Evidence Based Recommendations Diagnosis And Management Of Hand Osteoarthritis

Transcription

1 Evidence Based Recommendations Diagnosis And Management Of Hand Osteoarthritis Prof.Fitnat Dincer M.D. Specialist of Physical & Rehabilitation Medicine Hacettepe Medical School Dept of PRM Ankara Turkey

2 Portrait of a Youth Andro Boticelli, Marinus Van Reymerswaele, ,copyright 1567,copyright Prado Museum,Madrid

3 Dr.William Oliver and Mr.Jeremiah Peirce examining patients afflicted with Rheumatism, William Hoare,1742

4 The painter s s family Jacob Jordaens

5 The Holy family with St.Anne Peter Paul Rubens

6 OA is the most common age-related joint disorder throughout the world, Symptomatic HOA is a leading cause of disability among elders. HOA may sometimes contribute minutely to pain & physical disability with limitations in DAL Although HOA may reach same disabling levels induced by RA,evaluation of HOA has received little attention in the clinical setting. HOA and bone mineral density in postmenopausal women; clinical relevance to hand function, pain and disability. H. E. El-Sherif, R. Kamal, O. Moawyah. Osteoarthritis and Cartilage 2008; 16,

7 Over 66 years it occurs in 60-70% of the population. But a higher prevalence of radiographically diagnosed HOA is in women.(94.4%) Sherif. Osteoarthritis & Cartilage 2008

8 In a survey of 500 patients: the joints that are mostly effected Knee(41%) Hand (30%) (28 joints) Hip joint (19%)

9 Research activities in OA have concentrated on the Knee & Hip in recent years. Knowledge & research results for Hand OA are limited. Kloppenburg, Ann Rheum Dis 2007

10 Guidelines - Recommendations EULAR. European League Against Rheumatism - OARSI. Osteoarthritis Research Society International - ACR. American College of Rheumatology -

11 Hand Osteoarthritis Nodal OA :Heberden and/or Bouchard Heberden and/or Bouchard s s nodes plus underlying IPJ OA, defined clinically and/or radiologically. Non-nodal OA: IPJ OA, defined clinical and/or radiographically, without nodes Erosive OA: Subset of HOA defined radiographically by subchondral erosion, cortical destruction and subsequent reparative change which may include bony ankylosis Thumb base OA: First CMCJ (carpometacarpal) with or without STJOA (scaphotrapezioid) Generalised OA :HOA (+) OA at other sites. Weiya Zhang, M Doherty, B F Leeb,L Alekseeva, N K Arden, J W Bijlsma, F Dincer, K Dziedzic, HJ Hauselmann, P Kaklamanis, M Kloppenburg,LSLohmander,E Maheu,E Martin Mola, Pavelka, L Punzi, SReiter, J Smolen, G Verbruggen, I Watt, I Zimmermann-Gorska Eular Evidence Based Recommendations For The Diagnosis Of Hand Osteoarthritis O Ann.of Rheum.Diseases 2009;68:8 ;68:8-17

12 ACR Classification Criteria for Hand OA Hand pain, aching, or stiffness and 3 or 4 of the following features: - Hard tissue enlargement of 2 or more of 10 selected joints - Fewer than 3 swollen MCP joints - Deformity of at least 1 of 10 selected joints The 10 selected joints are: The 2nd and 3rd DIP, The 2nd and 3rd PIP, and The 1st CMC joints of both hands. This classification ation method yields a sensitivity ty of 94% and a specificity of 87%. Borenstein D, Brandt K, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hand. Arthritis Rheum 1990;33:1601 :

13 What are Heberden & Bouchard nodes

14 Heberden nodes are the marginal osteophytes that orginate from the dorsolateral or dorsomedial of DIP joints. Bouchard - PIP

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17 Twenty-one experts in OA consisting of : 16 rheumatologists, 1 Specialist of Physical and Rehabilitation Medicine 1 radiologist,1 orthopaedic surgeon 1 allied health professional,1 EBM expert representing 15 European countries take part. Literature search yielded 6101 hits, hits, including Medline 2451,Embase 1860, CINAHL 243, AMED 55, WOS 757, and COCHRANE 735. After deleting duplications, of them, only 2,525 hits remained, of them, only 108 studies met the inclusion criteria. Annals of the Rheumatic Diseases 2009;68:8-17

