Background - What is hand osteoarthritis and what is exercise?
Osteoarthritis (OA) is a disease of the joints that causes joint pain, stiffness and swelling. It may hinder people from doing what they want and need to do. Usually, symptoms come on slowly but get worse over time. OA may occur in any joint but is most commonly seen in the hip, knee and small joints of the hand. No cure for OA is known, but available treatment alternatives may reduce pain and stiffness, increase function and improve self-management of the disease.
Exercise is an activity done to improve or maintain your fitness, ability or performance. A period of planned exercise often aims to improve or maintain muscle strength, physical fitness, joint mobility and overall health.
This Cochrane review presents what we know about the effect of exercise in people with OA in the joints of the hand. After searching for relevant studies up to September 2015, we included seven studies (534 participants). These studies included more women than men. In six studies, half of the people underwent a hand exercise programme and were compared with those who did not exercise. One study compared two groups of people who underwent two different exercise programmes. Evidence from five studies shows the effect of exercise immediately after the exercise programme, and two studies provided results on medium- and long-term sustainability of exercise. We report below only the results reported immediately after the exercise programme was completed.
On a scale of 0 to 10 points (lower scores mean less pain), people who completed an exercise programme rated their hand pain 0.5 points lower (5% absolute improvement) at the end of treatment compared with people who did not exercise. People who did not exercise rated their pain at 3.9 points.
On a scale of 0 to 36 points (lower scores mean better function), people who completed an exercise programme rated their hand function 2.2 points lower (6% absolute improvement) compared with people who did not exercise. People who did not exercise rated their hand function at 14.5 points.
On a scale of 0 to 100 points (higher scores mean better quality of life), people who completed an exercise programme rated their quality of life 0.3 points higher (0.3% absolute improvement) compared with people who did not exercise. People who did not exercise rated their quality of life at 50.4 points.
On a scale of 0 to 10 points (lower scores mean less finger joint stiffness), people who completed an exercise programme rated their stiffness in the finger joints 0.7 points lower (7% absolute improvement) at the end of treatment compared with people who did not exercise. People who did not exercise rated their finger joint stiffness at 4.5 points.
A small number of people in the exercise group reported adverse events such as increased pain and/or joint swelling. We are uncertain as to whether exercise increases the number of people who experience adverse events.
Quality of the evidence
We graded the quality of the evidence as (very) low. Lack of blinding of participants, the small number of included studies and inclusion of few people in the analyses reduced the robustness and precision of these findings, and further research may change the results. Only half of the included studies reported on adverse effects, and the few adverse events reported occurred in the exercise group.
When we pooled results from five studies, we found low-quality evidence showing small beneficial effects of exercise on hand pain, function and finger joint stiffness. Estimated effect sizes were small, and whether they represent a clinically important change may be debated. One study reported quality of life, and the effect is uncertain. Three studies reported on adverse events, which were very few and were not severe.
Hand osteoarthritis (OA) is a prevalent joint disease that may lead to pain, stiffness and problems in performing hand-related activities of daily living. Currently, no cure for OA is known, and non-pharmacological modalities are recommended as first-line care. A positive effect of exercise in hip and knee OA has been documented, but the effect of exercise on hand OA remains uncertain.
To assess the benefits and harms of exercise compared with other interventions, including placebo or no intervention, in people with hand OA. Main outcomes are hand pain and hand function.
We searched six electronic databases up until September 2015.
All randomised and controlled clinical trials comparing therapeutic exercise versus no exercise or comparing different exercise programmes.
Two review authors independently selected trials, extracted data, assessed risk of bias and assessed the quality of the body of evidence using the GRADE approach. Outcomes consisted of both continuous (hand pain, physical function, finger joint stiffness and quality of life) and dichotomous outcomes (proportions of adverse events and withdrawals).
