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Conservative Treatment of Thumb Base Osteoarthritis: A Systematic Review

      Purpose

      To provide a systematic review of randomized controlled trials regarding the conservative treatment of thumb base osteoarthritis (OA).

      Methods

      A systematic literature search was conducted in the electronic bibliographic databases Medline (Pubmed) and Embase (both starting year to May 2014) using predetermined criteria for studies on nonoperative treatment of thumb base OA.

      Results

      Twenty-three articles fulfilled our inclusion criteria. Systematic evaluation demonstrated the following: (1) Hand therapy can possibly reduce pain. However, owing to the lack of good-quality (randomized controlled) trials with sufficient follow-up time, no proper conclusions can be drawn. (2) Although both steroid and hyaluronate intra-articular injections can provide pain relief, most authors conclude that injection of hyaluronate is more effective. Follow-up is rather short with a maximum of 12 months in 1 study. Furthermore, study comparison is hampered by heterogeneity of study design and outcome parameters. (3) The use of orthoses reduces pain without effect on function, strength, or dexterity. Included studies used various types of orthoses. Follow-up times varied (2 wk–7 y). (4) There is no justification for the use of transdermal steroid delivery. (5) There is insufficient evidence justifying the use of leech therapy. (6) There are no high-level evidence studies specifically evaluating the effect of analgesics and patient education in joint protection in patients with thumb base OA.

      Conclusions

      There are only a few high-quality studies addressing the conservative treatment of trapeziometacarpal OA. Available evidence suggests only some effect of orthoses and intra-articular hyaluronate or steroid injections.

      Type of study/level of evidence

      Therapeutic II.

      Key words

      Osteoarthritis (OA) of the base of the thumb is a disabling disease, which affects up to 36% of postmenopausal women.
      • Dahaghin S.
      • Bierma-Zeinstra S.M.A.
      • Ginai A.Z.
      • Pols H.A.P.
      • Hazes J.M.W.
      • Koes B.W.
      Prevalence and pattern of radiographic hand osteoarthritis and association with pain and disability (the Rotterdam study).
      • Sonne-Holm S.
      • Jacobsen S.
      Osteoarthritis of the first carpometacarpal joint: a study of radiology and clinical epidemiology. Results from the Copenhagen Osteoarthritis Study.
      It has substantial effects on stability of the trapeziometacarpal (TMC) joint, causes pain, and reduces the capacity to perform daily activities.
      • Gillis J.
      • Calder K.
      • Williams J.
      Review of thumb carpometacarpal arthritis classification, treatment and outcomes.
      Thus far, there is no curative treatment for thumb base OA. Over the past decades, several surgical procedures for thumb base OA have been advocated. Although no procedure has been proven superior, surgical intervention can be effective.
      • Vermeulen G.M.
      • Slijper H.
      • Feitz R.
      • Hovius S.E.R.
      • Moojen T.M.
      • Selles R.W.
      Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review.
      However, operative interventions are more prone to complications, and therefore, conservative options should be considered first. It is unclear which conservative measures, if any, are most effective.
      The aim of conservative treatment is to restore thumb functionality, including pain relief, stability, mobility, and strength. Commonly used conservative measures are injections (cortisone, hyaluronate), analgesics, patient education in joint protection, strengthening exercises, assistive devices, and orthosis.
      • Poole J.U.
      • Pellegrini Jr., V.D.
      Arthritis of the thumb basal joint complex.
      • Egan M.Y.
      • Brousseau L.
      Splinting for osteoarthritis of the carpometacarpal joint: a review of the evidence.
      Only a few review papers on conservative treatment of thumb base OA have been published. Egan and Brousseau
      • Egan M.Y.
      • Brousseau L.
      Splinting for osteoarthritis of the carpometacarpal joint: a review of the evidence.
      concluded that patients should be given the opportunity to try an orthosis, despite little evidence to support the use of orthoses in thumb base OA for pain relief. Mejjad and Maheu
      • Mejjad O.
      • Maheu E.
      Therapeutic trials in hand osteoarthritis: a critical review.
      and Mahendira and Towheed
      • Mahendira D.
      • Towheed T.E.
      Systematic review of non-surgical therapies for osteoarthritis of the hand: an update.
      reviewed nonsurgical therapies for OA of the hand, but these studies were not limited to treatment of the base of the thumb.
      The aim of the present systematic review was to provide an overview of the efficacy of available conservative treatment methods for symptomatic thumb base OA, to provide treatment recommendations, and to give suggestions for future studies.

      Materials and Methods

      We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic literature search in the electronic bibliographic databases Medline (Pubmed) and Embase was performed up to May 2014 using the following key words: basal, first, carpometacarpal, CMC, trapeziometacarpal, TMC, thumb, osteoarthritis, rhizarthrosis, arthritic, nonsurgical, symptomatic, conservative, splint, splinting, NSAID, analgesics, drug, pain, medication, hylan, hyaluronic, hyaluronidate, corticosteroid, steroid, orthosis, orthoses, exercise, physiotherapeutic, physiotherapy, hand therapy, occupational therapy, physical therapy, viscosupplementation, injection, tramadol, ibuprofen, acetaminophen, and diacerein.
      Combined searches were conducted to identify relevant studies. Furthermore, references were checked for identification of additional relevant articles.
      Subsequently, the title and abstract of all records were screened. Studies were included if the following criteria were fulfilled:
      • Primary study written in English
      • Conservative treatment of thumb base OA
      • Randomized controlled trial (RCT), review or meta-analysis of RCTs

      Results

      Initially, 1,951 articles were retrieved (1,141 in Embase and 810 in Medline). After screening of title and abstract, 35 studies were selected. Eleven studies were excluded after reading the full text or because no full text was available (only abstract for presentation). One additional study was identified by checking references.

      Study inclusion

      Application of the inclusion criteria resulted in 25 included RCTs. These studies described the effects of hand therapy, intra-articular injections with hyaluronate or steroid, various orthoses, transdermal steroid delivery, and leech therapy.
      The great degree of heterogeneity of the included studies in terms of population, intervention, and outcome did not allow for statistical pooling. Therefore, conclusions were drawn based on the main findings only.