18 *Evidence Hierarchy for Diagnosis Based on Study Design* Ia meta-analysis analysis of cohort studies Ib meta-analysis analysis of case control studies IIa cohort studies IIb case control / cross sectional comparative studies III non-comparative descriptive studies IV expert opinion Eular Evidence Based Recommendations For The Diagnosis Of Hand Osteoarthritis.Ann.of. Rheum.Diseases 2009;68:8 ;68:8-17

19 *The aim is to identify * Diagnostic tests, Risk factors, Co-morbidities for the diagnosis of Hand OA & to generate recommendations based on a combination of the best available evidence & expert opinion.

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21 1.Risk factors for Hand OA include Female sex, Increasing age over 40, Menopausal status, Family history, Higher bone density, Level of evidence: Ib - IIb Evidence Based Recommendations For The Diagnosis Of Hand Osteoarthritis Ann.of the Rheum.Dis ;68:8-17

22 Risk factors for HOA Obesity, Greater forearm muscle strength, Joint laxity, Prior hand injury Level of evidence Ib IIb Evidence Based Recommendations For The Diagnosis Of Hand OA Ann.of the Rheum. Dis. 2009;68:8 68:8-17

23 Occupation or recreation-related related usage.e.g cotton picking. Evidence Based Recommendations For The Diagnosis Of Hand OA Ann.of the Rheum. Dis. 2009;68:8 68:8-17

24 Hand Osteoarthritis has a multifactorial aetiology with a strong genetic component.

25 Hand Osteoarthritis - The existence of OA susceptibility loci on chromosome 6 for hip and knee OA patients has been suggested - Several chromosomes have been suggested to harbor Hand OA susceptibility genes Chromosomes 1, 2, 7, 11, 12, 13 and 19 SNP rs positioned on chromosome area 6p12.3-p12.1 p12.1 showed an association with PC1-OS, suggesting the existence of Hand OA susceptibility loci on chromosome 6 Jakowlew 2007 Human Biology

26 HAND OA IN OLDER WOMEN IS ASSOCIATED WITH CAROTID & CORONARY ATHEROSCLEROSIS: THE AGES REYKJAVIK STUDY Jonsson, Helgadottir, Aspelund,Eiriksdottir,Sigurdsson et al. a Iceland, Bethesda, United States. Ann Rheum Dis Objective: Is there some evidence that atherosclerosis may contribute to the initiation or progression of (OA). To test this the presence & severity of HOA with markers of atherosclerotic vascular disease in an elderly population is compared. Conclusions: The results indicate a linear association between the severity of HOA and atherosclerosis in older females. Thus, the pathological process of HOA seems to have some components common with atherosclerosis. Prospective studies may help elucidating possible mechanisms of this relationship.

27 Allelic variation at the C-reactive protein gene associates to both Hand OA severity & serum high sensitive C-reactive C protein levels in GARP study Genetics of OsteoArthritis Progression S Bos, M Kloppenburg et al. Ann. Rheum.Dis. 2008; 67:877 : Objective: To gain more insight into the role of genetic variation of the t C-reactive protein (CRP) gene in serum CRP levels & OA Conclusions: A haplotype of the CRP gene, associated to high basal S-HsCRP level, (Serum high sensitive CRP levels) is also associated to severity of hand OA,, indicating that innate high basal S-HsCRP S levels may influence OA onset.

28 2. Typical symptoms of Hand OA Evidence Based Recommendations for the Diagnosis of Hand OA Ann.of the Rheum. Dis. 2009;68:8-17

29 2. Typical symptoms of HOA Pain on usage, Only mild morning or inactivity stiffness affecting just one or a few joints at any one time, Symptoms are often intermittent, Target characteristic sites (DIPJs, PIPJs,thumb-base, base, index & middle MCPJs). With such typical features, a confident clinical diagnosis can be made in adults aged over 40. Level of evidence :IIb

30 3. Clinical hallmarks of Hand OA

31 3. Clinical hallmarks of HOA Heberden s s & Bouchard s s nodes,&/or Bony enlargement with or without deformity (e.g. lateral deviation of IPJs, subluxation & adduction of thumb-base) base) affecting characteristic target joints (DIPJs, PIPJs, thumb- base & index & middle MCPJs). Level of evidence : Ib IV Evidence Based Recommendations for the Diagnosis of Hand OA Ann.of the Rheum. Dis. 2009;68:8-17

