Is multimodal occupational therapy in addition to usual care cost-effective in people with thumb carpometacarpal osteoarthritis? A cost-utility analysis of a randomised controlled trial.

OBJECTIVE: The aim was to evaluate the cost-utility of a 3-month multimodal occupational therapy intervention in addition to usual care in patients with thumb carpometacarpal osteoarthritis (CMC1 OA). METHODS: A cost-utility analysis was performed alongside a multicentre randomised controlled trial including three rheumatology departments in Norway. A total of 180 patients referred to surgical consultation due to CMC1 OA were randomised to either multimodal occupational therapy including patient education, hand exercises, assistive devices and orthoses (n=90), or usual care receiving only information on OA (n=90). The outcome measure was quality-adjusted life-years (QALYs) derived from the generic questionnaire EQ-5D-5L over a 2-year period. Resource use and health-related quality of life of the patients were prospectively collected at baseline, 4, 18 and 24 months. Costs were estimated by taking a healthcare and societal perspective. The results were expressed as incremental cost-effectiveness ratios, and a probabilistic sensitivity analysis with 1000 replications following intention-to-treat principle was done to account for uncertainty in the analysis. RESULTS: During the 2-year follow-up period, patients receiving multimodal occupational therapy gained 0.06 more QALYs than patients receiving usual care. The mean (SD) direct costs were €3227 (3546) in the intervention group and €4378 (5487) in the usual care group, mean difference €-1151 (95% CI -2564, 262). The intervention was the dominant treatment with a probability of 94.5% being cost-effective given the willingness-to-pay threshold of €27 500. CONCLUSIONS: The within-trial analysis demonstrated that the multimodal occupational therapy in addition to usual care was cost-effective at 2 years in patients with CMC1 OA. TRIAL REGISTRATION NUMBER: NCT01794754.

Rheumatic disease and fatigue: Participants' experiences of an activity-pacing group.

BACKGROUND: Fatigue is a common symptom of inflammatory rheumatic disease and has a great impact on everyday life. Activity-pacing is proposed as an intervention to increase participation in meaningful activities. AIMS: To explore participants' experiences with an activity-pacing group, how participants perceived self-managing everyday life after group attendance, and their reflections on unmet needs that could enhance self-management of everyday life with fatigue. MATERIALS AND METHODS: Semi-structured interviews were conducted with 10 participants who had attended an activity-pacing group. Thematic analyses were conducted. FINDINGS: Prior to group attendance, the participants expressed an awareness of their lack of knowledge of fatigue. Through group attendance, they increased their understanding of fatigue and their ability to apply strategies to better manage everyday life. Participants found it difficult to balance their energy use and realised that implementing activity-pacing strategies takes time. Therefore, they requested follow-up sessions with the activity-pacing group. They also desire that rheumatologists pay more attention to and acknowledge fatigue. CONCLUSIONS AND SIGNIFICANCE: Enhancing the understanding of fatigue and how to manage everyday life with fatigue, appears to be important. Group interventions led by occupational therapists and with a focus on activity-pacing may be a suitable approach. Follow-up sessions are recommended.

Patient Goals and Motivation for Thumb Carpometacarpal Osteoarthritis Surgery.

