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Symptoms of hand osteoarthritis (OA), such as pain, reduced grip strength, loss of range of motion (ROM) and joint stiffness, can lead to impaired hand function and difficulty with daily activities. Rehabilitative interventions with orthoses are commonly in the treatment of hand OA to reduce pain, improve hand strength and ROM, provide support for improved function and help with joint stability.
Purpose
The objectives of this perception-based study were to evaluate the effect of a silicone wrist hand orthoses (SWHO) on pain and daily functioning.
Study Design
This study is a qualitative descriptive study. The patient received outcome (PRO) questions in the study were based on the Patient Rated Wrist and/or Hand Evaluation (PRWHE), a 15-item questionnaire designed to measure wrist pain and disability in activities of daily living.
Methods
Patients with OA using a SWHO were asked to complete a questionnaire about the effectiveness of the brace after wearing it for 3 weeks. Primary outcome measure was general daily functioning with and without the use of the SWHO. Secondary outcome measures were change in pain symptoms and limitations for certain activities with and without the aid.
Results
The results of this large-scale PROM study of 551 patients on the effectiveness of SWHOs in patients with hand OA show an improvement in overall daily functioning of 77% and a 61% reduction in perceived pain. This study adds to the evidence reported by systematic reviews of conservative interventions for hand OA and further quantifies the effects of a tailor made SWHO. This study confirms that wearing a wrist orthosis has a particularly significant impact on the execution of static and repetitive wrist-straining activities.
Conclusion
The study on the effectiveness of a SWHO in patients with hand OA shows that the use of a SWHO contributes to general daily function, reduces pain and increases the breadth of potential daily activities. This study shows that the use of a SWHO appears to offer pain relief and suitable support to the joint.
Symptoms of hand osteoarthritis (OA), such as pain, reduced grip strength, loss of range of motion (ROM) and joint stiffness, can lead to impaired hand function and difficulty with daily activities.
The prevalence and incidence of OA are significantly higher for women than for men and increase with age. The majority of people older than 55 years of age have radiological features of hand OA, and 20% experience clinical symptoms.
However, hand OA does not always develop progressively. Grip strength deteriorates with disease progression. Patients' quality of life with hand OA depends on the frequency and duration of pain symptoms, and the duration of OA pain largely determines the patient's level of (psychosocial) functioning.
According to the European League Against Rheumatism (EULAR), the optimal management of hand OA includes both non-pharmacologic and pharmacologic approaches.
Rehabilitative interventions with orthoses are commonly in the treatment of hand OA to reduce pain, improve hand strength and ROM, provide support for improved function and help with joint stability.
There is inadequate evidence to determine the effectiveness of nonpharmacological and nonsurgical interventions for hand osteoarthritis: an overview of high-quality systematic reviews.
systematic review reviewed studies of rehabilitative approaches, the main emphasis of these reviews was on methodological quality rather than treatment effects. The effectiveness of rehabilitation interventions, like SWHO, on specific treatment goals has not yet been fully explored. Previously published perception-based studies were based on relatively small population sizes, and therefore further research could add to our understanding of the effects of SWHO on patients with hand OA. To the best of our knowledge, there is a significant research gap in perception-based studies that seek to understand the short- and long-term effects of conservative treatments with orthoses and SWHO in particular on hand OA outcomes.
Knowledge of the treatment effects of specific rehabilitation techniques for hand OA will be useful to help guide best clinical practice, and greater knowledge as to the effects of selected interventions on specific treatment goals will aid therapists in the selection of the most effective rehabilitation strategies for improving the impairment and function of individuals with hand OA. Evidence of treatment effects can be used in clinical practice to guide informed decision making and meet patient-specific goals.
The objectives of this perception-based study were to evaluate the effect of a SWHO on pain and daily functioning. Secondly it was the aim to evaluate to what extent patients experience difficulties with or without SWHO on their daily live activities and evaluate the short- and longer-term effects of using a SWHO.
We know of no conflicts of interest associated with this publication, and there has been no significant financial support for this work that could have influenced its outcome.
Method
Patient-reported outcomes (PROs) provide reports from patients about their own health, quality of life, and functional status associated with the health care or treatment that they have received.
