The effect of a multimodal approach in CMC-1 OA

The effect of a multimodal hand therapy approach for thumb base osteoarthritis: a systematic review

By Sharon Nijkamp

Keywords: Thumb base osteoarthritis - conservative treatment - multimodal - pain

In the Netherlands, hand therapists provide noninvasive treatment for patients with thumb base osteoarthritis (OA).1 The three most commonly used interventions are educating on joint protection, using assistive devices, doing exercises, and providing patients with a thumb orthosis. These interventions are generally used together and are defined as a multimodal approach. The use of this multimodal approach is supported by the European League Against Rheumatism (EULAR).2 In 2018, the EULAR proposed recommendations on nonpharmacological interventions in managing hand osteoarthritis (HOA), which includes thumb base OA.2 The recommen-

Abstract

Background and purpose Hand therapists provide treatment for patients with thumb base osteoarthritis. There are three types of interventions that are often used together. These are education, exercises, and wearing a thumb orthosis. These interventions together are defined as a multimodal approach. This systematic review investigates the effect of a multimodal hand therapy approach consisting of education, exercises, and wearing an orthosis on thumb pain and function in patients with thumb base osteoarthritis. Methods A literature search of Pubmed, EMBASE, and Cochrane was performed. Randomized controlled trials (RCTs) and controlled clinical trials (CCTs) were included. Other inclusion criteria were: studies focused on thumb base osteoarthritis; investigated the multimodal approach; reported the outcome pain. Quality appraisal was done by two reviewers using the PEDro scale. A best-evidence synthesis by van Peppen was used. Results The search resulted in 670 hits. Six studies were included in this review. Five studies were RCTs. Three were of good quality, two were of fair quality. One study was a poor quality CCT. The studies showed a strong level of evidence for a multimodal approach providing significantly greater improvements in pain than a control. The control consisted of education only, education and orthosis, education and exercises, education, exercises and placebo orthosis, placebo cream, or waiting for surgery. There was no evidence of improvement in function. Conclusion There is strong evidence that a multimodal approach consisting of education, exercises, and an orthosis provides more significant improvements in pain in patients with thumb base OA than a control.

dations on interventions provided by hand therapists are in line with current practice in the Netherlands. The recommendations are: 1) education and training in ergonomic principles, pacing of activity, and the use of assistive devices; 2) exercises to improve function and muscle strength, as well as to reduce pain, and 3) wearing an orthosis for symptom relief. In addition to these non-pharmacologic modalities, the EULAR provides advice on topical treatments and the use of NSAIDs.2 There have been studies looking at the effects of the three interventions by themselves. The wearing of an orthosis has been proven effective in two systematic reviews for reducing pain and improving function in patients with thumb base OA.3,4 There is low-quality evidence that providing therapeutic exercises in patients with thumb base OA provides no significant improvement in pain.5 The last intervention, giving education and training in ergonomic principles and using assistive devices, has shown positive effects on activity performance and satisfaction with performance.6,7 However, this has only been studied in the general hand OA population and not solely in patients with thumb base OA. To this day, there have been no systematic reviews focusing on the effect of the three interventions together. However, there are reviews on the effect of different types of conservative management on pain and function in patients with thumb base OA in which the authors made a statement about multimodal approaches.5,8 The first systematic review was published in 2015.5 This review reported one study using a multimodal approach consisting of an orthosis, exercises, and education.9 The authors concluded there was low-quality evidence that this multimodal approach provided no significant improvement in pain or function.5 The second review, published in 2016, concluded that there was a moderate to high level of evidence for a multimodal approach being more effective on pain than single interventions.8 The authors did not define the meaning of the multimodal approach. The studies that were included as multimodal consisted of wearing an orthosis, education, exercises, mobilizations, and the use of neurodynamic techniques.10–14 A more recent systematic review on conservative management in thumb base OA was published in 2020 and did not make a statement about the effect of a multimodal approach.15 However, the review did include

four studies,10,12–14 that were identified as multimodal approaches in the review published in 2016.8 Altogether, there is insufficient evidence to show the positive effects of a multimodal approach on pain and function in patients with thumb base OA. Since the intervention is broadly used by hand therapists and recommended by the EULAR, it is essential to know what the effect is.2 Even though the EULAR recommendations are evidence-based, part of the studies included were performed in patients with general hand OA. In this review, only studies performed in patients with thumb base OA will be included. The aim of this review is to investigate the effect of a multimodal hand therapy approach consisting of education, exercises, and wearing an orthosis on thumb pain and function in patients with thumb base OA.