We included seven studies in the review. Most studies were free from selection and reporting bias, but one study was available only as a congress abstract. It was not possible to blind participants to treatment allocation, and although most studies reported blinded outcome assessors, some outcomes (pain, function, stiffness and quality of life) were self-reported. The results may be vulnerable to performance and detection bias owing to unblinded participants and self-reported outcomes. Two studies with high drop-out rates may be vulnerable to attrition bias. We downgraded the overall quality of the body of evidence to low owing to potential detection bias (lack of blinding of participants on self-reported outcomes) and imprecision (studies were few, the number of participants was limited and confidence intervals were wide for the outcomes pain, function and joint stiffness). For quality of life, adverse events and withdrawals due to adverse events, we further downgraded the overall quality of the body of evidence to very low because studies were very few and confidence intervals were very wide.
Low-quality evidence from five trials (381 participants) indicated that exercise reduced hand pain (standardised mean difference (SMD) -0.27, 95% confidence interval (CI) -0.47 to -0.07) post intervention. The absolute reduction in pain for the exercise group, compared with the control group, was 5% (1% to 9%) on a 0 to 10 point scale. Pain was estimated to be 3.9 points on this scale (0 = no pain) in the control group, and exercise reduced pain by 0.5 points (95% CI 0.1 to 0.9; number needed to treat for an additional beneficial outcome (NNTB) 9).
Four studies (369 participants) indicated that exercise improved hand function (SMD -0.28, 95% CI -0.58 to 0.02) post intervention. The absolute improvement in function noted in the exercise group, compared with the control group, was 6% (0.4% worsening to 13% improvement). Function was estimated at 14.5 points on a 0 to 36 point scale (0 = no physical disability) in the control group, and exercise improved function by 2.2 points (95% CI -0.2 to 4.6; NNTB 9).
One study (113 participants) evaluated quality of life, and the effect of exercise on quality of life is currently uncertain (mean difference (MD) 0.30, 95% CI -3.72 to 4.32). The absolute improvement in quality of life for the exercise group, compared with the control group, was 0.3% (4% worsening to 4% improvement). Quality of life was 50.4 points on a 0 to 100 point scale (100 = maximum quality of life) in the control group, and the mean score in the exercise group was 0.3 points higher (3.5 points lower to 4.1 points higher).
Four studies (369 participants) indicated that exercise reduced finger joint stiffness (SMD -0.36, 95% CI -0.58 to -0.15) post intervention. The absolute reduction in finger joint stiffness for the exercise group, compared with the control group, was 7% (3% to 10%). Finger joint stiffness was estimated at 4.5 points on a 0 to 10 point scale (0 = no stiffness) in the control group, and exercise improved stiffness by 0.7 points (95% CI 0.3 to 1.0; NNTB 7).
Three studies reported intervention-related adverse events and withdrawals due to adverse events. The few reported adverse events consisted of increased finger joint inflammation and hand pain. Low-quality evidence from the three studies showed an increased likelihood of adverse events (risk ratio (RR) 4.55, 95% CI 0.53 to 39.31) and of withdrawals due to adverse events in the exercise group compared with the control group (RR 2.88, 95% CI 0.30 to 27.18), but the effect is uncertain and further research may change the estimates.
Included studies did not measure radiographic joint structure changes. Two studies provided six-month follow-up data (220 participants), and one (102 participants) provided 12-month follow-up data. The positive effect of exercise on pain, function and joint stiffness was not sustained at medium- and long-term follow-up.
The exercise intervention varied largely in terms of dosage, content and number of supervised sessions. Participants were instructed to exercise two to three times a week in four studies, daily in two studies and three to four times daily in another study. Exercise interventions in all seven studies aimed to improve muscle strength and joint stability or function, but the numbers and types of exercises varied largely across studies. Four studies reported adherence to the exercise programme; in three studies, this was self-reported. Self-reported adherence to the recommended frequency of exercise sessions ranged between 78% and 94%. In the fourth study, 67% fulfilled at least 16 of the 18 scheduled exercise sessions.