From a clinical perspective, this review included a wide range of interventions, including splinting, exercise and mobilizations, and replicated common treatment plans that may be used in practice.
  • The authors assessed clinically relevant outcomes (pain, strength and function) for the target population.
Weaknesses:
  • Although the reviewers used the Cochrane domain-based risk of bias tool, they did not set a cut-point for determining an acceptable level of risk of bias. Particularly concerning is the fact that three of the five studies had high risk of performance and detection bias, and one did not specify allocation concealment. Based on this, it is unclear how a low risk of bias (or a high methodological quality, as stated in the Discussion) was determined.
  • With small sample sizes and limited estimates of effect, the suggested evidence for effectiveness was small/unclear for the outcomes studied.
  • The authors do not comment on clinically important differences and the clinical relevance of the findings. Assuming a minimum of 20% improvement typically required to establish clinically relevant change, the reported effect on hand function would not be considered clinically relevant.
  • Performing a meta-analysis with heterozygous interventions, varied outcome measures and with studies that did not report patient demographics greatly limits the utility of the pooled effects and clinical applicability of this review.
  • The conclusions made were not fully supported by the results.

Additional References:

  1. Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Organ 2003; 81(9): 646–656.
  2. Murphy L, Helmick CG. The impact of osteoarthritis in the United States: a population-health perspective: a population-based review of the fourth most common cause of hospitalization in U.S. adults. Orthop Nurs 2012; 31(2): 85–91.
  3. Haq I, Murphy E. Osteoarthritis. Postgrad Med 2003; 79: 377–383.
  4. Hootman JM, Helmick CG, Barbour KE et al. 2016. Updated projected prevalence of self-reported doctor-diagnosed arthritis and arthritis-attributable activity limitation among US adults, 2015–2040. Arthritis & Rheumatol 2016; 68(7): 1582–1587.
  5. Villafañe JH, Cleland JA, Fernandez-De-Las-Penas C. The effectiveness of a manual therapy and exercise protocol in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial. J Orthop Sports Phys Ther 2013; 43(4): 204–213.
  6. Wolock BS, Moore JR, Weiland AJ. Arthritis of the basal joint of the thumb: a critical analysis of treatment options. J Arthroplasty 1989; 4(1): 65–78.
  7. Prosser R, Conolly W, Prosser R et al. Hand and Wrist Arthritis. Rehabilitation of the Hand and Upper Limb. Elsevier, London 2003; pp. 187–206.
  8. Villafañe JH, Silva GB, Fernandez-Carnero J. Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis. J Manipulative Physiol Therap 2012; 35(2): 110–120.
  9. Bani MA, Arazpour M, Kashani RV et al. Comparison of custom-made and prefabricated neoprene splinting in patients with the first carpometacarpal joint osteoarthritis. Disabil Rehabil Assist Technol 2013; 8(3): 232–237.
  10. Carreira ACG, Jones A, Natour J. Assessment of the effectiveness of a functional splint for osteoarthritis of the trapeziometacarpal joint on the dominant hand: a randomized controlled study. J Rehabil Med 2010; 42(5): 469–474.
  11. Merritt M. Comparison of hand therapy to placebo in the treatment of thumb carpometacarpal osteoarthritis. Texas Woman's University 2012.
  12. Higgins J, Altman D, Sterne J. Chapter 8: Assessing risk of bias in included studies. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration.
  13. Herbert R, Sherrington C, Moseley A. Confidence Interval Calculator: Version 2015.
  14. Borenstein M, Hedges L, Higgins J et al. Comprehensive meta-analysis Version 2. Biostat, Englewood, NJ, 2005; pp. 104.