Hand and Thumb Osteoarthritis Evaluation: 10 Essential Recommendations

Hand or Thumb base Osteoarthritis are chronic degenerative conditions that frequently affect the populationn, leading to significant functional, occupational, and daily living limitations. Due to the complexity of osteoarthritis and its systemic implications, its treatment poses challenges for physicians, physiotherapists, and therapists working with these patients. However, a detailed and comprehensive evaluation of the hand can guide its optimal management.

To facilitate this process, Kjeken 2011 published an interesting article where conducted a literature review and a series of interviews with experts (Delphi study) in hand rehabilitation for osteoarthritis, in order to obtain the essential points that every healthcare professional should evaluated in their patients.

• Is it important to assess grip strength?
• How can I evaluate the functional ability of the hand?
• Is it important to evaluate deformities in fingers?

In this blog, we summarize the 10 essential points that every physiotherapist, occupational therapist, physician, or surgeon should evaluate in their patients with osteoarthritis in the hands and fingers.

Let’s go!

1️⃣ Ask your patient what he/she regards as the most significant problem they are experiencing

Our assessment and approach to osteoarthritis should always have one goal: Patient-Centred Practice.

In order to do so, we should ask specific questions about which meaningful activities generate the most problems for them. And among them, specify which are the most relevant for their day-to-day life. This approach will allow us to propose a specific treatment and exercise programme for their problem.

Here are some examples:

👉 At the beginning of the assessment of a hand osteoarthritis patient, it is important to ask the patient directly what he or she considers to be the most important problem. For example, the patient may mention that pain when gripping small objects is his or her main concern.

Thus, knowing this situation, we must analyse the mechanics of the hand grip:

🔸Excessively approximate thumb? It could be limiting grip capacity and, thus, affecting functional ability.
🔸Z-shaped thumb deformity? This classic thumb deformity is associated with thumb instability, commonly seen in rheumatoid arthritis and thumb osteoarthritis. Therapeutic intervention aims to restore stability and control. You can learn how to do it with exercise here.
🔸Lack of grip strength? This lack of strength can hinder hand capabilities.
🔸Poor wrist extensor control? Sometimes, poor control of wrist extension is associated with a loss of grip strength. The stable position is achieved with a slight wrist extension of 20-30 degrees. If not achieved, limitations may arise.

You can see that how the extensor musculature is associated with hand grip strength in our previous thread:

👉 Following a client-centred practice, personalised treatment plans should be developed focused on patient’s needs and wishes. For example, if a patient has difficulty performing everyday tasks such as combing hair due to osteoarthritis in the hands, the physiotherapist can design a treatment plan focused on improving the dexterity and grip needed for that particular activity.

2️⃣ Assess activity limitations and participation restrictions

A specific and detailed analysis of hand function is necessary to determine the limitations present in our patient. To do so, we can use direct questions on activities such as grasping, writing, opening jars or writing on a mobile phone (sometimes associated with symptomatic thumb osteoarthritis) that largely involve the hands.

Also, there are a large number of validated questionnaires to assess the functional status of the hand and limitations in ADL, such as:

• ✔️ Disabilities of the Arm, Shoulder and Hand (DASH) Questionnaire
• ✔️ QuickDASH Questionnaire
• ✔️ Michigan Hand Outcome Scale (MHQ)
• ✔️ Patient Rated Wrist Evaluation (PRWE) Questionnaire
• ✔️ Boston Carpal Tunnel Questionnaire (BCTQ)
• ✔️ FIHOA Scale (Functional Index for Hand Osteoarthritis)
• ✔️ Fugl-Meyer Upper Limb Questionnaire

Want to know more about these questionnaires? We have a Post with all the information… and FREE PDFs!!!! 👇

3️⃣ Evaluate Hand Grip Strength

We currently know that reduced hand grip strength is related to limitations in ADLs. Therefore, a very important point when assessing our patient is to carry out a specific assessment of hand strength.

How to Assess Hand Grip Strength?

According to the American Society for Hand Therapists (ASHT), the following protocol should be followed:

For the Grip Strength Test, “the patient will be seated in a chair with the hips flexed at 90° and the shoulders in a neutral position. The elbow shall be flexed at 90°, the forearm in neutral position and the wrist in a radial deviation of 0-15°. The test is performed twice and the highest mark is selected. The patient shall rest for 5 minutes between each measurement.“

What if I don’t have a dynamometer? Well, this can also be solved. Indirectly we can find out the strength status by asking questions about your ADLs that require strength and grip control such as opening a jar, gripping heavy objects or similar.

