Hand osteoarthritis and pinch grip strength among middle-aged female dentists and teachers
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1 84 Scand J Rheumatol 2010;39:8487 Hand osteoarthritis and pinch grip strength among middle-aged female dentists and teachers H Ding, S Solovieva, T Vehmas, E-P Takala, P Leino-Arjas Finnish Institute of Occupational Health, Centre of Expertise for Health and Work Ability, Helsinki, Finland Objectives: Among female dentists and teachers, we investigated the relationship of pinch grip strength with radiographic hand osteoarthritis (OA) and hand joint pain. Materials and methods: We studied 295 female dentists and 248 female teachers aged 4563 years for pinch grip strength using the Martin Vigorimeter. Hand radiographs were examined for the presence of OA in the wrist and each joint of the first, second, and third fingers. Joint pain and tasks with high hand loading during leisure were assessed by questionnaire. Glove size was used as proxy for hand size. Results: Symptomatic hand OA (jointwise co-occurrence of radiological findings and pain) increased the risk of low pinch grip strength in both hands, with an odds ratio (OR) of 3.3 (95% CI ) for the right and 2.0 (95% CI ) for the left hand, allowing for age, occupation, body mass index (BMI), hand size, and hand-loading leisure-time activity. The occurrence of findings and pain in non-corresponding joints was also associated with pinch grip strength in the right hand, but not in the left. Having only radiographic findings or pain was not associated with pinch grip strength. Conclusions: Our findings support the view that hand function is related to the severity of hand OA. Hand function plays an essential role in carrying out activities of daily living. Pinch and power grip strength is among the most essential characteristics related to the functional integrity of the hand (1). Power grip and pinch grip strength decline with age (2), possibly accompanied by underlying pathological conditions such as osteoarthritis (OA) or osteoporosis (3). However, data regarding the effect of hand OA on power grip and pinch strength are inconsistent. It has been suggested that hand function is affected by pain and tenderness rather than by the radiological grade of hand OA (4) and that the impact of OA on grip strength may be mediated by hand pain (5). The objective of the present study among middle-aged female dentists and teachers was to investigate the relationship of pinch grip strength with radiographic hand OA and hand pain, and the possible significance of symptomatic OA as a determinant of pinch grip strength. Päivi Leino-Arjas, Finnish Institute of Occupational Health, Centre of Expertise for Health and Work Ability, Topeliuksenkatu 41 a A, FIN Helsinki, Finland. paivi.leino-arjas@ttl.fi Accepted 22 July 2009 Materials and methods Study samples We randomly selected 436 women aged 4563 years from the Finnish Dental Association and Finnish Teachers Trade Union in Helsinki and its neighbouring cities. Of those who received the questionnaire (in 2002), 295 (67.7%) dentists and 248 (56.9%) teachers participated in a clinical examination between October 2002 and March Participation in the study was voluntary and based on informed consent. The Hospital District of Helsinki and Uusimaa Ethics Committee for Research in Occupational Health and Safety approved the study proposal. Pinch grip strength Pinch grip strength (later also pinch strength ) of both hands was measured between the pad of the thumb in opposition to the pads of the index and middle fingers by using the Martin Vigorimeter. The unit of measurement was the kilopascal (kpa). The test was administered during the clinical examination by a researcher trained for the purpose. The higher reading of the two maximal contractions was taken to represent the subject s pinch strength. # 2010 Taylor & Francis on license from Scandinavian Rheumatology Research Foundation DOI: /
2 Hand OA and pinch grip strength 85 Because of a different distribution of pinch strength between the occupations, the cut-off points of low strength (the lower 25th percentile) were defined separately for the two. Among the dentists, low pinch strength of either hand was defined as552 kpa, and among the teachers550 kpa. Most subjects (96.3%) were right-handed. Hand OA Both hands of the participants were X-rayed. The analogue radiographs were evaluated by an experienced radiologist who was blinded to the occupation, age, and all health data of the subjects. Each distal interphalangeal (DIP), proximal interphalangeal (PIP), thumb interphalangeal (IP), and metacarpophalangeal (MCP) joint of both hands and the wrists as a unit were graded separately using a modified Kellgren and Lawrence scoring system (6) with reference images (grade 0 no OA; grade 1 doubtful OA; grade 2 mild OA; grade 3 moderate OA, grade 4 severe OA). The weighted intra-observer Kappa coefficients of