NIVEL, IQ healthcare VSOP (Vereniging Samenwerkende Ouder- en Patiëntenorganisaties) en Patiëntenfederatie Nederland.
opdracht van Zorginstituut Nederland, PROM-wijzer.2018; 27 (juni)
Between October 2018 and December 2020, 1124 patients with hand OA were provided with a SWHO and asked about the effectiveness of the brace 3 weeks later.
Within this group of 1124 patients, two groups were identified. The group of first time users and the group of patients who were fitted with a new SWHO (repeat users). Repeat users wore a SWHO at least three times a week over a period of 3 years. Use was validated with a Certified Prosthetist and/or Orthotist (CPO).
All patients provided informed consent to participate in this study. Questionnaires were sent by e-mail, and responses were voluntary. All braces were custom made for each patient and supplied by Livit Orthopedie, a Dutch provider of orthopedic and prosthetic services and products. A physician (MD) confirmed the diagnosis of hand OA for all patients. Patients were asked about their activity limitations with and without a brace.
The PROM questions in this study were based on the Patient Rated Wrist/Hand Evaluation (PRWHE). The PRWHE is a 15-item questionnaire designed to measure wrist pain and disability during activities of daily living.
Responsiveness of the disability of the arm, shoulder, and hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) in evaluating change after hand therapy.
The following PROs were defined for this study based on the effectiveness of SWHOs:
1.
How has your daily function changed since you began using your SWHO?
2.
How have your pain symptoms changed since you began using your SWHO?
3.
On an average day, to what extent do you experience difficulty with and/or without your SWHO when undertaking the following activities: writing, buttoning clothes, holding a book when reading, picking up phone, unscrewing jar and/or pot lids, household chores, lifting groceries, showering, bathing and dressing?
These questions were asked to gain insights into different types of hand function and with different types of grip and finger use (Table 1). Questions related to daily activities were designed to address activities generally performed on a regular basis, were specific to various hand and wrist problems involving mobility and strength, and easy to understand for most patients. Questions covered three domains: personal care, household chores and work-related activities. Hand dexterity was generally defined under two categories: power grips and precision grips, and questions covered both grips.
The patients were asked to rate the impact of the SWHO on their degree of pain and ability to perform daily activities on a qualitative 7-point ordinal scale (ranging from very deteriorated to improved very significantly, Fig. 1. The second part of the questionnaire consisted of questions about specific daily activities. Patients were asked to rate the amount of difficulty experienced with and without the use of a SWHO while performing the presented activities, rating their experienced difficulty on a qualitative 5-point ordinal scale (from “no problems” to “unable to perform”, Fig. 4).
Fig. 1Example of silicone wrist hand orthoses (Source: Livit SWHO catalogue).
SWHO are custom made orthopedic aids that relieve pressure and stabilize the enclosed body parts. This stabilization can reduce pain and prevent luxation in order to improve overall function and provides support in daily activities. These orthoses are individually manufactured. This ensures that the aid fits closely to the skin and is therefore comfortable to wear despite any hand deformities. Silicone is a material that is both flexible and rigid. Because of these properties, a SWHO provides gentle movement restriction while maintaining a slight freedom of movement. The products included in this study were fitted with hook and loop closure and were passive, non-invasive medical devices classified as risk class I as defined by EU 93-42/EEC (Figs. 1 and 2).
Fig. 2Example of silicone wrist hand orthoses (Source: Livit SWHO catalogue).
To assess the experienced improvement in functionality and pain, peer information is required. In this study, we compare the feedback from patients with and without a SWHO. The results are presented in bar charts and in frequency tables to enable a proper comparison between the outcome measures with and without SWHO.
Descriptive statistics were used to describe the survey data and consisted of summary descriptions of frequency response distributions. The mode was used to measure central tendency.
With a population size of 6500 patients who started using WHO in the Netherlands during the study period and a confidence level of 95%, a margin of error of 3% was calculated.
This expresses the amount of random sampling error in the survey results.
Results
The response rate of this PROM study was 49% (551 of 1124 patients). All responses have been analyzed and included as acceptable data in this study.Table 2 includes the descriptive characteristics of the study population. Short-term effects were assessed based on the responses of new users (67% of the population), and the long-term effects on the response of repeat users (33% of the population). In total, 63% of the respondents were age 60 or over, with 30% of the total respondents age 70 years or over. The majority of the respondents (81%) in this study were women.
Table 2Descriptive characteristics of the study population.
