Osteoarthritis of the hands

Osteoarthritis (OA) is the most common form of arthritis. In this condition, the cartilage which is a firm, slippery tissue that covers the ends of the bones wears down over time. This affects the surface of bone that lies immediately below the cartilage leading to structural changes in the joint. Over time, the biomechanics of the joint can be so altered that the ligaments and muscles that support the joint are also weakened.

Osteoarthritis primarily affects the hands, knees, hips, and the spine. When osteoarthritis affects the hands, it commonly attacks the base of the thumb where the thumb and wrist joint meet (also called the carpometacarpal joint), the middle joint of a finger (the proximal interphalangeal joint), and the joint closest to the fingertip (the distal interphalangeal joint).

Different forms of osteoarthritis of the hand are recognized including thumb base osteoarthritis, nodal osteoarthritis, and erosive osteoarthritis. These different forms of osteoarthritis may be associated with varying degrees of inflammation which may be detectable clinically or via imaging modalities such as ultrasound or magnetic resonance imaging (MRI).

Risk factors for osteoarthritis of the hands

Osteoarthritis of the hands is more common in females, in patients over the age of 50, and in Caucasians. Genetic factors may predispose to osteoarthritis, particularly where the disease manifests in younger age groups. Joints that have been previously injured, used repetitively for activities such as playing certain sports or musical instruments, or joints that are hypermobile may be more at risk for developing osteoarthritis over time.

Additionally, there are certain metabolic factors and endocrine disorders such as diabetes mellitus which may predispose to osteoarthritis of the hands.

Some clinical findings in osteoarthritis

• Heberden’s nodes – bony enlargement of the distal interphalangeal joint
• Bouchard’s nodes – bony enlargement of the proximal interphalangeal joint
• Squaring of the thumb

Symptoms and signs of osteoarthritis of the hands

Common symptoms and signs include:

• Pain: the most common symptom is joint pain which is usually worse with the use of the joint.
• Stiffness: Joints in the hands may feel stiff, especially in the mornings
• Loss of motion: The range of motion of the joint may be lost or reduced
• Crepitus: grating or clicking sensations may occur due to the degradation of the cartilage and bones rubbing together
• Swelling: damage to the tissues of the joint leads to the release of molecules called cytokines that promote inflammation in the joint leading to swelling
• Nodules: Bony lumps may form on some of the joints
• Joint deformity: loss of cartilage, weak surrounding ligaments, bony overgrowth, and swelling can lead to visible deformities of the affected joints
• Weakness: pain, reduced joint mobility, and deformity can lead to weakness of the hands

Role of the rheumatologist

The role of the rheumatologist is to diagnose, and assess for important mimics of osteoarthritis such as psoriatic arthritis, identify treatable pre-disposing factors, and manage the disease.

Management of osteoarthritis of the hands

While there is no cure for osteoarthritis, several treatments can help manage symptoms and improve hand function. Management strategies may include a combination of pharmacologic, non-pharmacologic, and surgical interventions.

1 Medications:

• Pain Relievers: Over-the-counter medications such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) can help relieve pain and reduce inflammation.
• Topical Treatments: Creams and gels containing NSAIDs or capsaicin (a product derived from peppers) can be applied directly to the affected joints for pain relief
• Prescription Medications: In more severe cases, stronger pain relievers, corticosteroids delivered as injections to the affected joint, or other medications may be prescribed and/or administered by your doctor

A word on nutraceuticals

Nutraceuticals are products derived from food sources that have health benefits in addition to their basic nutritional value.

There are a variety of nutraceutical and herbal supplements which are marketed as being useful for osteoarthritis. These products are not regulated by the FDA, and rigorous clinical trials are lacking for some of these products. As such, many have not made their way into treatment guidelines such as those proposed by the American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR).

However, some small studies do suggest some benefit from chondroitin sulfate, a substance derived from animal sources such as bovine trachea. Chondroitin sulfate may help to strengthen the cartilage in osteoarthritis of the hands.

In day-to-day clinical practice, some patients may report improvement in joint pain and stiffness with other products such as methylsulphonylmethane, glucosamine, Boswellia Serratia, turmeric, ginger, and garlic preparations taken orally.

2 Physical and Occupational Therapy:

• Exercises: Hand exercises can improve range of motion, strengthen muscles, and reduce stiffness.
• Heat and Cold Therapy: Applying dry heat can relieve stiffness, Warmed oils massaged into joints may also be beneficial in relieving stiffness (castor oil being one of the favorites here in the Caribbean). Cold therapy may help to relieve swelling and pain
• Splints or Braces: Wearing a splint or brace can help support the joint, reduce pain, and prevent further damage. These must be carefully selected bearing in mind the size of the patient’s hand.

3 Lifestyle Modifications:

• Activity Modification: Avoiding activities that put excessive strain on the hands can help manage symptoms
• Assistive devices: Several devices are available such as modified jar openers, ergonomic keyboards, and padded tools that reduce pressure on joints when doing daily activities such as cooking and working at a computer

4 Surgery:

• In severe cases where other treatments have not provided relief or where the joint function is severely compromised, then surgical options may be considered. These options range from joint fusion to joint replacement.

Preventing the progression of osteoarthritis of the hands

Some of the drugs that have been used to treat rheumatoid arthritis (RA) including some biologic agents have thus far shown disappointing results in clinical trials of osteoarthritis of the hands.
However, attention is being paid to methotrexate – a drug which is prescribed for RA which has been shown in some studies to reduce progression of joint damage compared to placebo in osteoarthritis. Clinical trials are ongoing.
More recently, denosumab, a prescription injectable drug used in the management of osteoporosis has shown some encouraging results in preventing the progression of erosive osteoarthritis in clinical trials.

Conclusion

Osteoarthritis can significantly impact daily life, however, with early diagnosis and management, a patient can reduce symptoms and maintain hand function. If you suspect that you have osteoarthritis, consult with your rheumatologist or healthcare provider to develop a treatment plan tailored to your needs. To book an appointment with Dr. Sharon Chambers please call +1 345 325 9000