the readings varied from 0.59 to 1.00 (6), indicating good reliability. Information on pain in each joint was collected by a self-administered questionnaire that prompted: Please point out on the picture below, in which finger joint did you feel pain or tenderness during the past 30 days? Pain was graded from 0 never to 3 severe. In the current study, symptomatic hand OA was defined as follows: the subject had both radiographic findings (grade]2) and pain (grade]1) in at least one corresponding joint in the first (thumb), second (index), or third (middle) finger or in the wrist. Subjects with only pain, those with only radiographic findings, and subjects with both radiographic findings and pain but in non-corresponding joints were classified as separate categories. The reference group consisted of subjects with neither radiographic findings nor pain. Other risk factors Body mass index (BMI) was calculated based on self-reported height and weight measured during the clinical examination. Information on weekly hours of hand-loading leisure-time activities and glove size was collected by questionnaire. Most subjects were classified into the low-level (n 390, 72%) and 28% into the high-level hand-loading leisure-time activity group. The customary glove size, graded as small, medium, or large, was used as a proxy for hand size. Table 1. Description of the material. Total By occupation (n543) Dentists (n295) Teachers (n248) p-value Continuous variables (mean, SD) Pinch strength (kpa) Left hand Right hand Age (years) Current BMI (kg/m 2 ) Categorical variables (n,%) Hand-loading leisure-time activity Low High Hand size Small Medium Large OA in the joints of the firstthird finger or the wrist Left hand No OA, no pain Pain only Asymptomatic OA Pain and OA, but not in corresponding joints Symptomatic OA Right hand No OA, no pain Pain only Asymptomatic OA Pain and OA, but not in corresponding joints Symptomatic OA
3 86 H Ding et al Mean of pinch strength (kpa) Pinch strength among the dentists 60 Pinch strength among the teachers Age group Age group left hand right hand left hand right hand Mean of pinch strength (kpa) Figure 1. Pinch strength by age group among dentists and teachers. Statistical analysis The differences between dentists and teachers in the distribution of risk factors were compared using the t-test (continuous variables) and the x 2 -test (categorical variables). Binomial logistic regression models were used to estimate the association of hand OA with pinch strength by occupation. Odds ratios (ORs) and their 95% confidence intervals (CIs) were adjusted for age, occupation, BMI, and handloading leisure-time activity. The analyses were performed with the SPSS (version 14.0) program. Results The overall prevalence of symptomatic hand OA was 10.1% in the left hand and 12.2% in the right hand (Table 1). There was no difference in the prevalence between the dentists and the teachers. The dentists had a lower mean BMI and a smaller hand size than the teachers. Age and hand-loading leisure-time activity did not differ between the occupations. Pinch grip strength declined with increasing age in both occupations (Figure 1). The highest strength was observed among the dentists aged years (right hand) and the lowest among the teachers above 60 years of age (left hand). A steepened reduction in pinch strength began after the age of 5054 years among the dentists in the right hand and among the teachers in the left hand. The dentists had higher pinch strength than the teachers in the left hand, while no difference was found in the right hand (Table 1). Women with symptomatic hand OA had a higher risk of low pinch grip strength in both hands after adjustment for age, occupation, BMI, hand size, and hand-loading leisure-time activities (Table 2). Pain or radiographic findings (asymptomatic OA) alone were not associated with pinch strength. Neither did the subjects with OA and pain but in non-corresponding joints differ from the reference group when the left hand was considered. However, this group had an increased risk of low pinch strength in the right hand. Table 2. Association of OA in the joints of the firstthird fingers or the wrist, with low pinch strength*. Logistic regression analysis. Unadjusted Adjusted for age and occupation Adjusted for multiple covariates% n$ OR 95% CI OR 95% CI OR 95% CI Left hand No OA, no pain 261 (82) Pain only 111 (33) Asymptomatic OA 70 (27) Pain and OA but not in corresponding joints 45 (19) Symptomatic OA 55 (28) Right hand No OA, no pain 213 (49) Pain only 183 (47) Asymptomatic OA 56 (15) Pain and OA but not in corresponding joints 22 (11) Symptomatic OA 66 (34) OR, Odds ratio; CI, confidence interval. * Cut-off points for low pinch strength, both hands: dentists 552 kpa, teachers 550 kpa. $ Number of subjects (number of cases with low pinch strength). % Adjusted for age, occupation, BMI, hand size, and hand-loading leisure-time activities.