      Hand therapy

      The effect of hand therapy has been studied in 6 RCTs (Appendix A, available on the Journal’s Web site at www.jhandsurg.org). Four different types of physical therapy were compared with similar control groups in which patients were treated with ultrasound at nontherapeutic doses.
      Restoration of the glide component of joint movement to facilitate a full pain-free range of movement (Kaltenborn manual therapy) significantly decreased pain without increase in motor function in 1 study.
      • Villafañe J.H.
      • Silva G.B.
      • Diaz-Parreño S.A.
      • Fernandez-Carnero J.
      Hypoalgesic and motor effects of Kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      The authors concluded that joint mobilization may be effective in reducing pain.
      • Villafañe J.H.
      • Silva G.B.
      • Diaz-Parreño S.A.
      • Fernandez-Carnero J.
      Hypoalgesic and motor effects of Kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      A second RCT cautiously concluded that pressure pain threshold increased significantly after passive mobilization, without increase in motor function.
      • Villafañe J.H.
      • Silva G.B.
      • Fernandez-Carnero J.
      Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis.
      Secondary analysis also found limited hypoalgesic effects over the contralateral TMC joint.
      • Villafañe J.H.
      • Cleland J.A.
      • Fernandez-de-las-Peñas C.
      Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis.
      Hypoalgesia and increased pinch strength resulted from mobilization of the superficial cutaneous branch of the radial nerve.
      • Villafañe J.H.
      • Silva G.B.
      • Bishop M.D.
      • Fernandez-Carnero J.
      Radial nerve mobilization decreases pain sensitivity and improves motor performance in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      The same authors also found reduced pain in the contralateral limb, suggesting a hypothetical bilateral hypoalgesic effect of the intervention.
      • Villafañe J.H.
      • Bishop M.D.
      • Fernández-de-las-Peñas
      • Langford D.
      Radial nerve mobilisation had bilateral sensory effects in people with thumb carpometacarpal osteoarthritis: a randomised trial.
      In the last RCT patients received multimodal manual treatment consisting of Kaltenborn joint mobilization, neurodynamic techniques, and an exercise protocol.
      • Villafañe J.H.
      • Cleland J.A.
      • Fernández-de-las-Peñas C.
      The effectiveness of a manual therapy and exercise protocol in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      There was a significant reduction in pain intensity, without differences in strength or pressure pain thresholds. The authors concluded that a multimodal treatment approach is more beneficial in treating pain than a placebo intervention.
      Overall, based on the present literature, hand therapy seems to provide some pain reduction in patients with symptomatic TMC OA. However, level of evidence was low based on only a few published RCTs with a short follow-up time and a relatively aged population.
      • Villafañe J.H.
      • Silva G.B.
      • Diaz-Parreño S.A.
      • Fernandez-Carnero J.
      Hypoalgesic and motor effects of Kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      • Villafañe J.H.
      • Silva G.B.
      • Fernandez-Carnero J.
      Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis.
      • Villafañe J.H.
      • Cleland J.A.
      • Fernandez-de-las-Peñas C.
      Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis.
      • Villafañe J.H.
      • Silva G.B.
      • Bishop M.D.
      • Fernandez-Carnero J.
      Radial nerve mobilization decreases pain sensitivity and improves motor performance in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      • Villafañe J.H.
      • Bishop M.D.
      • Fernández-de-las-Peñas
      • Langford D.
      Radial nerve mobilisation had bilateral sensory effects in people with thumb carpometacarpal osteoarthritis: a randomised trial.
      • Villafañe J.H.
      • Cleland J.A.
      • Fernández-de-las-Peñas C.
      The effectiveness of a manual therapy and exercise protocol in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.

      Intra-articular injections

      Intra-articular corticosteroid injections are thought to decrease pain and inflammation in OA.
      • Patel T.J.
      • Beredjiklian B.K.
      • Matzon J.L.
      Trapeziometacarpal joint arthritis.
      Alternatively, hyaluronate can be injected with the aim of restoring the reduced viscoelasticity of synovial fluids in osteoarthritic joints.
      • Fam H.
      • Bryant J.T.
      • Kontopoulou M.
      Rheological properties of synovial fluids.
      • Peyron J.G.
      A new approach to the treatment of osteoarthritis: viscosupplementation.
      Seven RCTs studied the effect of intra-articular injections (Appendix B, available on the Journal’s Web site at www.jhandsurg.org).
      Meenagh et al
      • Meenagh G.K.
      • Patton J.
      • Kynes C.
      • Wright G.D.
      A randomised controlled trial of intra-articular corticosteroid injection of the carpometacarpal joint of the thumb in osteoarthritis.
      concluded that there was no clinical difference between intra-articular steroid injections compared with placebo injections.
      Figen Ayhan and Üstün
      • Figen Ayhan F.
      • Üstün N.
      The evaluation of efficacy and tolerability of Hylan G-F 20 in bilateral thumb base osteoarthritis: 6 months follow-up.
      compared the effect of intra-articular hyaluronate injections with saline injections and found significant improvements in hand function, pinch strength, and visual analog scale score for pain at the end of the follow-up time of 24 weeks in the hyaluronate group.
      Roux et al
      • Roux C.
      • Fontas E.
      • Breuil V.
      • Brocq O.
      • Albert C.
      • Euller-Ziegler L.
      Injection of intra-articular sodium hyaluronidate (Sinovial) into the carpometacarpal joint of the thumb (CMC1) in osteoarthritis. A prospective evaluation of efficacy.
      studied 3 groups in which patients received 1, 2, or 3 hyaluronate injections. They found no statistically significant differences between the groups regarding pain and function. After 3 months, patients in all groups improved; however, a placebo effect could not be excluded.
      Three RCTs have compared intra-articular steroid with hyaluronate injections.
      • Bahadir C.
      • Onal B.
      • Dayan V.Y.
      • Gürer N.
      Comparison of therapeutic effects of sodium hyaluronate and corticosteroid injections on trapeziometacarpal joint osteoarthritis.
      • Fuchs S.
      • Mönikes R.
      • Wohlmeiner A.
      • Heyse T.
      Intra-articular hyaluronic acid compared with corticoid injections for the treatment of rhizarthrosis.
      • Stahl S.
      • Karsh-Zafrir I.
      • Ratzon N.
      • Rosenberg N.
      Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints.
      Bahadir et al
      • Bahadir C.
      • Onal B.
      • Dayan V.Y.
      • Gürer N.
      Comparison of therapeutic effects of sodium hyaluronate and corticosteroid injections on trapeziometacarpal joint osteoarthritis.
      showed that pain decreased significantly for a period of 12 months in the steroid group and for 6 months in the hyaluronate group. The authors suggested that, based on significant improvement in hand function in the steroid group, steroid injections were more effective in the improvement of pain and hand function.
      Studies of Fuchs et al
      • Fuchs S.
      • Mönikes R.
      • Wohlmeiner A.
      • Heyse T.
      Intra-articular hyaluronic acid compared with corticoid injections for the treatment of rhizarthrosis.
      and Stahl et al
      • Stahl S.
      • Karsh-Zafrir I.
      • Ratzon N.
      • Rosenberg N.
      Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints.
      showed that both injections were effective in relieving pain and improving joint function. However, both groups of authors suggested that intra-articular hyaluronate injections seemed to be the better alternative because of a superior long-lasting effect of at least 6 months.
      Heyworth et al
      • Heyworth B.E.
      • Lee J.H.
      • Kim P.D.
      • Lipton C.B.
      • Strauch R.J.
      • Rosenwasser M.P.
      Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective, randomized, double-blinded clinical trial.
      also suggested hyaluronate injections. They compared steroid, hyaluronate, and placebo injections and found that all patients had decreased pain, which persisted in the hyaluronate group during the entire follow-up period of 26 weeks. The placebo and steroid groups experienced less pain for only 4 weeks.
      Overall, we concluded there is some evidence for pain relief by both steroid and hyaluronate intra-articular injections in patients with TMC OA.
      • Figen Ayhan F.
      • Üstün N.
      The evaluation of efficacy and tolerability of Hylan G-F 20 in bilateral thumb base osteoarthritis: 6 months follow-up.
      • Roux C.
      • Fontas E.
      • Breuil V.
      • Brocq O.
      • Albert C.
      • Euller-Ziegler L.
      Injection of intra-articular sodium hyaluronidate (Sinovial) into the carpometacarpal joint of the thumb (CMC1) in osteoarthritis. A prospective evaluation of efficacy.
      • Bahadir C.
      • Onal B.
      • Dayan V.Y.
      • Gürer N.
      Comparison of therapeutic effects of sodium hyaluronate and corticosteroid injections on trapeziometacarpal joint osteoarthritis.
      • Fuchs S.
      • Mönikes R.
      • Wohlmeiner A.
      • Heyse T.
      Intra-articular hyaluronic acid compared with corticoid injections for the treatment of rhizarthrosis.
      • Stahl S.
      • Karsh-Zafrir I.
      • Ratzon N.
      • Rosenberg N.
      Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints.
      • Heyworth B.E.
      • Lee J.H.
      • Kim P.D.
      • Lipton C.B.
      • Strauch R.J.
      • Rosenwasser M.P.
      Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective, randomized, double-blinded clinical trial.
      Most authors found injection of hyaluronate more effective with a superior long-lasting effect.
      • Figen Ayhan F.
      • Üstün N.
      The evaluation of efficacy and tolerability of Hylan G-F 20 in bilateral thumb base osteoarthritis: 6 months follow-up.
      • Roux C.
      • Fontas E.
      • Breuil V.
      • Brocq O.
      • Albert C.
      • Euller-Ziegler L.
      Injection of intra-articular sodium hyaluronidate (Sinovial) into the carpometacarpal joint of the thumb (CMC1) in osteoarthritis. A prospective evaluation of efficacy.
      • Fuchs S.
      • Mönikes R.
      • Wohlmeiner A.
      • Heyse T.
      Intra-articular hyaluronic acid compared with corticoid injections for the treatment of rhizarthrosis.
      • Stahl S.
      • Karsh-Zafrir I.
      • Ratzon N.
      • Rosenberg N.
      Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints.
      • Heyworth B.E.
      • Lee J.H.
      • Kim P.D.
      • Lipton C.B.
      • Strauch R.J.
      • Rosenwasser M.P.
      Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective, randomized, double-blinded clinical trial.