BACKGROUND: Knowledge is lacking on patient goals and motivation for carpometacarpal joint osteoarthritis (CMCJ OA) surgery. The objective of this study was to explore patient goals and motivation for surgery, whether patient goals were reflected in self-reports of pain and function, and factors characterizing patients highly motivated for surgery. METHODS: This cross-sectional study included 180 patients referred from their general practitioner for CMCJ surgical consultation. Goals for surgery were collected with an open-ended question, categorized with the International Classification of Functioning, Disability and Health coding system, and compared to self-reports of pain and function. Motivation for surgery was rated with a Numeric Rating Scale (NRS, 0-10, 0 = not motivated). Factors characterizing patients highly motivated for surgery (NRS ≥ 8) were explored with multivariate regression analyses. RESULTS: The mean age of the participants was 63 years (SD = 7.6), and 142 (79%) were women. The most common goals for surgery were to reduce pain and improve arm and hand use, but these were not reflected in self-reports of pain and function. Fifty-six (31%) of the patients were characterized as highly motivated for surgery. High motivation for surgery was strongly associated with reporting more activity limitations (odds ratio [OR] = 4.00, P = .008), living alone (OR = 3.18, P = .007), and a young age (OR = 0.94, P = .002). CONCLUSIONS: Decisions on CMCJ OA surgery should be based on assessment and discussion of patients' life situation, hand pain, activity limitations for, and goals and motivation for surgery. According to the european league against rheumatism (EULAR) recommendations, previously received conservative and pharmacological treatment should also be evaluated.

The Measure of Activity Performance of the hand (MAP-Hand) - A reliable and valid questionnaire for use in patients with hand osteoarthritis with specific involvement of the thumb.

STUDY DESIGN: Cross-sectional methodological study with test-retest design. INTRODUCTION: The Measure of Activity Performance of the Hand (MAP-Hand) is an assessment tool measuring hand-related activity limitations. PURPOSE: To assess reliability, validity, and interpretability of the MAP-Hand in patients with hand osteoarthritis with specific involvement of the thumb (CMC1). METHODS: One hundred-and-eighty patients referred to surgical consultation for hand osteoarthritis affecting the CMC1 were included in the evaluation of validity and interpretability. Among these, 59 stable patients were included in reliability analyses, completing the questionnaire twice with a 2-week retest interval. The MAP-Hand has 18 predefined and 5 optional patient-specific items, scored on a 4-point scale (1 = no difficulty to 4 = not able to do). Relative (ICC2.1) and absolute (SDC95%ind) reliability were calculated. An ICC of >0.70 was considered acceptable. Nine (75%) or more of 12 predetermined hypotheses had to be confirmed for acceptable construct validity. Interpretability was assessed using floor and ceiling effects and considered present if 15% scored at eitherend of the scale. RESULTS: Mean (SD) age was 63 (8) years, and most patients were women (79%). The mean total score of predefined items showed acceptable reliability (ICC2.1 0.74, SDC95%ind 0.60) and construct validity. The mean total score of the patient-specific items did not reach acceptable reliability. Ceiling effect was found for the predefined items. DISCUSSION AND CONCLUSIONS: We found that the mean total score of the predefined items on MAP-Hand had acceptable reliability and construct validity but a ceiling effect in patients with hand osteoarthritis with CMC1 affection.

Short-Term Effects of Occupational Therapy on Hand Function and Pain in Patients With Carpometacarpal Osteoarthritis: Secondary Analyses From a Randomized Controlled Trial.

OBJECTIVE: To assess the short-term effects of multimodal occupational therapy on pain and hand function in patients referred for surgical consultation due to first carpometacarpal (CMC1) joint osteoarthritis (OA). METHODS: In this randomized controlled trial, patients with CMC1 joint OA referred for surgical consultation at 3 rheumatology departments were randomized to 3 months multimodal occupational therapy (including patient education, hand exercises, orthoses, and assistive devices) or usual treatment (OA information). Pain was measured on a numeric rating scale from 0 to 10 (0 = no pain). Function included grip and pinch strength (Newtons), range-of-motion (palmar and CMC1 joint abduction [°]; flexion deficit in digits 2-5 [mm]), and self-reported Measure of Activity Performance of the Hand (MAP-Hand; range 1-4, 1 = no activity limitation) and short version of the Disability of the Arm, Shoulder, and Hand (QuickDASH; range 0-100, 0 = no disability). Between-group difference was assessed with follow-up values as dependent variables and group as an independent variable, adjusted for baseline values and time to follow-up. RESULTS: Among 180 patients (mean ± SD age 63 ± 8 years; 81% women), 170 completed the short-term follow-up assessment (3-4 months after baseline). Compared to usual treatment, occupational therapy yielded significantly improved pain at rest (-1.4 [95% confidence interval (95% CI) -0.7, -2.0]; P < 0.001), pain following grip strength (-1.1 [-0.5, -1.7]; P = 0.001), grip strength (23.4 [95% CI 7.5, 39.3]; P = 0.004), MAP-Hand score (-0.18 [95% CI -0.09, -0.28]; P = 0.001), and QuickDASH score (-8.1 [95% CI -4.6, -11.5]; P < 0.001). CONCLUSION: The multimodal occupational therapy intervention had significant short-term effects on pain, grip strength, and hand function in patients with CMC1 joint OA.