Methods Design This systematic review was conducted following the Cochrane Handbook for Systematic Reviews of Interventions and reported according to the Preferred Reporting Items of Systematic reviews and Meta-analyses (PRISMA).16,17

Search strategy A comprehensive systematic literature search was performed up to February 27th, 2022 in the electronic databases Pubmed, EMBASE, and Cochrane. These databases were chosen since they are recommended by the MECIR guideline for carrying out Cochrane Intervention Reviews.18 The search queries were formulated using the Domain, Determinant, and Outcome (DDO) framework. Queries included keywords from the title and abstract. The main keywords were thumb base osteoarthritis, multimodal treatment, and pain. In addition, synonyms, plurals, alternate spellings, Medical Subject headings (MeSH), and Embase subject headings (Emtree) were added. The search was limited to articles published in English or Dutch between January 2000 and February 2022. A secondary search was performed by screening the reference lists of the articles included in this review and by searching for citations in Scopus.19 The complete search string is presented in appendix 1 in the supplementary online material.

Inclusion criteria Studies were included if they met the following inclusion criteria: 1) studies focused on adults with thumb base osteoarthritis, either clinically diagnosed, radiographically diagnosed, or both; 2) studies investigated the role of a multimodal hand therapy approach in thumb base osteoarthritis, consisting of education, exercises and wearing an orthosis; 3) studies reported on the outcome pain; 4) studies were randomized controlled trials (RCTs) or controlled clinical trials (CCTs, defined as experimental studies in which two non-randomized groups are assigned to either an intervention or control); 5) studies were written in English or Dutch. Studies were excluded if they met one of the following criteria: 1) studies focused on adults with general HOA, which included thumb base OA, but there was no subgroup analysis for thumb base osteoarthritis alone; 2) studies had participants receiving an intra-articular thumb base injection as part of the study.

Prior to this study, the effects of a multimodal approach were unknown

Study selection All the studies identified were first transported to Mendeley and subsequently Rayyan to search for duplicates.20,21 Additionally, studies were hand-searched for duplicates. Study screening and selection were done by the author by using the in- and exclusion criteria.

Data extraction The following data were extracted: first author, year of publication, country, study design, studies in- and exclusion criteria, participant characteristics (including age, gender, and severity of thumb base OA), intervention and comparator (with baseline number of participants per group), follow-up, outcome measures, and the authors’ conclusion. Moreover, means in the intervention and comparator group, the between-group differences with their 95% confidence interval and statistical significance, and effect sizes were extracted from the studies.

Methodological quality appraisal The methodological quality of the studies was assessed using the PEDro scale for RCTs and CCTs.22 The quality of each article included was independently judged by two reviewers (author and colleague). After they independently rated all included studies, they came together to seek agreement. In case of disagreement, a third reviewer was asked to rate the study and discuss the outcome with the other reviewers. Quality appraisal was not used to select trials for inclusion.

Synthesis Pooling of studies was not possible, mainly due to the heterogeneity in control group treatments, outcome measures, and differences in the exact content of the multimodal approach. The different studies, for example, used all sorts of different exercises. Therefore, the best-evidence synthesis by van Peppen et al. was used.23 This synthesis rates the level of evidence based on the methodological quality of the studies and their findings. An RCT is of high quality when it scores at least four points on the PEDro scale.22 There are five levels of evidence: strong evidence, moderate evidence, limited evidence, indicative findings, and no or insufficient evidence.23 Strong evidence consists of statistically significant findings in outcome measures in at least one high-quality RCT and at least one low-quality RCT or one high-quality CCT. For limited evidence, this is at least one high-quality RCT, or at least two high-quality CCTs. For indicative evidence, this is one high-quality CCT or low-quality RCT, or two non-experimental studies. No or insufficient evidence means the studies do not meet the criteria for one of the formerly mentioned levels of evidence, or there are conflicting findings among RCTs and CCTs. Lastly, if the number of studies that show evidence is less than 50% of the total number of studies within the same category of methodological quality and study design, no evidence will be classified. An overview of the best-evidence synthesis can be found in supplementary table 1 in the online supplementary material.