      Orthoses

      Ten RCTs studied the effect of orthoses in patients with symptomatic TMC OA (Appendix C, available on the Journal’s Web site at www.jhandsurg.org).
      Gomes Carreira et al
      • Gomes Carreira A.C.
      • Jones A.
      • Natour J.
      Assessment of the effectiveness of a functional splint for osteoarthritis of the trapeziometacarpal joint of the dominant hand: a randomized controlled study.
      and Rannou et al
      • Rannou F.
      • Dimet J.
      • Boutron I.
      • et al.
      Splint for base-of-thumb osteoarthritis: a randomized trial.
      compared the use of orthoses with control groups. Both concluded that the use of an orthosis reduced pain but did not change functional capacity, grip, or pinch strength.
      Six RCTs compared the effect of various orthoses. The difference between prefabricated and custom-made orthoses was studied by Sillem et al
      • Sillem H.
      • Bockman C.L.
      • Miller W.C.
      • Li L.C.
      Comparison of two carpometacarpal stabilizing splints for individuals with thumb osteoarthritis.
      and Bani et al.
      • Bani M.A.
      • Arazpour M.
      • Kashani R.V.
      • Mousavi M.E.
      • Hutchins S.W.
      Comparison of custom-made and prefabricated neoprene splinting in patients with the first carpometacarpal joint osteoarthritis.
      The second study included a control group. Pain improved after use of both orthoses; however, the custom-made orthosis gave significantly more pain reduction in both studies. Bani et al
      • Bani M.A.
      • Arazpour M.
      • Kashani R.V.
      • Mousavi M.E.
      • Hutchins S.W.
      Comparison of custom-made and prefabricated neoprene splinting in patients with the first carpometacarpal joint osteoarthritis.
      also found improvements in pinch strength and Disabilities of the Arm, Shoulder, and Hand (DASH) score in the orthosis groups. Sixty-three percent of patients preferred the prefabricated orthosis.
      • Sillem H.
      • Bockman C.L.
      • Miller W.C.
      • Li L.C.
      Comparison of two carpometacarpal stabilizing splints for individuals with thumb osteoarthritis.
      The authors concluded that both types of orthoses had therapeutic effects.
      Weiss et al
      • Weiss S.
      • LaStayo P.
      • Mills A.
      • Bramlet D.
      Prospective analysis of splinting the first carpometacarpal joint: an objective, subjective, and radiographic assessment.
      compared the use of short and long prefabricated opponens orthoses. Significant pain reduction was observed in both groups. The short orthosis was preferred by 73% (19 out of 26) of the patients. The authors also studied the difference between long prefabricated orthoses and short custom-made orthoses. Both types significantly reduced pain, but the prefabricated orthosis gave more pain reduction and was preferred by most patients (72%). The authors concluded that these studies supported current evidence that, in early stages of OA, pain relief can be obtained with use of an orthosis.
      • Weiss S.
      • LaStayo P.
      • Mills A.
      • Bramlet D.
      Splinting the degenerative basal joint: Custom-made or prefabricated neoprene?.
      In an RCT by Buurke et al,
      • Buurke J.H.
      • Grady J.H.
      • Vries J de
      • Baten C.T.M.
      Usability of thenar eminence orthoses: report of a comparative study.
      in which the effect of 3 different orthoses was studied, no significant differences in pain scores between the orthoses could be demonstrated. A flexible elastic orthosis, made of soft material, scored significantly better on comfort and function than the more rigid types. Eight out of 10 patients preferred use of an orthosis for the entire day. Of these 8 patients, 6 preferred a flexible elastic orthosis and 2 patients preferred a semirigid orthosis.
      Wajon and Ada
      • Wajon A.
      • Ada L.
      No difference between two splint and exercise regimens for people with osteoarthritis of the thumb: A randomised controlled trial.
      randomized patients to compare the efficacy of a thumb strap orthosis and abduction exercises on one hand with a short opponens orthosis and pinch exercises on the other. Both groups showed reduced pain and increased strength and hand function after 6 weeks. No differences were found between the 2 groups. The authors suggested that patients could expect an improvement in pain, strength, and hand function within 6 weeks of conservative interventions, regardless of mechanism.
      Hermann et al
      • Hermann M.
      • Nilsen T.
      • Eriksen C.S.
      • Slatkowsky-Christensen B.
      • Kristin Haugen I.
      • Kjeken I.
      Effects of a soft prefabricated thumb orthosis in carpometacarpal osteoarthritis.
      compared the effect of a prefabricated soft orthosis and hand exercises with hand exercises only. After 2 months, they concluded that a soft orthosis had an immediate pain-relieving effect when worn, but no general effect when not worn.
      Berggren et al
      • Berggren M.
      • Joost-Davidsson A.
      • Lindstrand J.
      • Nylander G.
      • Povlsen B.
      Reduction for the need for operation after conservative treatment of osteoarthritis of the first carpometacarpal joint: a seven-year prospective study.
      randomly assigned 33 patients with isolated TMC OA waiting for joint replacement arthroplasty to 3 treatment groups: technical accessories (special developed occupational therapy devices, like a pen handle), technical accessories and a semistable orthosis or technical accessories, and a nonstabilizing orthosis. All patients received advice on how to accommodate activities of daily living. After 7 months, 70% of patients no longer required an operation. During the following 7 years, only 10% of the remaining patients still requested surgery. No differences between the groups were found. The authors recommended that patients with TMC OA should first be treated with technical accessories for 6 months and eventually with an orthosis before deciding to perform an operation.
      Overall, some evidence suggested that orthoses can reduce pain in patients with TMC joint OA but do not alter function, strength, or dexterity.
      • Gomes Carreira A.C.
      • Jones A.
      • Natour J.
      Assessment of the effectiveness of a functional splint for osteoarthritis of the trapeziometacarpal joint of the dominant hand: a randomized controlled study.
      • Rannou F.
      • Dimet J.
      • Boutron I.
      • et al.
      Splint for base-of-thumb osteoarthritis: a randomized trial.
      • Sillem H.
      • Bockman C.L.
      • Miller W.C.
      • Li L.C.
      Comparison of two carpometacarpal stabilizing splints for individuals with thumb osteoarthritis.
      • Bani M.A.
      • Arazpour M.
      • Kashani R.V.
      • Mousavi M.E.
      • Hutchins S.W.
      Comparison of custom-made and prefabricated neoprene splinting in patients with the first carpometacarpal joint osteoarthritis.
      • Weiss S.
      • LaStayo P.
      • Mills A.
      • Bramlet D.
      Prospective analysis of splinting the first carpometacarpal joint: an objective, subjective, and radiographic assessment.
      • Weiss S.
      • LaStayo P.
      • Mills A.
      • Bramlet D.
      Splinting the degenerative basal joint: Custom-made or prefabricated neoprene?.
      • Buurke J.H.
      • Grady J.H.
      • Vries J de
      • Baten C.T.M.
      Usability of thenar eminence orthoses: report of a comparative study.
      • Hermann M.
      • Nilsen T.
      • Eriksen C.S.
      • Slatkowsky-Christensen B.
      • Kristin Haugen I.
      • Kjeken I.
      Effects of a soft prefabricated thumb orthosis in carpometacarpal osteoarthritis.
      • Berggren M.
      • Joost-Davidsson A.
      • Lindstrand J.
      • Nylander G.
      • Povlsen B.
      Reduction for the need for operation after conservative treatment of osteoarthritis of the first carpometacarpal joint: a seven-year prospective study.