The MAP-Hand: Psychometric properties and differences in activity performance between patients with carpometacarpal osteoarthritis and rheumatoid arthritis.

OBJECTIVE: To assess construct validity (Rasch analyses) of the Measure of Activity Performance of the Hand (MAP-Hand) in people with carpometacarpal osteoarthritis (CMC1 OA), and to explore differences in activity performance between people with CMC1 OA and those with rheumatoid arthritis. DESIGN: Cross-sectional study. SUBJECTS: A total of 180 people with CMC1 OA referred for surgical consultation were recruited from rheumatology clinics in Norway, and 340 people with rheumatoid arthritis were recruited from outpatient rheumatology clinics in the UK. METHODS: The MAP-Hand consists of 18 predefined items scored on a 4-point scale from 1 (no difficulty) to 4 (unable to do), from which a mean score is calculated. Construct validity was assessed using Rasch analyses. Differences between the 2 groups were assessed using an independent sample t-test at the group level and differential item functioning (condition as grouping variable) at the item level. RESULTS: Some mis-targeting of data and clusters of dependency were found, but the MAP-Hand scores showed an overall fit to the model. No between-group difference in total mean MAP-Hand score was found, but there were significant differences between the 2 groups on item levels. CONCLUSION: The MAP-Hand showed satisfactory construct validity and could differentiate between people with CMC1 OA and those with rheumatoid arthritis on item levels.

Does occupational therapy delay or reduce the proportion of patients that receives thumb carpometacarpal joint surgery? A multicentre randomised controlled trial.

Objectives: To evaluate whether occupational therapy, provided in the period between referral and surgical consultation, might delay or reduce the need of surgery in thumb carpometacarpal joint (CMCJ) osteoarthritis and to explore predictors for CMCJ surgery. Methods: This multicentre randomised controlled trial included patients referred for surgical consultation due to CMCJ osteoarthritis. An occupational therapy group received hand osteoarthritis education, assistive devices, CMCJ orthoses and exercises. A control group received only hand osteoarthritis information. Primary outcome was the proportion of patients that had received CMCJ surgery after 2 years. We examined the primary outcome and predictors for surgery with regression models, and time to surgery with the log-rank test and cox regression analyses. Results: Of 221 patients screened for eligibility, 180 were randomised. Information on the primary outcome was collected from medical records for all included patients. Surgery was performed on 22 patients (24%) that had received occupational therapy and 29 (32%) control patients (OR 0.56, 95% CI 0.26 to 1.21; p=0.14). Median time to surgery was 350 days (IQR 210-540) in the occupational therapy group and 296 days (IQR 188-428) in the control group (p=0.13). Previous non-pharmacological treatment (OR 2.72, 95% CI 1.14 to 6.50) and higher motivation for surgery (OR 1.25, 95% CI 1.09 to 1.43) were significant predictors for CMCJ surgery. Conclusions: Occupational therapy showed a small non-significant tendency to delay and reduce the need for surgery in CMCJ osteoarthritis. Previous non-pharmacological treatment and higher motivation for surgery were significant predictors for surgery.

Non-pharmacological treatment gap preceding surgical consultation in thumb carpometacarpal osteoarthritis - a cross-sectional study.