Identification

Records identified from Databases (n = 670):

Pubmed (n = 195)

Embase (n = 129)

Cochrane (n = 346) Records removed before screening:

Duplicate records removed (n = 184)

Records screened (n = 486) Records excluded** (n = 466)

Reports sought for retrieval

(n = 20)10,11,14,27-43

Reports assessed for eligibility

(n = 12)10,11,14,29-33,35,39,42,43

Included

Studies included in review

(n = 6)10,12,29,30,32,33 Reports not retrieved (n = 8): - Conference abstract:

(n = 7)27,28,34,36-38,40 - Full text is in Italian: (n = 1)41

Reports excluded (n = 7): - Domain: general hand osteoarthritis (n = 1)39 - Not multimodal (n = 4)11,14,35,42 - No outcomes on pain or function (n = 1)43 - Subgroup analysis (n = 1)31 Records identified from

Reference searching (n = 4)

Conference abstract forward searching (n = 2)

Citation searching (n = 1)

Reports assessed for eligibility

Reports sought for retrieval

(n = 7)6,7,9,12,24-26

(n = 7) 6,7,9,12,24-26 Reports not retrieved (n = 0)

Reports excluded (n = 6): - Domain general HOA and not multimodal (n = 4)6,24-26 - Domain general HOA (n = 2)7,9

Figure 1 Flow diagram of the study selection process

Results Study selection The primary search resulted in 670 hits, of which 184 were duplicate studies. After screening the 486 titles and abstracts of the primary search, 20 records remained. 10,11,14,27-43 An additional seven studies were identified from reference lists and citation searching. 6,7,9,12,24-26 A total of six studies were included in this review.10,12,29,30,32,33 A flow diagram of the study selection process is presented in figure 1.

Study characteristics Table 1 shows the main characteristics of the six studies included. Five studies were RCTs.12,29,30,32,33 One study was a CCT.10 Two studies included participants only when there was radiographic evidence for osteoarthritis.29,30 Two studies had a minimal threshold for pain at baseline as an inclusion criterion.30,32 Over 70% of participants in all studies were female, with one study being solely about females as this was their inclusion criterion.10 Not all studies reported the grade of radiographic thumb base OA in the participant characteristics.10,12,32 All but two studies had a different comparator.10,32 In these two studies, a multimodal approach was compared with education and exercises. One of these studies also compared the intervention to education, exercises and a placebo orthosis.32 The other studies compared the multimodal approach with education,30 education and an orthosis,29 usual care which consisted of staying on the waiting list for surgery,33 and a placebo cream.12 The interventions varied in types of exercises and number of repetitions,

There is a strong level of evidence for the multimodal approach to reduce pain

type of orthosis, and wearing advice. All but one study focused on self-management, and in some cases home exercises. Participants in the five studies focusing on selfmanagement had a maximum of three sessions with the therapist.12,29,30,32,33 The remaining study used group therapy sessions and had ten supervised visits.10

Methodological quality Table 2 shows the methodological quality of the studies. Three studies were scored ‘good’.29,32,33 Two studies scored ‘fair’,12,30 and one study was deemed ‘poor’.10 There was consensus between the two reviewers on the scores. None of the studies scored positive on the randomization criterion since subjects were not randomly allocated. Most studies used stratification instead. Studies, for example, used stratification by the severity of osteoarthritis,30 or stratified on the severity of baseline pain.32 Blinding of the assessors was not achieved in three out of six studies10,30,33. Lastly, two studies failed to perform an intention-to-treat analysis10,12 .

Results of individual studies Pain All six studies reported on the outcome pain. Three RCTs found improvement in either usual pain, pain at rest, and pain after pinch and grip strength testing, in a time range from four weeks to four months.12,30,33 One CCT reported a significant improvement in pain reduction at night and on motion in favor of the intervention group at six weeks.10 In contrast, two RCTs showed no significant differences in pain reduction between the groups in a time range from six to twelve weeks.29,32

Author (year) Design Studies in- and country exclusion criteria Participant

Intervention and comparator characteristics (n= baseline number of participants)

I(n=102): Multimodal Deveza LA RCT In: Age over 40 years, I A: 66.0 (7.8) - Education about osteoarthritis (2021) thumb pain half of the days, F: 85.3% and joint protection advise

Australia30 VAS pain >40, FIHOA >6, G:KL gr 2 39.2% - Neoprene orthosis. Advise to wear radiographic evidence thumb KL gr 3 43.1% during daily activities for a base OA KL gr 4 17.6% minimum of 4 hours a day. - Exercises on ROM, neuromuscular control,

Ex: concomitant to conditions contributing thumb pain. C A: 65.2 (8.5) endurance, and proprioception of

F: 68% the thumb. 3 times a week for 6 weeks.

G:KL gr 2 39.2% - Diclofenac gel 1% (non-prescription drug)

KL gr 3 43.1%

KL gr 4 17.6% C(n=102): Education - Education on joint protection.

Use of pain medication was allowed. Both groups had 2 sessions with the therapist. Intervention duration was 12 weeks. Follow-up Outcome measures Authors conclusion

Primary: 2, 6, and - Pain measured The intervention group had 12 weeks. with VAS (0-100). small improvements in hand - Hand function function at 6 weeks compared assessed by FIHOA to the comparison group. (0-30) at 6 weeks At week 12, both pain and function improved more

Secondary:

in the intervention group. - Pain (VAS) and The effect of the intervention function (FIHOA) was potentially clinically at 2 and 12 weeks meaningful for function but not for pain.