Fig. 3 presents changes in the general daily functioning of patients who wore a SWHO. A total of 77% of respondents indicated that their daily functioning improved since they started wearing a SWHO, and 38% indicated that it had improved slightly and 36% stated that it had improved significantly. There was only a small difference between the patients who used a SWHO for the first time (improvement in 79% of respondents) and those who received a repeat provision (improvement in 74% of respondents). Only 7% of respondents stated that their functioning deteriorated after using the SWHO.
Fig. 3Change of general daily functioning expressed in percent of total.
Fig. 4 depicts changes in pain symptoms, which improved in 71% of patients. Only a small difference was noted between improvement in new users (improvement in 71% of respondents) and repeat users (improvement in 69% of respondents). Only 6% of those surveyed stated that their pain symptoms deteriorated after they started using the SWHO.
Fig. 4Change in pain symptoms expressed in percent of total.
Fig. 5 includes the results of questions asked regarding daily activities with and without SWHO. Results are presented for each daily activity in order of experienced difficulty. Patients experienced the most difficulty when performing household chores, activities that require a wide range of motor skills and hand grips. Only 4% of patients had ‘no difficulties’ with this activity without the use of a SWHO. The group experiencing ‘no or slight difficulties’ increased from 19% of the population without aid to 57% with the SWHO. The group experiencing limited difficulty more than doubled with SWHO use, while the group experiencing major difficulties declined by 67%.
Fig. 5Experienced problems during daily activities with and without a silicone wrist hand orthosis.
By assessing respondents’ ability to unscrew a jar, the effect of the SWHO on cylindrical grip was analyzed. The group experiencing “no or slight difficulties” increased from 19% of the population without aid to 48% with a SWHO, representing an increase of 153%. The group experiencing “major problems” reduced 55% with SWHO use, from 38% of the population to 17%. Insight into a hooked grip was gained with the question related to experienced difficulties lifting groceries. For this activity, the group experiencing “no or slight difficulties” increased from 24% of the population without a device to 56% with a SWHO. The group unable to lift groceries changed from 12% to 9%.
Patients reported a similar impact of the SWHO when holding a book: the group experiencing “no or slight difficulties” increased from 38% without to 72% with the SWHO. The open hand grip when holding a book is clearly supported, as the ’no difficulties’ group increased from 16% to 37% while the group with severe difficulties reduced by 77% whilst wearing a SWHO (22% to 5%. With respect to buttoning clothing with and without a SWHO, the group experiencing “no or slight difficulties” increased from 42% of the population without aid to 62% with a SWHO. The group unable to carry out this activity remained unchanged. To button clothing a pincer grip is needed, and a SWHO had a clear positive effect on the ability to do this. The group experiencing “no or slight difficulties” with writing increased from 41% of the population without aid to 61% with SWHO. Holding a pen means that the patient is able to hold a small, thin object and operate it using fine motor skills. It appears that the patients experienced relatively fewer difficulties with showering, bathing and dressing, as the patient group experiencing “minor or no difficulties” was relatively high with and without the use of a SWHO (55% and 66% respectively).
For phone use, the group experiencing ‘no difficulties’ increased from 34% to 48% of the population, an increase of 41%. The group experiencing “no or slight difficulties” increased from 59% of the population without a device to 78% with a SWHO. The group experiencing major difficulties picking up the phone reduced from 10% to 4%. When wearing the aid, almost half of patients experienced no difficulties when operating or using a mobile telephone, a very important activity in modern life. When combined with the patient group experiencing minor problems, this percentage increased to 78%.
Table 3 depicts patients with “minor or no difficulties” with each activity with and without the silicone WHO.
Table 3Daily activities for best two groups combined (no problems and minor problems).
The greatest relative improvement was demonstrated in “household chores” (+200%), “unscrewing jar and/or pot lids” (+153%) and “lifting groceries” (+133%). This study indicates that wearing a SWHO has a particularly significant impact on the performance of activities that require strength in their execution. These activities were in general experienced as more difficult, substantiated by the small number of patients who did not wear a SWHO experiencing “minor or no difficulties.”
Table 4 shows the results when combining the patients with “major problems” with those who were “unable to perform” the activity for each activity with and without the use of a SWHO. There was a general improvement in all groups, and the range of outcomes was narrower compared with improvements in groups with “no or minor difficulties” (Table 3). The biggest relative improvement was demonstrated in activities “holding a book” and “domestic chores.”