      Other conservative interventions

      Jain et al
      • Jain R.
      • Jain E.
      • Dass A.G.
      • Wickstrom O.
      • Walter N.
      • Atkinson P.J.
      Evaluation of transdermal steroids for trapeziometacarpal arthritis.
      randomized patients to receive either transdermal steroid or placebo delivery by iontophoresis or phonophoresis (Appendix D, available on the Journal’s Web site at www.jhandsurg.org). No differences were found among the 4 groups regarding pain, strength, or well-being. The authors concluded that transdermal steroid delivery was not helpful in providing relief of symptomatic TMC OA.
      Michalsen et al
      • Michalsen A.
      • Lüdtke R.
      • Cesur Ö
      • et al.
      Effectiveness of leech therapy in women with symptomatic arthrosis of the first carpometacarpal joint: a randomized controlled trial.
      studied the effectiveness of leech therapy (Appendix D, available on the Journal’s Web site at www.jhandsurg.org). Female patients were randomized to a single treatment with locally applied leeches or a 30-day course with topical diclofenac twice a day. Patients in the leech therapy group experienced significantly less pain, better DASH scores, quality of life, and grip strength during the study period of 2 months. The authors concluded that a single course of leech therapy was effective in relieving pain and improving joint function. However, because the sample size was small and the intervention not blinded, they found the results of their study preliminary.