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33 4. Functional impairment in Hand OA may be as severe as in RA. Function should be carefully assessed & monitored using validated outcome measures. Level of Evidence :IIb Evidence Based Recommendations for the Diagnosis of Hand OA Ann.of the Rheum. Dis. 2009;68:8-17

34 4.Functional impairment in Hand OA may be as severe as in RA. Function should be carefully assessed & monitored using validated outcome measures. HAQ (Health Assessment Questionnaire); AUSCAN (Australian Canadian OA Hand Index); DREISER s s Functional Index AIMS2 (Arthritis Impact Measurement Scale 2); SACRAH (Score for Assessment and Quantification of Chronic Rheumatic Affections of The Hands); Duruöz z Scale FIHOA (Functional Index for the OA of the Hand); AHFT (The Arthritis Hand Function Test);

35 5.. Patients with polyarticular Hand OA are at Increased risk of Knee & Hip OA, Generalised OA, should be assessed & examined. Level of Evidence :IIa - IIb Evidence Based Recommendations for the Diagnosis of Hand OA Ann.of the Rheum. Dis. 2009;68:8-17

36 6. Recognised subsets with different risk factors, associations & outcomes include Inter Phalangeal Joint OA (with or without nodes), Thumb-base base OA, Erosive OA. Level of Evidence: IIa IIb Evidence Based Recommendations for the Diagnosis of Hand OA Ann.of the Rheum. Dis. 2009;68:8-17

37 7. Erosive Hand OA - Targets IPJs - Radiographic subchondral erosion is seen which may progress to - Marked bone & cartilage attrition, - Instability & - Bony ankylosis. Evidence Based Recommendations for the Diagnosis of Hand OA Ann.of the Rheum. Dis. 2009;68:8-17

38 Abrupt onset (Typical); Marked pain ; Functional impairment; Inflammatory symptoms & signs (stiffness, soft tissue swelling,erythema, paresthesiae); Mildly elevated CRP; Worse outcome than non-erosive IPJ OA. Level of Evidence:IIa - IIb

39 8.Differential Diagnosis HOA is wide. for

40 8.. The differential diagnosis for HOA is wide. The commonest conditions are Psoriatic A. (which may target DIPJs or affect just one ray); RA (mainly targeting MCPJs, PIPJs, wrists); Gout (which may superimpose on pre-existing existing HOA) Haemochromatosis mainly targeting MCPJs, wrists). Level of Evidence:Ib IIb (mainly targeting Evidence Based Recommendations for the Diagnosis of Hand OA Ann.of the Rheum. Dis. 2009;68:8 ;68:8-17

41 9 Plain radiographs provide the gold standard for morphological assessment of HOA. Evidence Based Recommendations for the Diagnosis of Hand OA Ann.of the Rheum. Dis. 2009;68:8-17 Level of Evidence: Ib - IIb

42 9 Plain radiographs provide the GOLD standard for morphological assessment of HOA. AP,X-Ray of both hands on a single film/field of view is adequate for diagnosis. Classical features are joint space narrowing, osteophyte, subchondral bone sclerosis & cyst; Subchondral erosion occurs in Erosive HOA. Further imaging modalities are seldom indicated for diagnosis Level of Evidence: Ib - IIb

43 Prominent Osteophytes.(red arrows) central erosions at DIP ve PIP joints (yellow arrows) mcp are protected ( yellow box)

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46 Blood tests are not required BUT to exclude co-existent disease it should be undertaken to screen for additional inflammatory arthritis. Level of Evidence Ib IIb Evidence Based Recommendations for the Diagnosis of Hand OA Ann.of the Rheum. Dis. 2009;68:8 ;68:8-17

47 Future Research Agenda for Diagnosis of Hand OA After 3 Delphi rounds 9 propositions for future research were developed 1.The relative utility of imaging techniques (plain x-rays, x MRI, ultrasonography,scintigraphy) in both early diagnosis and evaluation of progression of the HOA sub-sets sets needs to be determined. 2.Risk factors both for development and long term clinical outcome of the different sub-sets sets of HOA need to be determined. 3.Potential biomarkers of bone, cartilage, synovium and inflammation should be examined in HOA subsets for utility in terms of early diagnosis, assessment of disease activity and prediction of outcome. 4.Diagnostic and classification criteria to better define HOA and its sub- sets need to be developed and validated.

