Public defense: Else Marit Holen Gravås

Osteoarthritis (OA) of the hand is a highly prevalent joint disease that can cause severe pain and functional limitations, but for which there is yet no cure.

International guidelines state that all patients, as core treatment, should be offered non-pharmacological interventions consisting of patient education, assistive devices and hand exercises. Patients with thumb carpometacarpal osteoarthritis (CMCJ OA) should additionally be offered thumb orthoses.

These interventions are most frequently delivered by occupational therapists. Surgery for CMCJ OA should only be considered if non-pharmacological and pharmacological treatment have not been sufficiently effective in relieving persistent pain, however, the optimal timing of surgical interventions remains unknown.

The main responsibility for OA care lies with the primary health care services. Nevertheless, studies indicate suboptimal OA care, as current treatment for people with hand OA usually is limited to general practitioner (GP) consultations, while those with CMCJ OA may be referred for surgical consultation.

However, little is known about level of pain and function in patients referred to surgical consultation in specialist health care, their goals and motivation for surgery, and if occupational therapy may influence the need for surgery.

Aim

The main aim of this thesis is to investigate whether occupational therapy, provided in the period between referral from a GP and surgical consultation in special health care, can delay or reduce the need for surgery in CMCJ OA.

Additionally, we will explore personal and clinical characteristics and prior non-pharmacological treatment received by patients referred to surgical consultation, predictors for CMCJ surgery, and patients’ goals and motivation for CMCJ surgery, including factors associated with high motivation for surgery.

Methods

The thesis is based on data from a multicenter randomized controlled trial (RCT), where patients with CMCJ OA who received occupational therapy in the waiting period before surgical consultation were compared to patients who received OA information only. The primary outcome was the number of patients receiving surgery after two years.

The International Classification of Functioning, Disability and Health framework was used to categorize variables and patients’ goals for surgery. Differences between subgroups at baseline were analysed using t-tests, Wilcoxon Signed rank or Chi-square tests.

Associations between variables, the primary outcome and predictors for surgery were examined with regression models, and time to surgery with Kaplan-Meier analysis, the log-rank test and cox regression analyses. 

Results

Of 221 eligible patients, 180 (81percent) were included in the RCT and randomized to the occupational therapy group (n=90) and the control group (n=90). The results show that CMCJ OA negatively affects all aspect of hand function.

Most patients reported mild or no pain in referred hand for surgery. Unilateral referral patients reported consistently more pain and functional limitations in referred hand compared to non-referred hand. No significant differences were found in activity limitations and participation restriction in unilateral referral patients compared to bilateral referral patients.

Patients with OA in other finger joints in addition to CMCJ OA (35 percent) reported significant more severe symptoms and functional limitations compared to those with isolated CMCJ OA. Women reported statistically significant more pain and functional limitations compared to men. Only 21 percent had received non-pharmacological treatment before the surgical consultation referral.

A total of 22 (24 percent) of the patients in the occupational therapy group underwent surgery, compared to 29 (32 percent) in the control group (OR 0.56, 95 percent CI 0.26 to 1.21; p=0.14).

Median days to surgery were 350 in the occupational therapy group and 296 and the control group. The hazard ratio for receiving surgery was 0.68 (95 percent CI 0.39 to 1.17; p=0.16) for the occupational therapy group compared to the control group. Previous non-pharmacological treatment (OR 2.72) and high motivation for surgery (OR 1.25) were significant associated with surgery (p<0.05).

The two most frequently reported goals for CMCJ surgery were reduced pain and improved hand function. Fifty-six (31 percent) of the patients were classified as highly motivated for surgery (Numeric Rating Scale score ≥8). High motivation for surgery was strongly associated with reporting more activity limitations (OR=4.00), living alone (OR=3.18) and younger age (OR=0.94).

Conclusions

The results of this study show a small non-significant tendency for delay and reduction in CMCJ surgery in patients receiving occupational therapy, compared to a control group. Most patients reported no pain or mild pain, and that they had not received non-pharmacological treatment before being referred to surgical consultation.

Thus, there seems to be a non-pharmacological treatment gap in OA care. The results furthermore show that CMCJ OA negatively affects all aspects of function.

Strategies need to be developed to improve hand OA care, including educating GPs in evidence-based treatment recommendations and in the assessment of hand pain, and encourage the routine referral of patients to occupational therapy before considering surgery.

Decisions on CMCJ surgery should be based on assessment and discussion of patients’ life situation, hand pain, activity limitations, and goals and motivation for surgery.