Osteoarthritis hand trial

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

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Presented by Peter Brooks

These outcome measures for future phase 3 clinical studies in hip, knee, and hand osteoarthritis have been developed at OMERACT 3 - Recommendations for a core set of outcome measures for future phase 3 clinical trials in knee, hip, and hand osteoarthritis. Consensus development of OMERACT 3; Bellamy N, Kirwan J, Boers M, et al. J Rheumatol 1997; 24:799-802

The core set of outcome measures in OA should be pain; physical function; patient global assessment; and for studies of 1 year or longer, joint imaging (using standardised methods for taking and rating radiographs, or any demonstrably superior imaging technique).

Quality of life and/or utility measures are also strongly recommended. Further work should be carried out to assess the usefulness of biologic markers, stiffness, measures of inflammation, and other assessments, such as performance-based measures, time to surgery, flares, or analgesic consumption before they are accepted as core measures.

Most investigational therapies are targeted toward the inhibition of collagenolytic enzymes using, for example, oral doxycycline (Vibramycin) or specific metalloproteinase inhibitors. Other developments include tissue engineering using autologous chondrocytes cultured in vitro and reintroduced into the joint. The clinical applications of these approaches are currently limited to research

Low Level Laser Therapy for osteoarthritis and rheumatoid arthritis: a metaanalysis.

J Rheumatol 2000 Aug;27(8):1961-9

Brosseau L, Welch V, Wells G, Tugwell P, de Bie R, Gam A, Harman K, Shea B, Morin M.Physiotherapy Program, School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ontario, Canada. lbrossea@uottawa.ca

OBJECTIVE: Osteoarthritis (OA) and rheumatoid arthritis (RA) affect a large proportion of the population. Low level laser therapy (LLLT) was introduced as an alternative noninvasive treatment for RA and OA about 10 years ago, but its effectiveness is still controversial. We assessed the effectiveness of LLLT in the treatment of RA and OA. METHODS: A systematic review was conducted, following an a priori protocol, according to the methods recommended by the Cochrane Collaboration. Trials were identified by a literature search of Medline, Embase, and the Cochrane Controlled Trials Register. Only randomized controlled trials of LLLT for the treatment of patients with a clinical diagnosis of RA or OA were eligible. Thirteen trials were included, with 212 patients randomized to laser and 174 patients to placebo laser, and 68 patients received active laser on one hand and placebo on the opposite hand. Treatment duration ranged from 4 to 10 weeks. Followup was reported by only 2 trials for up to 3 months. RESULTS: In patients with RA, relative to a separate control group, LLLT reduced pain by 70% relative to placebo and reduced morning stiffness by 27.5 min (95% CI -52.0 to -2.9), and increased tip to palm flexibility by 1.3 cm (95% CI -1.7 to -0.8). Other outcomes such as functional assessment, range of motion, and local swelling were not different between groups. There were no significant differences between subgroups based on LLLT dosage, wavelength, site of application, or treatment length. In RA, relative to a control group using the opposite hand, there was no difference between control and treatment hand, but all hands were improved in terms of pain relief and disease activity. For OA, a total of 197 patients were randomized. Pain was assessed by 3 trials. The pooled estimate (random effects) showed no effect on pain (standardized mean difference -0.2, 95% CI -1.0 to +0.6), but there was statistically significant heterogeneity (p > 0.05). Other outcomes of joint tenderness, joint mobility, and strength were not significant. CONCLUSION: LLLT should be considered for short term relief of pain and morning stiffness in RA, particularly since it has few side effects. For OA, the results are conflicting in different studies and may depend on the method of application and other features of the LLLT. Clinicians and researchers should consistently report the characteristics of the LLLT device and the application techniques. New trials on LLLT should make use of standardized, validated outcomes. Despite some positive findings, this metaanalysis lacked data on how effectiveness of LLLT is affected by 4 factors: wavelength, treatment duration of LLLT, dosage, and site of application over nerves instead of joints. There is a need to investigate the effects of these factors on effectiveness of LLLT for RA and OA in randomized controlled clinical trials.