BACKGROUND: Osteoarthritis (OA) in the thumb carpometacarpal joint (CMCJ) is a prevalent disease which may lead to structural damage, severe pain and functional limitations. Evidence-based treatment recommendations state that all patients with hand OA should be offered non-pharmacological treatment. Surgery should be considered only when other treatment has proven insufficient in relieving pain. The purpose of this study was to investigate prior treatment and characteristics of patients referred to specialist health care surgical consultation due to CMCJ OA. The study includes exploring differences in pain and function between referred and non-referred hand, between men and women, and between patients with and without OA affection of other finger joints than CMCJ. METHODS: Patients in this cross-sectional study reported prior non-pharmacological treatment for CMCJ OA. Patient demographics, disease and functional variables were assessed based on hand radiographs, patient-reported and observer-based outcome measures. Differences in pain and function between referred and non-referred hand, men and women, and between patients with and without additional affection of finger joints other than CMCJ, were analysed using Paired-samples T-tests, Wilcoxon Signed Rank, or Chi-Square tests. RESULTS: One hundred and eighty patients were included. The mean age was 63 years and 79% were women. Only 21% reported having received non-pharmacological treatment before referral to surgical consultation. The results show a statistically significant worse function for referred hands, women and involvement of additional interphalangeal joints. Most patients reported no pain or mild pain in their referred hand. CONCLUSIONS: The results of this study show a non-pharmacological treatment gap in OA care. Most patients report no pain or mild pain, and that they had not received non-pharmacological treatment prior to being referred to CMCJ OA surgical consultation. The results furthermore show that CMCJ OA negatively affects all aspects of function. Strategies need to be developed to improve OA care, including educating general practitioners in evidence-based treatment recommendations and in the assessment of hand pain, and encourage the routine referral of patients with symptomatic hand OA to occupational therapy before considering surgery.

Does occupational therapy reduce the need for surgery in carpometacarpal osteoarthritis? Protocol for a randomized controlled trial.

BACKGROUND: In the absence of disease-modifying interventions for hand osteoarthritis (OA), occupational therapy (OT) comprising patient education, hand exercises, assistive devices and orthoses are considered as core treatments, whereas surgery are recommended for those with severe carpometacarpal (CMC1) OA. However, even though CMC1 surgery may reduce pain and improve function, the risk of adverse effects is high, and randomized controlled trials comparing surgery with non-surgical interventions are warranted. This multicentre randomized controlled trial aims to address the following questions: Does OT in the period before surgical consultation reduce the need for surgery in CMC1-OA? What are patients' motivation and reasons for wanting CMC1-surgery? Are there differences between departments of rheumatology concerning the degree of CMC1-OA, pain and functional limitations in patients who are referred for surgical consultation for CMC1 surgery? Is the Measure of Activity Performance of the Hand a reliable measure in patients with CMC1-OA? Do patients with CMC1-OA with and without affection of the distal and proximal interphalangeal finger joints differ with regard to symptoms and function? Do the degree of CMC1-OA, symptoms and functional limitations significantly predict improvement after 2 years following OT or CMC1-surgery? Is OT more cost-effective than surgery in the management of CMC1-OA? METHODS/DESIGN: All persons referred for surgical consultation due to their CMC1-OA at one of three Norwegian departments of rheumatology are invited to participate. Those who agree attend a clinical assessment and report their symptoms, function and motivation for surgery in validated outcome measures, before they are randomly selected to receive OT in the period before surgical consultation (estimated n = 180). The primary outcome will be the number of participants in each group who have received surgical treatment after 2 years. Secondary and tertiary outcomes are pain, function and satisfaction with care over the 2-year trial period. Outcomes will be collected at baseline, 4, 18 and 24 months. The main analysis will be on an intention-to-treat basis, using logistic regression, comparing the number of participants in each group who have received surgical treatment after 2 years. DISCUSSION: The findings will improve the evidence-based management of HOA. TRIAL REGISTRATION IDENTIFIER: NCT01794754 . First registrated February 15th 2013.