      Discussion

      The aim of this systematic review was to provide an overview of the efficacy of reported conservative measures in the treatment of symptomatic TMC OA to provide treatment recommendations and to give suggestions for future studies. To ensure quality of evidence in present literature, only RCTs were included in this review.
      We could not find RCTs on the effects of analgesics or patient education for TMC OA specifically.
      Based on present evidence, hand therapy can reduce pain according to Villafañe et al.
      • Villafañe J.H.
      • Silva G.B.
      • Diaz-Parreño S.A.
      • Fernandez-Carnero J.
      Hypoalgesic and motor effects of Kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      • Villafañe J.H.
      • Silva G.B.
      • Fernandez-Carnero J.
      Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis.
      • Villafañe J.H.
      • Cleland J.A.
      • Fernandez-de-las-Peñas C.
      Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis.
      • Villafañe J.H.
      • Silva G.B.
      • Bishop M.D.
      • Fernandez-Carnero J.
      Radial nerve mobilization decreases pain sensitivity and improves motor performance in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      • Villafañe J.H.
      • Bishop M.D.
      • Fernández-de-las-Peñas
      • Langford D.
      Radial nerve mobilisation had bilateral sensory effects in people with thumb carpometacarpal osteoarthritis: a randomised trial.
      • Villafañe J.H.
      • Cleland J.A.
      • Fernández-de-las-Peñas C.
      The effectiveness of a manual therapy and exercise protocol in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      However, follow-up time was short (2 wk up to 2 mo), the population relatively aged (70–90 y), and all patients had severe grades of OA. Different forms of hand therapy were studied, making comparison of outcomes impossible.
      • Villafañe J.H.
      • Silva G.B.
      • Diaz-Parreño S.A.
      • Fernandez-Carnero J.
      Hypoalgesic and motor effects of Kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      • Villafañe J.H.
      • Silva G.B.
      • Fernandez-Carnero J.
      Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis.
      • Villafañe J.H.
      • Cleland J.A.
      • Fernandez-de-las-Peñas C.
      Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis.
      • Villafañe J.H.
      • Silva G.B.
      • Bishop M.D.
      • Fernandez-Carnero J.
      Radial nerve mobilization decreases pain sensitivity and improves motor performance in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      • Villafañe J.H.
      • Bishop M.D.
      • Fernández-de-las-Peñas
      • Langford D.
      Radial nerve mobilisation had bilateral sensory effects in people with thumb carpometacarpal osteoarthritis: a randomised trial.
      • Villafañe J.H.
      • Cleland J.A.
      • Fernández-de-las-Peñas C.
      The effectiveness of a manual therapy and exercise protocol in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      The efficacy of hand therapy should be studied with longer follow-up in a more varied population with different grades of OA. In addition, future studies should focus on different hand therapy interventions.
      Another treatment option that warrants more study is a specific exercise program. Valdes and von der Heyde
      • Valdes K.
      • von der Heyde R.
      An exercise program for carpometacarpal osteoarthritis based on biomechanical principles.
      provided specific recommendations for the development of a hand exercise program based on a biomechanical analysis. RCTs are needed to further investigate this subject.
      There is some evidence that both steroid and hyaluronate intra-articular injections can reduce pain in patients with thumb base OA.
      • Figen Ayhan F.
      • Üstün N.
      The evaluation of efficacy and tolerability of Hylan G-F 20 in bilateral thumb base osteoarthritis: 6 months follow-up.
      • Roux C.
      • Fontas E.
      • Breuil V.
      • Brocq O.
      • Albert C.
      • Euller-Ziegler L.
      Injection of intra-articular sodium hyaluronidate (Sinovial) into the carpometacarpal joint of the thumb (CMC1) in osteoarthritis. A prospective evaluation of efficacy.
      • Bahadir C.
      • Onal B.
      • Dayan V.Y.
      • Gürer N.
      Comparison of therapeutic effects of sodium hyaluronate and corticosteroid injections on trapeziometacarpal joint osteoarthritis.
      • Fuchs S.
      • Mönikes R.
      • Wohlmeiner A.
      • Heyse T.
      Intra-articular hyaluronic acid compared with corticoid injections for the treatment of rhizarthrosis.
      • Stahl S.
      • Karsh-Zafrir I.
      • Ratzon N.
      • Rosenberg N.
      Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints.
      • Heyworth B.E.
      • Lee J.H.
      • Kim P.D.
      • Lipton C.B.
      • Strauch R.J.
      • Rosenwasser M.P.
      Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective, randomized, double-blinded clinical trial.
      However, most authors concluded that injection of hyaluronate was more effective.
      • Figen Ayhan F.
      • Üstün N.
      The evaluation of efficacy and tolerability of Hylan G-F 20 in bilateral thumb base osteoarthritis: 6 months follow-up.
      • Roux C.
      • Fontas E.
      • Breuil V.
      • Brocq O.
      • Albert C.
      • Euller-Ziegler L.
      Injection of intra-articular sodium hyaluronidate (Sinovial) into the carpometacarpal joint of the thumb (CMC1) in osteoarthritis. A prospective evaluation of efficacy.
      • Fuchs S.
      • Mönikes R.
      • Wohlmeiner A.
      • Heyse T.
      Intra-articular hyaluronic acid compared with corticoid injections for the treatment of rhizarthrosis.
      • Stahl S.
      • Karsh-Zafrir I.
      • Ratzon N.
      • Rosenberg N.
      Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints.
      • Heyworth B.E.
      • Lee J.H.
      • Kim P.D.
      • Lipton C.B.
      • Strauch R.J.
      • Rosenwasser M.P.
      Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective, randomized, double-blinded clinical trial.
      Based on present literature, we concluded that the effect of steroids is achieved faster, but is short lived, compared with hyaluronate, which seemed to have a longer-lasting effect but starts more slowly.
      • Fuchs S.
      • Mönikes R.
      • Wohlmeiner A.
      • Heyse T.
      Intra-articular hyaluronic acid compared with corticoid injections for the treatment of rhizarthrosis.
      • Stahl S.
      • Karsh-Zafrir I.
      • Ratzon N.
      • Rosenberg N.
      Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints.
      Limitations of the included studies were the great variety in type of medication, the number of injections, and the amount of medication injected. Therefore, the studies were difficult to compare. Also, follow-up time was short (with a maximum of 12 mo in 1 study).
      • Bahadir C.
      • Onal B.
      • Dayan V.Y.
      • Gürer N.
      Comparison of therapeutic effects of sodium hyaluronate and corticosteroid injections on trapeziometacarpal joint osteoarthritis.
      Studies suggested that hyaluronate injections in knee joints were less effective in the more advanced stages of knee OA.
      • Bellamy N.
      • Campbell J.
      • Robinson V.
      • Gee T.
      • Bourne R.
      • Wells G.
      Intra-articular corticosteroid for treatment of osteoarthritis of the knee.
      • Wang C.T.
      • Lin J.
      • Chang C.J.
      • Lin Y.T.
      • Hou S.M.
      Therapeutic effects of hyaluronic acid on osteoarthritis of knee. A meta-analysis of randomized controlled trials.
      However, this conclusion could not be made for TMC joints based on studies included in this review. Included studies used three different radiographic classification systems.
      • Eaton R.G.
      • Littler J.W.
      A study of the basal joint of the thumb. Treatment of its disabilities by fusion.
      • Eaton R.G.
      • Glickel S.Z.
      Trapeziometacarpal osteoarthritis. Staging as a rationale for treatment.
      • Kellgren J.H.
      • Lawrence J.S.
      Radiological assessment of osteo-arthrosis.
      Also, Heyworth et al
      • Heyworth B.E.
      • Lee J.H.
      • Kim P.D.
      • Lipton C.B.
      • Strauch R.J.
      • Rosenwasser M.P.
      Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective, randomized, double-blinded clinical trial.
      did not mention the radiographic stage, and Meenagh et al
      • Meenagh G.K.
      • Patton J.
      • Kynes C.
      • Wright G.D.
      A randomised controlled trial of intra-articular corticosteroid injection of the carpometacarpal joint of the thumb in osteoarthritis.
      reported the radiographic stage but did not describe which classification system was used. Most studies have considerable dispersion in their study groups, not allowing for subgroup analyses. For evidence-based conclusions, high-evidence studies are needed with more patients, evaluating the effect of both intra-articular injections compared with placebo and with a follow-up of at least 1 year. Furthermore, to conclude which specific type, dose, and frequency of hyaluronate or steroid is most effective, more studies are needed.
      Present evidence suggests that orthoses can give some pain reduction in patients with TMC OA up to 1 year but do not influence hand function or strength. Seven RCTs did not include patients with concomitant scaphotrapeziotrapeziod OA.
      • Gomes Carreira A.C.
      • Jones A.
      • Natour J.
      Assessment of the effectiveness of a functional splint for osteoarthritis of the trapeziometacarpal joint of the dominant hand: a randomized controlled study.
      • Bani M.A.
      • Arazpour M.
      • Kashani R.V.
      • Mousavi M.E.
      • Hutchins S.W.
      Comparison of custom-made and prefabricated neoprene splinting in patients with the first carpometacarpal joint osteoarthritis.
      • Weiss S.
      • LaStayo P.
      • Mills A.
      • Bramlet D.
      Prospective analysis of splinting the first carpometacarpal joint: an objective, subjective, and radiographic assessment.
      • Weiss S.
      • LaStayo P.
      • Mills A.
      • Bramlet D.
      Splinting the degenerative basal joint: Custom-made or prefabricated neoprene?.
      • Wajon A.
      • Ada L.
      No difference between two splint and exercise regimens for people with osteoarthritis of the thumb: A randomised controlled trial.
      • Hermann M.
      • Nilsen T.
      • Eriksen C.S.
      • Slatkowsky-Christensen B.
      • Kristin Haugen I.
      • Kjeken I.
      Effects of a soft prefabricated thumb orthosis in carpometacarpal osteoarthritis.
      • Berggren M.
      • Joost-Davidsson A.
      • Lindstrand J.
      • Nylander G.
      • Povlsen B.
      Reduction for the need for operation after conservative treatment of osteoarthritis of the first carpometacarpal joint: a seven-year prospective study.
      The other 3 studies did not mention the stage of OA.
      • Rannou F.
      • Dimet J.
      • Boutron I.
      • et al.
      Splint for base-of-thumb osteoarthritis: a randomized trial.
      • Sillem H.
      • Bockman C.L.
      • Miller W.C.
      • Li L.C.
      Comparison of two carpometacarpal stabilizing splints for individuals with thumb osteoarthritis.
      • Buurke J.H.
      • Grady J.H.
      • Vries J de
      • Baten C.T.M.
      Usability of thenar eminence orthoses: report of a comparative study.
      Therefore, no conclusions can be drawn about the effect of orthoses in patients with OA of both the TMC and the scaphotrapeziotrapezoid joints.
      In addition, varied degrees of OA, different length, make, and material of orthoses worn under different circumstances and for varied time periods made comparison impossible. Follow-up times ranged from 2 weeks to 7 years.
      • Berggren M.
      • Joost-Davidsson A.
      • Lindstrand J.
      • Nylander G.
      • Povlsen B.
      Reduction for the need for operation after conservative treatment of osteoarthritis of the first carpometacarpal joint: a seven-year prospective study.
      Nevertheless, findings in the included studies indicated that orthoses decreased pain in patients with TMC OA. There was no strong evidence that a custom-made orthosis was superior to a prefabricated orthosis, that length of one orthosis was superior to another, or that a patient should constantly wear the orthosis.
      • Gomes Carreira A.C.
      • Jones A.
      • Natour J.
      Assessment of the effectiveness of a functional splint for osteoarthritis of the trapeziometacarpal joint of the dominant hand: a randomized controlled study.
      • Rannou F.
      • Dimet J.
      • Boutron I.
      • et al.
      Splint for base-of-thumb osteoarthritis: a randomized trial.
      • Sillem H.
      • Bockman C.L.
      • Miller W.C.
      • Li L.C.
      Comparison of two carpometacarpal stabilizing splints for individuals with thumb osteoarthritis.
      • Bani M.A.
      • Arazpour M.
      • Kashani R.V.
      • Mousavi M.E.
      • Hutchins S.W.
      Comparison of custom-made and prefabricated neoprene splinting in patients with the first carpometacarpal joint osteoarthritis.
      • Weiss S.
      • LaStayo P.
      • Mills A.
      • Bramlet D.
      Prospective analysis of splinting the first carpometacarpal joint: an objective, subjective, and radiographic assessment.
      • Weiss S.
      • LaStayo P.
      • Mills A.
      • Bramlet D.
      Splinting the degenerative basal joint: Custom-made or prefabricated neoprene?.
      • Buurke J.H.
      • Grady J.H.
      • Vries J de
      • Baten C.T.M.
      Usability of thenar eminence orthoses: report of a comparative study.
      • Wajon A.
      • Ada L.
      No difference between two splint and exercise regimens for people with osteoarthritis of the thumb: A randomised controlled trial.
      The results of the study of Berggren et al
      • Berggren M.
      • Joost-Davidsson A.
      • Lindstrand J.
      • Nylander G.
      • Povlsen B.
      Reduction for the need for operation after conservative treatment of osteoarthritis of the first carpometacarpal joint: a seven-year prospective study.
      seem promising. The majority of their patients did not require an operation after conservative management. Therefore, we recommend repeating this study with a larger number of patients.
      Ideally, future studies should have a follow-up period of at least 1 year; should focus on prefabricated orthoses immobilizing only the TMC joint; and should assess the effect of using the orthosis at night, during activities of daily living, or both. The effect of additionally immobilizing the first metacarpophalangeal joint is also of interest.
      Transdermal steroid delivery is not effective.
      • Jain R.
      • Jain E.
      • Dass A.G.
      • Wickstrom O.
      • Walter N.
      • Atkinson P.J.
      Evaluation of transdermal steroids for trapeziometacarpal arthritis.
      Because there are other conservative treatment options with better outcomes, there seems to be no need for more research on this subject.
      Leech therapy can reduce pain.
      • Michalsen A.
      • Lüdtke R.
      • Cesur Ö
      • et al.
      Effectiveness of leech therapy in women with symptomatic arthrosis of the first carpometacarpal joint: a randomized controlled trial.
      However, sample size in this single study was small, and the intervention was not blinded. The potential mechanism of action should be further clarified before consideration of further clinical investigations.
      The varied results in the described studies could be explained by the fact that TMC OA is a chronic disease with exacerbations and remissions. Any intervention when patients are most symptomatic will often result in perceived improvement. However, the same improvement could occur with mere observation and education. This certainly reinforces the idea that conservative treatment or just observation is warranted for a considerable period of time before deciding to perform an operation, as done by Berggren et al.
      • Berggren M.
      • Joost-Davidsson A.
      • Lindstrand J.
      • Nylander G.
      • Povlsen B.
      Reduction for the need for operation after conservative treatment of osteoarthritis of the first carpometacarpal joint: a seven-year prospective study.
      Although nonsurgical measures like hyaluronate injections are not necessarily inexpensive, the question should be raised whether these conservative measures have any value over mere observation or counselling of the patient. Poole and Pellegrini
      • Poole J.U.
      • Pellegrini Jr., V.D.
      Arthritis of the thumb basal joint complex.
      described patient education in joint protection as the most valuable therapeutic intervention. It seems important for patients to understand why symptoms exist and how functional use patterns contribute to problems. Although of great interest, no RCTs on this subject have been published.
      There is a need for higher-quality RCTs investigating the different conservative treatment modalities for TMC OA. Because TMC OA is one of the most commonly seen hand surgery diagnoses, the implementation of much larger studies should be a realistic and achievable research goal. Ideally, future studies should include more patients, have longer follow-up times, and subgroup analyses regarding grade of OA and should include pain scores, strength measurements, and patient-reported outcome measures. Focus on oral analgesics, patient education, and comparison between modalities are of main interest for future studies in the context of present available data.