Using Chopsticks a Risk Factor for Osteoarthritis in the Hand

Using chopsticks contributes to osteoarthritis (OA) in the hand, according to researchers studying elderly Chinese individuals. Chopstick use puts stress on certain joints, specifically joints of the thumb and second and third fingers. X rays of the subjects’ hands showed OA in those joints, even if the subjects reported no pain. This study was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Approximately 2,500 Beijing residents aged 60 and older participated in the study, led by David J. Hunter, M.D., Ph.D., of Boston University Arthritis Center in Massachusetts. Dr. Hunter and his colleagues looked closely at x rays of the hands the subjects used to hold chopsticks (the “chopstick hand,” usually the right hand) and compared them to x rays of the nonchopstick hands.

OA was more common in several of the joints in the three fingers of the chopstick hand than in the nonchopstick hand. Twenty-six percent of the subjects had OA in the interphalangeal joint of the thumb; i.e., the joint closest to the tip of the thumb. Dr. Hunter’s group took into account all kinds of daily activities, such as sewing, writing and handling paper, which require subjects to use the pincer grip (pressing the tips of the first and second fingers against the tip of the thumb), and chopsticks use remained a risk factor.

Women, more than men, showed a higher prevalence of OA in several joints of the fingers of the chopstick hand compared to the nonchopstick hand. Dr. Hunter attributes the higher prevalence in women to the fact that women generally develop more hand OA than men. Interestingly, though, OA in both men and women was less prevalent in the joint at the base of the thumb. Apparently, holding chopsticks puts little stress there, offering a protective effect on that particular joint.

OA is a degenerative condition in which cartilage, which cushions the ends of bones, wears away, often leading to joint pain, stiffness and limited movement. OA is the most common type of arthritis, especially among older people. It can occur in any joint, but most often affects the hands, knees, hips or spine.

The mission of the NIAMS, a part of the Department of Health and Human Services’ National Institutes of Health, is to support research into the causes, treatment and prevention of arthritis and musculoskeletal and skin diseases, the training of basic and clinical scientists to carry out this research, and the dissemination of information on research progress in these diseases. For more information about NIAMS, call the information clearinghouse at (301) 495-4484 or (877) 22-NIAMS (free call) or visit the NIAMS Web site at http://www.niams.nih.gov.

Galactosaminoglycuronglycan sulfate in erosive osteoarthritis of the hands: early diagnosis, early treatment.

This study examined the effect of an oral chondroprotective drug, galactosaminoglycuronglycan sulfate (GAGs), on the evolution of erosive osteoarthritis of the hands (EOA). Twenty-four patients affected with EOA of the hands were evaluated. The patients had painful, frank arthritis of DIP and PIP joints; X-rays reduced joint space; X-rays central joint erosions; positive joint scintiscan, in absence of other inflammatory and erosive arthropathies. Twelve patients were treated with a chondroprotective drug, GAGs 800 mg/ die; twelve patients were the control group. The results at two years documented that the GAGs treatment influenced certainly joint pain and doubtfully bone scintiscan in EOA.

Rovetta-G; Monteforte-P
Int-J-Tissue-React. 1996; 18(1): 43-6

Therapeutic trials in digital osteoarthritis. A critical review.

Although common, hand osteoarthritis is controversial and rarely used as a model for clinical trials in osteoarthritis. We found only 13 therapeutic trials conducted in digital or trapeziometacarpal osteoarthritis between 1983 and 1994. Eleven of these trials were published. Seven were on nonsteroidal antiinflammatory drugs given either per os (two trials, meclofenamate and ibuprofen) or percutaneously (one trial each on etofenamate, ibuprofen, and ketoprofen gel, and two trials on niflumic acid gel), three were on symptomatic slow-acting drugs (glycosaminoglycanes in two trials and chondroitin sulfate in one), and three were on miscellaneous agents (the muscle relaxant idrocilamide, as a gel; the antisubstance P agent capsaicin, also as a gel; and a spa treatment). We have reviewed the methodology and findings of these trials with the goal of determining the optimal approach to realize better standardized trials in the next future for identifying symptomatic slow-acting drugs and/or "chondroprotective" agents with beneficial effects in digital osteoarthritis.

Treves-R; Maheu-E; Dreiser-RL
Rev-Rhum-Engl-Ed. 1995 Jun; 62(6 Suppl 1): 33S-41S

Other clinical trials in hand OA have evaluated topical non-steroidal anti-inflammatory drugs.

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