4 Hand OA and pinch grip strength 87 Discussion We found that among middle-aged women from two occupations, dentists and teachers, symptomatic hand OA increased the risk of low pinch grip strength in both hands. Having only pain or only radiographic findings in the hand joints showed no association with pinch strength. In our study, pinch grip strength between the pad of the thumb in opposition to the pads of the index and middle fingers was measured by Vigorimetry, frequently used to reliably assess grip strength in clinical and research settings (7). The values for pinch strength observed in our study cannot be directly compared with the few available normative data because we measured strength in kpa, while normative data are given either in kilograms (kg) or in newtons (N). Hand function seems to stay unchanged until the age of 65 years, after which a slow decrease begins (3). However, recent findings indicate that key pinch grip (8) strength in fact starts to decline from the fifth decade of life onwards. Similarly, we found a reduction in pinch strength with age among our study material of women aged 4563 years. Anthropometric factors were correlated with hand function. We used glove size as proxy for hand size and found that the dentists had smaller hands than the teachers. The difference may be due to selection to the occupation of a dentist according to the requirements of dental work, in which applying precision tools and operation in the patient s mouth cavity may be easier with smaller hands. Within each occupation, we observed an association between hand size and pinch strength. To reduce the influence of anthropometry, and because of differing strength distributions by occupation, we used occupationspecific cut-off points to define low pinch grip strength. OA is the most common age-related joint disorder worldwide and finger joints are among the most frequently affected sites, especially among women (9). Symptomatic hand OA is a leading cause of disability among the elderly (10). The strength of the association of radiographic hand OA with hand function varies widely in the published studies (11). Pattrick et al (12) suggested that hand function is not associated with the extent of radiographic change, while Bagis et al (13) found that both hand pain and OA had significant effects on hand function. Results from the Framingham study showed that the subjects with symptomatic hand OA had lower grip strength than those without the disease (14). The categorization of joint pathology that we used has not been applied previously. The finding that the occurrence of pain and radiographic findings in non-corresponding joints was associated with low pinch strength, but in the right hand only, needs further clarification. A possibility is that inaccuracy in the recognition of the origin of pain might play a role in this small group of subjects. In conclusion, our findings support the view that hand function is related to the severity of hand OA. The subjects with hand OA may develop pain as the consequence of disease progression and, as a result, have difficulty in performing daily activities that require pinching and gripping (15). A longitudinal study on the influence of OA, and the role of associated symptoms, on hand function seems warranted. References 1. Goodson A, McGregor AH, Douglas J, Taylor P. Direct, quantitative clinical assessment of hand function: usefulness and reproducibility. Man Ther 2007;/12:/ Ranganathan VK, Siemionow V, Sahgal V, Yue GH. Effects of aging on hand function. J Am Geriatr Soc 2001;/49:/ Carmeli E, Patish H, Coleman R. The aging hand. J Gerontol A Biol Sci Med Sci 2003;/58:/ Ozkan B, Keskin D, Bodur H, Barça N. The effect of radiological hand osteoarthritis on hand function. Clin Rheumatol 2007;/26:/ El-Sherif HE, Kamal R, Moawyah O. Hand osteoarthritis and bone mineral density in postmenopausal women: clinical relevance to hand function, pain and disability. Osteoarthritis Cartilage 2008;/16:/ Solovieva S, Vehmas T, Riihimäki H, Luoma K, Leino-Arjas P. Hand use and patterns of joint involvement in osteoarthritis. A comparison of female dentists and teachers. Rheumatology (Oxford) 2005;/44: / Desrosiers J, Bravo G, Hébert R, Dutil E. Normative data for grip strength of elderly men and women. Am J Occup Ther 1995;/49:/ Günther CM, Bürger A, Rickert M, Schulz CU. Key pinch in healthy adults: normative values. J Hand Surg Eur Vol 2008;/ 33:/ Arden N, Nevitt MC. Osteoarthritis: epidemiology. Best Pract Res Clin Rheumatol 2006;/20:/ Felson DT. The course of osteoarthritis and factors that affect it. Rheum Dis Clin North Am 1993;/19:/ Dahaghin S, Bierma-zeinstra SM, Hazes JM, Koes BW. Clinical burden of radiographic hand osteoarthritis: a systematic appraisal. Arthritis Rheum 2006;/55:/ Pattrick M, Aldridge S, Hamilton E, Manhire A, Doherty M. A controlled study of hand function in nodal and erosive osteoarthritis. Ann Rheum Dis 1989;/48: / Bagis S, Sahin G, Yapici Y, Cimen OB, Erdogan C. The effect of hand osteoarthritis on grip and pinch strength and hand function in postmenopausal women. Clin Rheumatol 2003;/22:/ Zhang Y, Niu J, Kelly-Hayes M, Chaisson CE, Aliabadi P, Felson DT. Prevalence of symptomatic hand osteoarthritis and its impact on functional status among the elderly: The Framingham Study. Am J Epidemiol 2002;/156:/ Estes JP, Bochenek C, Fassler P. Osteoarthritis of the fingers. J Hand Ther 2000;/13:/10823.
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