      Appendix

      Appendix APhysical Therapy Interventions
      AuthorsGrade of OASample SizeTreatmentDosageFollow-UpAuthors' Conclusions
      Villafañe et al, 2013
      • Villafañe J.H.
      • Cleland J.A.
      • Fernández-de-las-Peñas C.
      The effectiveness of a manual therapy and exercise protocol in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      Eaton-Littler III–IV30

      30
      Multimodal manual treatment approach: Kaltenborn joint mobilization, neurodynamic techniques, exercise protocol

      Control (ultrasound at nontherapeutic doses)
      12 sessions in 4 wk3 moSignificant improvement in pain, no difference in pressure pain threshold, grip strength, or pinch strength.

      Patients 65–90 y (mean, 82 y)
      Villafañe et al, 2012,
      • Villafañe J.H.
      • Silva G.B.
      • Fernandez-Carnero J.
      Effect of thumb joint mobilization on pressure pain threshold in elderly patients with thumb carpometacarpal osteoarthritis.
      and Villafañe et al, 2013
      • Villafañe J.H.
      • Cleland J.A.
      • Fernandez-de-las-Peñas C.
      Bilateral sensory effects of unilateral passive accessory mobilization in patients with thumb carpometacarpal osteoarthritis.
      Eaton-Littler III–IV14

      14
      Maitland's passive accessory mobilization

      Control (ultrasound at nontherapeutic doses)
      4 sessions in 2 wk2 wkPassive accessory mobilization increases pressure pain threshold, but does not increase pinch or grip strength.