48 5.Further studies are required to confirm the associations between HOA and systemic risk factors such as menopausal state, bone density, obesity & metabolic syndrome, & to explain the mechanisms that underlie such associations. 6.The genetic factors that predispose to the different phenotypes of HOA need to be identified. 7.The population incidence & prevalence of HOA & its sub-types (both symptomatic & asymptomatic), standardised by age and gender, need to be confirmed. 8.Studies should be undertaken to determine whether erosive HOA is a discrete subset with specific risk factors & pathogenesis, or a subgroup of HOA with a worse outcome. 9.The association between the different HOA phenotypes & large joint OA (ie Gen.OA) needs further examination.

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50 Evidence Based Recommendations for Management Of Hand Osteoarthritis

51 Task Force Members of Eular Evidence Based Recommendations For The Management Of Hand Osteoarthritis W Zhang, M Doherty,BLeeb,LAlekseeva,NK Arden,JW Bijlsma, F Dinçer, K Dziedzic, H J Häuselmann, H GHerreroBeaumont, P Kaklamanis, S Lohmander, E Maheu, E Martín-Mola,Pavelka, Mola,Pavelka, L Punzi, S Reiter, J Sautner, J Smolen, Verbruggen, I Zimmermann-Górska rska

52 Evidence Based Recommendations For The Management Of Hand Osteoarthritis Literature search yielded 1706 hits, Of them, only 309 studies met inclusion criteria. Annals of the Rheumatic Diseases 2007;66:

53 Evidence Hierarchy for Management Ia meta-analysis analysis of randomised controlled trials Ib randomised controlled trial IIa controlled study without randomisation IIb quasi-experimental study III non-experimental descriptive studies, such as comparative, correlation, & case-control control studies IV expert opinion or,committee reports or clinical experience of respected authorities, or both

54 1.Optimal Management of Hand OA requires a combination of Non pharmacological & Pharmacological treatment modalities Individualised to the patient s requirements. Level of evidence: IV Evidence Based Recommendations for the Management of Hand OA. Ann.of the Rheum.Dis. 2007;66:377 ;66:

55 2. Therapy of Hand OA should be individualised According to: localization of OA; Risk factors (age, gender, adverse mechanical factors); Type of OA (nodal, erosive, traumatic); Presence of inflammation;

56 Severity of structural change; Level of pain, Disability & restriction of quality of life; Co-morbidity & co-medication (including OA at other sites); The wishes & expectations of the patient. Level of evidence: IV Evidence Based Recommendations for the Management of Hand OA. Ann.of the Rheum.Dis. 2007;66:377 ;66:

57 *3. Education concerning *joint protection (how to avoid adverse mechanical factors) together with an *exercise regime,both *range of motion & *strengthening exercises, are recommended for all patients with HOA Level of evidence: IV Evidence Based Recommendations for the Management of Hand OA. Ann.of the Rheum.Dis. 2007;66:377 ;66:

58 4. *Local application of heat * (eg paraffin wax, hot pack), Especially prior to: *Exercise & *ultrasound* are beneficial treatments. Level of evidence: IV Evidence Based Recommendations for the Management of Hand OA. Ann.of the Rheum.Dis. 2007;66:377 ;66:

59 5. *Splints* for thumb base OA & *orthoses* to prevent/correct lateral angulation flexion deformity are recommended. Level of evidence: IV Evidence Based Recommendations for the Management of Hand OA. Ann.of the Rheum.Dis. 2007;66:377 ;66:

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61 A wide range of commercial and custom-made made designs is used: thumb straps, short and long opponens splints, including or excluding the first MCP joint, made in thermoplastics, elastic fabric or neoprene No RCTs have been conducted, but four small studies have compared different thumb-splint designs over the short term (1 6 6 weeks) in established OA CMC, suggesting that any changes from baseline are attributable to the splint. They suggest that the splint improves pain & hand function & reduces joint subluxation as being worn, with shorter, more flexible neoprene or elastic models being preferred for comfort & function Egan M 2007 Am J OccupTherapy