Table 4Daily activities for groups with major problems and unable to perform combined.
In this PROM study, 77% of patients reported improved overall daily functioning when wearing a SWHO. Good progress was seen overall, but 23% of patients experienced no improvement or even deterioration in their function. Further research may help gain more insight into the reasons why patients do not experience improvement. Learning from their individual preferences improves the possibility that this work can potentially help improve the SWHO model. This study adds to the evidence reported by systematic reviews of conservative interventions for hand OA and further quantifies the effects of a tailor made SWHO.
There is inadequate evidence to determine the effectiveness of nonpharmacological and nonsurgical interventions for hand osteoarthritis: an overview of high-quality systematic reviews.
Consensus polsorthesen bij artritis Sectie ergotherapie van de Nederlandse Health Professionals in de Reumatologie, (NHPR).
maart.2010;
Common goals for the treatment of hand OA are pain relief, improved hand strength and ROM, and reduced stiffness, with an overall goal to improve physical hand function.
There is inadequate evidence to determine the effectiveness of nonpharmacological and nonsurgical interventions for hand osteoarthritis: an overview of high-quality systematic reviews.
Although critics of immobilization report that retaining normal tissue requires mobility, excessive mobilization of unstable arthritic joints may encourage further instability. Various studies have reported that an orthosis reduced pain and improved function during daily activities in patients with arthritis.
Improvement in functioning during daily activities
This study confirms that wearing a wrist orthosis has a particularly significant impact on the execution of static and repetitive wrist-straining activities. Examples of such activities are: lifting a bag of groceries and carrying items, household chores and holding a book. However, positive effects have also been observed in activities that require a lot of wrist movement or fine motor skills, such as: buttoning clothes, handling the phone, showering, bathing and getting dressed.
Mechanically, an orthosis supports the hand or wrist in a favorable position, thereby avoiding unfavorable forces on the cartilage and caps and/or ligaments and allowing patients to experience less pain. Patients also experience more support with an orthosis, which is seen as an advantage when performing these activities. Wearing a SWHO may make an activity possible due to less pain and more support. In the past, advice was often given to wear a wrist orthosis throughout the entire day. In recent years, however, advice often involves wearing the wrist orthoses mainly during activities that put a strain onto the wrists.
Consensus polsorthesen bij artritis Sectie ergotherapie van de Nederlandse Health Professionals in de Reumatologie, (NHPR).
maart.2010;
Given the results of this study, current advice can be further improved by including static activities that put a strain on the wrists so that those activities do not require wrist movement.
Support for loss of strength
Grip strength was shown to improve with SWHO use, as the group that experienced “no or mild problems” increased significantly for activities requiring grip strength while wearing a SWHO, including; “lifting shopping bag” (+133%), “unscrewing jar and/or pot lids” (+153%) and “household chores” (+200%). All three more than doubled.
There is no consensus in the literature about the effects of wrist orthoses on hand strength.
The effectiveness of joint-protection programs on pain, hand function, and grip strength levels in patients with hand arthritis: A systematic review and meta-analysis.
concluded in their review that wrist orthoses may increase grip strength immediately after wrist orthosis provision, the results of prior work are not unequivocally in agreement with this. Gomes Carreira
Assessment of the effectiveness of a functional splint for osteoarthritis of the trapeziometacarpal joint on the dominant hand: a randomized controlled study.
previously found insufficient evidence of hand strength improvement with a SWHO. The findings of these studies were based on smaller research populations of 60 patients or even less, while the present large scale study of 551 patients strengthens the suggestion of a positive effect of a SWHO on grip strength.
Controlled studies are necessary to draw definite conclusions on the effects of SWHOs on grip strengths, and the positive findings of this study support the need for further research using a larger scale controlled study.
Pain reduction
This study shows that pain reduced by 71% with the use of a SWHO. Scientifically, most evidence was found for a short-term effect immediately after the wrist orthosis was provided. Several studies found that wearing a (thumb) orthosis led to a significant reduction in pain when carrying out activities.
Assessment of the effectiveness of a functional splint for osteoarthritis of the trapeziometacarpal joint on the dominant hand: a randomized controlled study.
The effect of two different orthoses on pain, hand function, patient satisfaction and preference in patients with thumb carpometacarpal osteoarthritis: a multicenter, crossover, randomized controlled trial.