Check out the questions on the questionnaries mentioned above for ideas!

4️⃣ Assess Hand Pain

Pain is the main cause of consultation with a doctor or therapist associated with osteoarthritis of the hand. It is the most prevalent and disabling symptom of the disease, and as such should be carefully assessed.

How do we assess Pain?

🟠 VAS scale: the patient quantifies their perceived level of pain intensity on a scale of 0-10 cm.

The pain intensity allows us to dose exercise programmes and monitor progress. In general, it is generally considered that patients can and should work within a pain range of 0-5 out of 10, which should not be exceeded during the session or during the 24 hours post-exercise. This range allows us to work safely and without pain flare-ups.

This system of dosing exercise has demonstrated that, even if pain is present after the session, the long-term effect of the painful experience is very positive. The work of Hennig T et al 2013 showed how the mean initial pain VAS was 5.6, and decreased down to 4.2 at 12 weeks.

To know the context and to know more about how pain affects the patient, when and in which gestures, it is interesting to refer back to the scales. Some of them are:

🟠 AUSCAN pain subscale: the scale has 5 specific items to determine the pain status of the hand. Specifically, it asks about the pain perceived during resting, holding objects, lifting objects, turning them over or squeezing them.

The scale was described by Bellamy N et al. 2002.

🟠 Michigan Hand Outcome Questionnaire: has a specific subsection for hand pain. This scale asks about the temporality of the pain, the intensity, and whether it is associated with sleep, daily activities or even the psychological profile.

Realistic and objective therapeutic goals must be defined in order to be able to monitor the patient’s progress.

5️⃣ Assess Flexion and Extension ROM deficits of the 2nd-5th fingers

Although it is important to take this fact into account, the evidence has not related the existence of finger flexion and extension limitations to functional limitations.

It will be necessary to assess in each case what type of limitation it causes in the patient and whether it is important to address it directly.

To treat mobility deficits, one of the techniques most widely used in the evidence and in clinical practice is the TERT (Total End Range Time) methodology, which consists of applying stretching stimuli through low-intensity stretching for long periods of time. It can be applied manually or by means of splints.

Evidence has shown that its use can significantly increase mobility, although it requires perseverance and discipline on the part of the patient.

If you want to know how to apply them, take a look at our blog: 👇

6️⃣ Observe deformities of the PIP and DIP joints

The most common deformities in osteoarthritis of the hand are Heberden’s nodes (distal interphalangeal joints), Bouchard’s nodes (proximal interphalangeal joints), lateral deviation and hyperextension (thumb interphalangeal joints).

Studies have linked its occurrence to functional limitations in the hand, so it will be important to assess its presence.

7️⃣ Observe the subluxation in the Carpometacarpal joint in the thumb

This deformity typical of Thumb Base Osteoarthritis is characterised by a dorso-radial subluxation of the base of the First Metacarpal, a compensatory Adduction of the Metacarpal, and a compensatory hyperextension of the Metacarpophalangeal joint. You can see in the image how this deformity normally presents itself:

In milder or early cases of osteoarthritis of the thumb, this deformity is not visible to the naked eye. We will have to expose it to load using the pinch strength test to objectify the deformity. Once the deformity and joint degeneration progresses, the anatomical alterations become more and more evident and can be definitively implanted.

Learn how to treat Thumb Deformity with Exercise Therapy!

8️⃣ Observe the ability to grasp large objects

The objetctive with grip observation in people with osteoarthritis of the hands is to analyse the interdigital space between the thumb and index finger, as this can limit the function of reaching for objects.

👉The physiotherapist can provide the patient with different objects of varying size and shape (balls, bottles, plates, boxes, etc.) and observe how the patient grasps and manipulates them. This can help to assess grip strength and dexterity and detect possible limitations or difficulties.

9️⃣ Observe the ability to grasp smaller objects

Another important point is to assess the ability to pick up small objects and the thumb-index pinch gesture. Something as simple as asking the patient to pick up objects such as coins, tweezers, pens or paper clips can reveal their manual dexterity.

A validated method for this process is the Nine Hole Peg Test (NHPT).

The NHPT is a simple test that consists of placing nine small cylinders in the nine holes in the base or container of the console. The examiner will direct the measurement with the following commands: “Take the sticks one at a time, using the affected hand, and place them in the holes in any order until all the holes are filled. Then remove the sticks one by one and return them to the container. Stabilise the board with the sound hand. This is a practice test. See how quickly you can put all the sticks in and take them out again. Are you ready? Go!”. When the subject finishes the practice, the examiner says: “This will be the real test. The instructions are the same. Work as fast as you can. Are you ready? Come on!” [During the test] “Faster” [When the last stick is placed on the board] “Out again… Faster”.