62 6. Local treatments are preferred over systemic treatments especially for mild to moderate pain & when only a few joints are involved. Topical NSAIDs & capsaicin are effective & safe treatments for hand OA. Level of evidence: Ia

63 7. Paracetamol Due to efficacy & safety first choice (up to 4g/day), if successful, is the preferred long term oral analgesic. Level of evidence: IV Although paracetamol has been used to treat hand OA for decades there are no placebo controlled trials. Evidence Based Recommendations for the Management of Hand OA. Ann.of the Rheum.Dis. 2007;66:377 ;66:

64 8. ORAL NSAIDs at the lowest effective dose & for the shortest duration should be used in patients who respond inadequately to paracetamol. In patients with increased GIS risk, non selective NSAIDs + gastroprotective agent,or a selective COX-2 2 inhibitor should be used. In patients with increased cardiovascular risk, coxibs are contraindicated & non-selective NSAIDs should be used with caution. Level of evidence: I a

65 9. SYSADOA-STMOAD STMOAD Symptomatic Slow Acting Drugs for Osteoarthritis Structure Modifying Drugs for Osteoarthritis

66 9. SYSADOA-STMOAD STMOAD OARSI Evidence-Based, Expert Consensus Guidelines. For The Management Of Hip And Knee OA, Osteoarthritis & Cartilage (2008) W. Zhang, R. W. Moskowitz, G. Nuki M.B., S. Abramson,R. D. Altman, N. Arden,S. Bierma-Zeinstra, K. D. Brandt,P. Croft, M. Doherty, M.Dougados M. Hochberg, M.P.H.,D. J. Hunter,K. Kwoh,L. S. Lohmander,P. Tugwell 18. Glucosamine and/or Chondroitin Sulphate symptomatic benefit in Knee OA. Level of evidence: Ia (glucosamine) Ia (chondroitin) 19. GS & CS may have Structure-Modifying Effects Knee OA Diacerein may have structure-modifying effects Hip OA. Level of evidence:ib (knee), Ib (hip)

67 The use of other SYSADOAs is entirely based on evidence extrapolated from hip or knee OA and is therefore primarily supported by expert opinion (IV). Level of evidence: Ib-IV IV for different SYSADOAs Future Research Agenda: Further studies are required to better evaluate the symptom & structure modifying effects of SYSADOA.

68 10. Intra-articular articular injection long-acting corticosteroid is effective for painful flares of OA, especially trapeziometacarpal joint OA. Level of evidence: Ib Evidence Based Recommendations for the Management of Hand OA. Ann.of the Rheum.Dis. 2007;66:377 ;66:

69 11. Surgery (eg interposition arthroplasty,osteotomy or arthrodesis) is an effective treatment for severe thumb base OA & should be considered in patients with marked pain and/or disability when conservative treatments have failed. Level of evidence: III Evidence Based Recommendations for the Management of Hand OA. Ann.of the Rheum.Dis. 2007;66:377 ;66:

70 FUTURE RESEARCH AGENDA After 3 Delphi rounds 8 propositions for future research were developed 1. Clinical trials on hand OA should separately consider the localization (thumb-base, base, ip joints) & the stage or type of OA (non-erosive, erosive, nodal) & examine clinical predictors of response. 2. Thorough evaluation is required of physical treatments, such as US, laser, TENS, and local application of heat (eg paraffin wax, hot pack). 3. Studies are required to determine the most appropriate form or combination of exercise (eg strengthening,rom) for the different subsets of hand OA. 4. Further studies are required to better evaluate the symptom and structure modifying effects of SYSADOA.

71 5. The benefits of i.a. injection of either corticosteroid or hyaluronan should be determined both for thumb-base base and ip OA. 6. Existing slow acting anti-rheumatic drugs and biologic agents (especially anti-tnf therapy) should be investigated in erosive ip OA, to determine possible symptom benefits and structure modifying effects. 7. The efficacy & safety (both short & long-term) of paracetamol, weak opiods, & oral NSAIDs need to be assessed & compared. 8. The potential benefits of surgery compared to conservative management, and the most appropriate surgical procedure for thumb-base base OA, remain to be determined.

72 Conclusion Pain relief and restoration of function remain the primary treatment objectives These are best achieved by a combination of pharmacological & nonpharmacological treatment especially by Phsical & Rehabilitation Medicine procedures Surgery remains the last resort for restoration of function if all else fails

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