The effect of two different orthoses on pain, hand function, patient satisfaction and preference in patients with thumb carpometacarpal osteoarthritis: a multicenter, crossover, randomized controlled trial.
noted a minor reduction in pain scores in a group of 63 patients with hand OA when both tailor-made orthoses and ready to wear models were used. In the current study, a stronger improvement was shown following the use of a SWHO. Although this indicates that the use of a SWHO has a strong impact on daily activity performance whilst using a SWHO, further research is required with a comparative study between ready to wear and custom made SWHO to substantiate this hypothesis further. Repeat provisions are supplied 3 years after starting to wear a SWHO. This study noted long-term pain reduction in patients who used the SWHO for 3 years or longer. The positive effect on pain reduction for patients who received a repeat provision was 69%, of which 37% reported ‘significant improvement’ in pain reduction. These results were very similar to those of new users.
The long-term effects of SWHOs are less uniform in literature. To date, only a few randomized controlled trials have been carried out where patients who wore a wrist orthosis for a certain time period were compared with control patients. Kjeken
found no significant difference between the intervention group and the control group in pain reduction after a period of 6 months for patients with hand OA, while Kloppenburg
concluded that high-quality clinical trials now show that splints are effective in pain alleviation for thumb base OA, but the optimum splint type and instruction for use has not been defined.
for a longer-term effect of SWHOs and even demonstrates a pain reduction effect beyond 3 years, thereby contributing additional insight into the longer-term efficacy of SWHOs.
Adverse effects of wrist orthoses
This study shows that all activity groups improved with the use of the SWHO, with activities requiring more fine motor skills improving less than the activities that require gross motor skills. Patients cited both benefits and hindering effects when wearing wrist orthoses with respect to functional capabilities.
Wrist orthoses are more often considered cumbersome during activities that require a lot of wrist movement, and may potentially reduce the speed of an action. Main adverse effect of a wrist orthosis in the literature is reduced dexterity and there is substantial proof in literature that immobilization of the wrist increases motion demands on proximal joints.
To manage expectations, it is important to inform patients that limitations due to their hand OA will not be eliminated altogether by a SWHO. The ultimate success of the wrist orthosis largely comes down to the individual patient; after all, the patient has to use the orthosis during daily work and routines and will experience both advantages and disadvantages.
Limitations
This work has several limitations. First, it was not recorded which model of SWHO the patient wore (Figs. 1 and 2), or on which hand (dominant or not dominant) and if the orthosis matches the appropriate diagnosis. These aspects could have an influence on function with the SWHO. This study does not adjust for factors (sex, age, type of diagnosis) that can influence how people score on the PRWHE. However, doing so would add to the quality of the outcomes, and should be taken into account in future follow-up studies.
Conclusions on the long-term effect of SWHOs are based on repeat supply to patients with a minimum use of 3 years. No insight is given into difference in SWHO efficacy at >3 years. It would be of interest for future research to evaluate the possibility of benefit deterioration with a SWHO based on a longer time frame.
Conclusion
The results of this large-scale PROM study on the effectiveness of a SWHO in patients with hand OA shows that the use of a SWHO contributes to general daily function, reduces pain and increases the breadth of potential daily activities. Less pain makes it easier for patients to move and be active so that their lives can be more active once again and their quality of life can improve. Staying active actually helps enhance the patient's self-reliance. Interventions to promote independent mobility should focus not only on preventing hand OA disability but also on restoring and maintaining independent mobility in older persons who become disabled.
LIFE study investigators. Effect of structured physical activity on prevention of major mobility disability in older adults: the LIFE study randomized clinical trial.
There is inadequate evidence to determine the effectiveness of nonpharmacological and nonsurgical interventions for hand osteoarthritis: an overview of high-quality systematic reviews.
Responsiveness of the disability of the arm, shoulder, and hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) in evaluating change after hand therapy.
The effectiveness of joint-protection programs on pain, hand function, and grip strength levels in patients with hand arthritis: A systematic review and meta-analysis.
Assessment of the effectiveness of a functional splint for osteoarthritis of the trapeziometacarpal joint on the dominant hand: a randomized controlled study.
The effect of two different orthoses on pain, hand function, patient satisfaction and preference in patients with thumb carpometacarpal osteoarthritis: a multicenter, crossover, randomized controlled trial.
LIFE study investigators. Effect of structured physical activity on prevention of major mobility disability in older adults: the LIFE study randomized clinical trial.
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