The timer is activated by the examiner as soon as the subject touches the first peg and stops when the last peg touches the container. The container was then placed on the opposite side of the board.

Practical examples that any physiotherapist can understand:

👉 For example, the physiotherapist may provide the patient with small objects such as coins, pens or paper clips and observe how the patient grasps them with the thumb and index finger. This can help to assess accuracy and dexterity in grasping small objects and detect possible limitations or difficulties.

👉 There are questions on the scales that can help us:

• 🔸PRWE scale: Rate the difficulty experienced in “Buttoning the buttons of a shirt” or “Using toilet paper with the affected hand“.
• 🔸QuickDASH Questionnaire: “Using a knife to cut food“.
• 🔸Boston Carpal Tunnel Questionnaire , functional ability subscale, assesses the ability to “write” or “Pick up and hold the phone“.
• 🔸 Michigan Hand Function Questionnaire (MHQ) includes questions such as “holding a glass of water“, “uncorking a jar” or “tying shoelaces“.
• 🔸 URAM (Unite Rhumatologique des Affections de la Main) questionnaire with items such as “Can you spread your fingers?” or “Can you caress something or someone?“.
• 🔸 AUSCAN Questionnaire: with questions such as “How much difficulty have you had in the last week due to the problem with your hands in peeling fruit and vegetables?“.

This can help assess finger strength and coordination and detect possible limitations in grasping smaller objects.

🔟 Use methods that are valid, reliable and sensitive to functional changes

As we have been saying and explaining more or less clearly, all the methods we use to assess our patient must be based on instruments backed by evidence.

Validated questionnaires, grip strength tests, dexterity tests, etc. can be used.

Can you think of any other important points for assessing a hand with osteoarthritis?

Learn how to Prescribe and Monitor with Validated Questionnaires your patients with Osteoarthritis in Hands and Thumb with ReHand App!

References:

Bellamy N, Campbell J, Haraoui B, Gerecz-Simon E, Buchbinder R, Hobby K, et al. Clinimetric properties of the AUSCAN Osteoarthritis Hand Index: an evaluation of reliability, validity and responsiveness. Osteoarthritis Cartilage 2002;10:863–9. PubMed https://doi.org/10.1053/joca.2002.0838

Hennig, T., Hæhre, L., Hornburg, V. T., Mowinckel, P., Norli, E. S., & Kjeken, I. (2015). Effect of home-based hand exercises in women with hand osteoarthritis : a randomised controlled trial. Annals of the Rheumatic Diseases, 74(8), 1501–1508. https://doi.org/10.1136/annrheumdis-2013-204808

Hincapie OL, Elkins JS, Vasquez-Welsh L. Proprioception retraining for a patient with chronic wrist pain secondary to ligament injury with no structural instability. J Hand Ther [Internet]. 2016;29(2):183–90. Available from: http://dx.doi.org/10.1016/j.jht.2016.03.008

Kjeken (2011) Occupational therapy-based and evidence-supported recommendations for assessment and exercises in hand osteoarthritis, Scandinavian Journal of Occupational Therapy, 18:4, 265-281, DOI: 10.3109/11038128.2010.514942

Marshall M, Watt FE, Vincent TL, Dziedzic K. Hand osteoarthritis: clinical phenotypes, molecular mechanisms and disease management. Nat Rev Rheumatol [Internet]. 2018;14(11):641–56. Available from: http://dx.doi.org/10.1038/s41584-018-0095-4

Chung KC, Pillsbury MS, Walters MR, Hayward RA. Reliability and validity testing of the Michigan Hand Outcomes Questionnaire. J Hand Surg Am. 1998;23(4):575-87.

Terri M. Skirven A., Lee Osterman, Jane Fedorczyk et al. Rehabilitation of the Hand and Upper Extremity. 2020; Elsevier. ISBN 0323509134

Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH. Green´s Operative Hand Surgery Vol 1. Sixth Ed. 2010. ISBN: 978-1-4160-5279-1

Wolff AL, Wolfe SW. Rehabilitation for scapholunate injury: Application of scientific and clinical evidence to practice. J Hand Ther. 2016;29(2):146–53.

Pablo Rodríguez Sánchez-Laulhé
PhD Candidate | Hand Therapy and eHealth Researcher