      Limited hypoalgesic effects over the contralateral TMC joint

      Patients 70–90 y
      Villafañe et al, 2012,
      • Villafañe J.H.
      • Silva G.B.
      • Bishop M.D.
      • Fernandez-Carnero J.
      Radial nerve mobilization decreases pain sensitivity and improves motor performance in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      and Villafañe et al, 2013
      • Villafañe J.H.
      • Bishop M.D.
      • Fernández-de-las-Peñas
      • Langford D.
      Radial nerve mobilisation had bilateral sensory effects in people with thumb carpometacarpal osteoarthritis: a randomised trial.
      Eaton-Littler III–IV30

      30
      Radial nerve mobilization

      Control (ultrasound at nontherapeutic doses)
      6 sessions in 4 wk2 moRadial nerve mobilization decreases pain sensitivity and increases tip pinch strength

      It also induced hypoalgesic effects on the contralateral hand, suggesting bilateral hypoalgesic effects of the intervention

      Patients 70–90 y
      Villafañe et al, 2011
      • Villafañe J.H.
      • Silva G.B.
      • Diaz-Parreño S.A.
      • Fernandez-Carnero J.
      Hypoalgesic and motor effects of Kaltenborn mobilization on elderly patients with secondary thumb carpometacarpal osteoarthritis: a randomized controlled trial.
      Eaton-Littler III–IV14

      15
      Kaltenborn mobilization

      Control (ultrasound at nontherapeutic doses)
      6 sessions in 2 wk2 wkKaltenborn manual therapy decreased pain; however, it did not confer an increase in motor function

      Patients 70–90 y
      Appendix BIntra-Articular Hyaluronic Acid and Corticosteroid Injections
      AuthorsGrade of OASample Size
      Numbers in parentheses indicate the number of patients who completed the follow-up measurements.
      TreatmentDosageFollow-UpAuthors' Conclusions
      Figen Ayhan and Üstün, 2009
      • Figen Ayhan F.
      • Üstün N.
      The evaluation of efficacy and tolerability of Hylan G-F 20 in bilateral thumb base osteoarthritis: 6 months follow-up.
      Eaton-Glickel I–IV33 with bilateral TMC OAHyaluronic acid (Hylan G-F 20)

      Control group (saline)
      1 injection of 1 mL

      1 injection of 1 mL
      24 wkSignificant improvements in function, pinch strength, and VAS for pain in the hyaluronic acid group

      Only VAS for pain scores temporarily decreased in the control group at the sixth week
      Bahadir et al, 2009
      • Bahadir C.
      • Onal B.
      • Dayan V.Y.
      • Gürer N.
      Comparison of therapeutic effects of sodium hyaluronate and corticosteroid injections on trapeziometacarpal joint osteoarthritis.
      Eaton-Littler II–III20

      20
      Sodium hyaluronate (Ostenil)

      Triamcinolone acetonide (Kenacort-A)
      3 injections (weekly) of 5 mg/0.5 mL

      1 injection of 20 mg/0.5 mL
      12 moBoth injections are effective in reducing pain and improving grip strength

      Corticosteroid injections provide more effective and longer-lasting pain relief
      Heyworth et al, 2008
      • Heyworth B.E.
      • Lee J.H.
      • Kim P.D.
      • Lipton C.B.
      • Strauch R.J.
      • Rosenwasser M.P.
      Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective, randomized, double-blinded clinical trial.
      NA20

      22

      18
      Hyaluronic acid (Hylan G-F 20)

      Corticosteroid (betamethasone acetate)

      Control group
      2 injections (weekly) of 1 mL

      First wk, 1 mL saline; second wk, 1 mL betamethasone acetate

      2 injections saline 1 mL
      26 wk

      Also 2 weeks neoprene thumb splint for all patients
      No significant differences among the 3 groups

      Based on the durable relief of pain, improved grip strength, and the long-term improvement in symptoms compared with preinjection values, Hylan injections should be considered
      Roux et al, 2007
      • Roux C.
      • Fontas E.
      • Breuil V.
      • Brocq O.
      • Albert C.
      • Euller-Ziegler L.
      Injection of intra-articular sodium hyaluronidate (Sinovial) into the carpometacarpal joint of the thumb (CMC1) in osteoarthritis. A prospective evaluation of efficacy.
      Kellgren II–IV14

      14

      14
      Hyaluronic acid (Sinovial)

      Hyaluronic acid (Sinovial)

      Hyaluronic acid (Sinovial)
      1 injection of 1 mL

      2 injections of 1 mL (weekly)

      3 injections of 1 mL (weekly)
      3 moNo significant differences between the groups regarding pain and function

      In all groups, improvement of pain and function, significant in the groups with 2 and 3 injections
      Fuchs et al, 2006
      • Fuchs S.
      • Mönikes R.
      • Wohlmeiner A.
      • Heyse T.
      Intra-articular hyaluronic acid compared with corticoid injections for the treatment of rhizarthrosis.
      Kellgren mean II28

      28
      Hyaluronic acid (Ostenil mini)

      Triamcinolone (Volon A10)
      3 injection (weekly) of 1 mL

      1 injection of 1 mL
      26 wk88% of patients in the hyaluronic acid group and 79% of patients in the corticosteroid group had improvements in pain

      Patients in the corticosteroid group had faster onset of pain relief, which decreased to the end of the study
      Stahl et al, 2005
      • Stahl S.
      • Karsh-Zafrir I.
      • Ratzon N.
      • Rosenberg N.
      Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints.
      Eaton-Littler II25

      27
      Methylprednisolone acetate (Depomedrol)

      Sodium hyaluronate (Orthovisc)
      1 mL/40 mg

      1 mL/15 mg
      6 moSignificant improvement of pain in both groups after 1 mo; no difference between the groups

      Significant improvement in grip strength in the steroid group during the whole period

      In the hyaluronate group, improvement in grip strength after 6 mo and in pinch strength after 3 mo
      Meenagh et al, 2004
      • Meenagh G.K.
      • Patton J.
      • Kynes C.
      • Wright G.D.
      A randomised controlled trial of intra-articular corticosteroid injection of the carpometacarpal joint of the thumb in osteoarthritis.
      Mean III (used classification system not specified)20 (18)

      20 (17)
      Triamcinolone hexacetonide

      Saline (control group)
      0.25 mL/5 mg

      0.25 mL 0.9%
      24 wk

      All patients 48 h thumb spica splint
      No significant differences between the groups regarding VAS for pain, joint stiffness, joint tenderness, or global assessments

      No improvement in VAS for pain compared with preinjection measurement
      VAS, visual analog scale.
      Numbers in parentheses indicate the number of patients who completed the follow-up measurements.
      Appendix COrthoses
      AuthorsGrade of OASample SizeTreatmentDosageFollow-UpAuthors' Conclusions
      Hermann et al, 2014
      • Hermann M.
      • Nilsen T.
      • Eriksen C.S.
      • Slatkowsky-Christensen B.
      • Kristin Haugen I.
      • Kjeken I.
      Effects of a soft prefabricated thumb orthosis in carpometacarpal osteoarthritis.
      Kellgren and Lawrence I–IV28

      27
      Prefabricated soft orthosis and hand exercises

      Only hand exercises
      Orthosis was worn as much as patients wanted, especially when symptomatic and when performing heavy manual tasks2 moSoft orthosis has an immediate pain-relieving effect when worn, but no general effectswhen not worn
      Bani et al, 2013
      • Bani M.A.
      • Arazpour M.
      • Kashani R.V.
      • Mousavi M.E.
      • Hutchins S.W.
      Comparison of custom-made and prefabricated neoprene splinting in patients with the first carpometacarpal joint osteoarthritis.
      I–II used system not specified12

      12

      11
      Prefabricated neoprene orthosis

      Custom-made orthosis

      Control group
      Both orthoses 4 wk (during routine activities of daily living), with 2 wk wash-out period10 wk

      Cross-over design
      With both orthoses, reduction of pain and better Disabilities of the Arm, Shoulder, and Hand scores, function, and pinch

      Custom-made orthosis: better pain reduction compared with prefabricated orthosis
      Sillem et al, 2011
      • Sillem H.
      • Bockman C.L.
      • Miller W.C.
      • Li L.C.
      Comparison of two carpometacarpal stabilizing splints for individuals with thumb osteoarthritis.
      NA54Custom-made hybrid orthosis

      Prefabricated Comfort Cool orthosis
      Both orthoses 4 wk (when symptomatic, during heavier manual tasks, and eventually at night) with 1 wk wash-out period9 wk

      Cross-over design
      No significant difference between the orthoses regarding hand function, grip strength, and pinch strength

      63% of patients preferred the prefabricated orthosis, although this one gave less pain reduction
      Gomes Carreira et al, 2010
      • Gomes Carreira A.C.
      • Jones A.
      • Natour J.
      Assessment of the effectiveness of a functional splint for osteoarthritis of the trapeziometacarpal joint of the dominant hand: a randomized controlled study.
      Classification of American College of Rheumatology II–III20

      20
      Custom-made functional thermoplastic orthosis

      Control group: after 90 d, this group also wore an orthosis
      180 d (during activities of

      daily living)
      180 dAfter 45 days: use of orthosis during activities of daily living reduces pain, but has no effect on function, grip or pinch strength, or dexterity
      Rannou et al, 2009
      • Rannou F.
      • Dimet J.
      • Boutron I.
      • et al.
      Splint for base-of-thumb osteoarthritis: a randomized trial.
      NA57

      55
      Custom-made neoprene orthosis

      Usual care
      Nighttime use1 yNo difference in pain after one mo between both groups

      More reduction in pain and disability after 12 mo with use of orthosis
      Wajon and Ada, 2005
      • Wajon A.
      • Ada L.
      No difference between two splint and exercise regimens for people with osteoarthritis of the thumb: A randomised controlled trial.
      Eaton-Glickel I–III19

      21
      Thumb strap orthosis and abduction exercise

      Short opponens thumb orthosis and pinch exercise
      Full-time use for 2 wk, then also start exercises (4 wk)6 wkBoth groups showed improvement

      No significant difference between the groups regarding pain, strength, and hand function
      Weiss et al, 2004
      • Weiss S.
      • LaStayo P.
      • Mills A.
      • Bramlet D.
      Splinting the degenerative basal joint: Custom-made or prefabricated neoprene?.
      Eaton-Littler I–II25Prefabricated neoprene orthosis (immobilizing TMC and metacarpophalangeal joints)

      Custom-made thermoplastic orthosis (immobilizing TMC joint)
      Both orthoses for 1 wk; use when symptomatic2 wk

      Cross-over design
      Significant reduction of pain after use of both orthoses; the prefabricated orthosis gave significantly more pain reduction

      No difference in strength

      72% of patients preferred the prefabricated orthosis
      Berggren et al, 2001
      • Berggren M.
      • Joost-Davidsson A.
      • Lindstrand J.
      • Nylander G.
      • Povlsen B.
      Reduction for the need for operation after conservative treatment of osteoarthritis of the first carpometacarpal joint: a seven-year prospective study.
      Maximum level III11

      11

      11
      Technical accessories

      Technical accessories and a semistable textile orthosis

      Technical accessories and a nonstabilizing leather orthosis
      7 mo7 yAt 7 mo, only 10 of 33 patients still wanted an operation

      During the following 7 y, only 2 more patients wanted an operative intervention
      Weiss et al, 2000
      • Weiss S.
      • LaStayo P.
      • Mills A.
      • Bramlet D.
      Prospective analysis of splinting the first carpometacarpal joint: an objective, subjective, and radiographic assessment.
      Eaton-Littler I–IV26Prefabricated short opponens orthosis (immobilizing TMC joint)

      Prefabricated long opponens orthosis (immobilizing metacarpophalangeal and TMC joints and wrist)
      Both orthoses for 1 wk; use when symptomatic2 wk

      Cross-over design
      Both orthoses gave reduction of pain, but no increase in strength

      73% of the patients preferred the short orthosis
      Buurke et al, 1999
      • Buurke J.H.
      • Grady J.H.
      • Vries J de
      • Baten C.T.M.
      Usability of thenar eminence orthoses: report of a comparative study.
      NA10Thermoplastic semirigid orthosis (Sporlastic 07051)

      Firm elastic orthosis (Gibortho 6302)

      Supple elastic orthosis (Uriel 25)
      All orthoses for 4 wk12 wk8 of 10 patients preferred the permanent use of an orthosis

      6 patients choose the supple elastic and 2 the semirigid orthosis
      Appendix DOther Treatment Modalities
      AuthorsGrade of OASample Size
      Numbers in parentheses indicate the number of patients who completed the follow-up measurements.
      TreatmentDosageFollow-UpAuthors' Conclusions
      Michalsen et al, 2008
      • Michalsen A.
      • Lüdtke R.
      • Cesur Ö
      • et al.
      Effectiveness of leech therapy in women with symptomatic arthrosis of the first carpometacarpal joint: a randomized controlled trial.
      Eaton Glickel; however, grade NA16

      15
      Leech therapy

      Nonsteroidal anti-inflammatory gel
      Single session with 2–3 leeches

      30 d twice a day
      2 moSignificant decrease in pain score, improvement in

      Disabilities of the Arm, Shoulder, and Hand score, quality of life, and grip strength for at least 2 mo in leech therapy group.
      Jain et al, 2010
      • Jain R.
      • Jain E.
      • Dass A.G.
      • Wickstrom O.
      • Walter N.
      • Atkinson P.J.
      Evaluation of transdermal steroids for trapeziometacarpal arthritis.
      Eaton-Glickel mostly III17 (11)

      18 (10)

      15 (7)

      17 (6)
      Iontophoresis with placebo delivery

      Iontophoresis with steroid delivery

      Phonophoresis with steroid delivery

      Phonophoresis with placebo delivery
      6 sessions in 3 wk6 moOnly 40% of patients could be evaluated after 6 mo

      No relief of symptoms, improvement in hand strength, or satisfaction

      Transdermal steroid application might not be effective.
      Numbers in parentheses indicate the number of patients who completed the follow-up measurements.

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      Linked Article

      • Commentary to “Conservative Treatment of Thumb Base Osteoarthritis: A Systematic Review”
        Journal of Hand SurgeryVol. 40Issue 1
        • Preview
          Spaans et al,1 the authors of “Conservative Treatment of Thumb Base Osteoarthritis: A Systematic Review,” have tried to answer a question that has plagued the profession of hand surgery and hand therapy for quite some time: Which, if any, of our conservative treatment methods are effective for patients with osteoarthritis (OA) of the thumb trapeziometacarpal (TMC) joint. They draw conclusions based on the 23 articles they culled through a literature search. Their suggestions on further research studies needed in this arena are admirable.
        • Full-Text
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      • Letter Regarding “Conservative Treatment of Thumb Base Osteoarthritis: A Systematic Review”
        Journal of Hand SurgeryVol. 40Issue 5
        • Preview
          We would like to thank the authors for the undertaking a systematic review for conservative treatment for carpometacarpal osteoarthritis.1 The authors report that they followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA).2 The PRISMA systematic review checklist asks authors to describe methods used for assessing the risk of bias.3 The methodological characteristics of the studies were not analyzed using a standardized tool.
        • Full-Text
        • PDF