Mcveigh KH RCT In: Age between 18 and 86, I A: 66.5 (48-86) I(n=42): Multimodal Primary:

(2021)29 diagnosis of thumb base F: 84.8% Standard conservative therapy. In addition: 6 weeks - Change in pain score The findings of this study OA based on clinical and G:Eat gr 1 6.3% - Home exercises on stretching and measured with NRS indicate that both groups

USA radiographic examination. Eat gr 2 34.4 % strengthening of the thumb. 6 months (0-10) at 6 weeks. led to improved function

Eat gr 3 34.4% 10 repetitions 3 times a day, Ex: Comorbidities of the upper Eat gr 4 25% every day of the week for 6 weeks. extremity, thumb passive flexion of fewer than 30 degrees C A: 63.9 (46-86) C(n=42): Education + orthosis F: 70.6% Standard conservative therapy consisting of: and reduced pain.

Secondary:

There were no noticeable - Change in function differences between the measured with groups in change in pain quickDASH (0-100) or QuikDASH scores from

G:Eat gr 1 5.9% - Education on pain reduction, joint protection,

Eat gr 2 44.1% using adaptive equipment.

Eat gr 3 41.2% - Rigid custom-made of custom-fitted thumb

Eat gr 4 8.8% orthosis (6 different types of orthoses) - Change in pain and baseline to 6 months. function measured There were significant with NRS and improvements in pain quickDASH at and QuikDASH score at 6 months 6 weeks and 6 months

Both groups had 1 session with the therapist. Intervention duration was 6 weeks. within each group.

Adams J (2021)32 RCT In: Referred to hospital, aged over 30 years, symptomatic thumb base OA, hand pain >5 and dysfunction >9 on AUSCAN, sign of clinical thumb base OA such as pain on palpation G1 A: 62.1 (9.1) F: 78%

G2 A: 64 (9.4) F: 78%

G3 A: 61.7 (10.1) F: 79%

Ex: current treatment of thumb, fractures, corticosteroid injections, orthoses wear, skin diseases. G1(n=116): Multimodal - SSM and a custom-made thermoplastic orthosis or neoprene orthosis. Advise wearing at least 6 hours a day during activities.

G2(n=116): Education + exercise - Supported self-management (SSM) consisting of education on joint protection and thumb base pain, and exercises. The exercise program focused on ROM and strength of the thumb and functional pinch 8 and 12 weeks

6 months

tasks. 3 times a week for at least 20 minutes for 8 weeks.

G3(n=117): Education + exercise + placebo - SSM and a placebo orthosis.

All groups had 2 sessions with the therapist and 1 phone call. Intervention duration was 8 weeks. Primary: - Pain measured with AUSCAN hand pain index (0-20)

Secondary: - Hand function measured with AUSCAN index (0-36) The study found that adding thumb orthoses provided no additional clinical benefit to the 8-week SSM program. Pain and function improved from baseline to 8 and 12 weeks across all treatment groups. However, there were no clinically relevant or statistically significant

- Hand function measured with GAT differences in outcomes between groups.

Tveter A (2020)33

Norway RCT In: Everyone referred for surgical consultation due to thumb base OA.

Ex: Persons with cognitive dysfunction or other diseases or injury that may negatively impact hand function. I A: 62.8 (7.5) F: 81% G: KL 3 (3-4)

C A: 63.3 (7.8) F: 77% G: KL 3 (3-4)

Merritt M (2012) RCT12

USA RCT In: age >30 years, independent in self-care, any kind of pain in the thumb base joint, positive grindtest

Ex: surgery, therapy, or medical treatment involving thumb or wrist. I A: 67.6 (11.4) F: 94%

C A: 65.9 (6.7) F: 100% I(n=17): Multimodal - Education on joint protection. Advice on using assistive devices - Neoprene orthosis to wear while sleeping and with light activities. Custom-made orthoplastic orthosis to wear with heavier activities. - Exercises on thumb ROM, stability and strength. 3 times per day, every day. Advise to apply heat before exercises.

I(n=90): Multimodal -Education about osteoarthritis. Advice on using five assistive devices. - Daytime orthosis prefabricated. Nigh-time orthosis custom-made. - Exercises focused on ROM of thumb and fingers, and thumb and wrist strength. 3 times a week for 12 weeks.The group had a total of 2 sessions with the therapist. 3-4 months after baseline

C(n=90): Usual care Usual care. Staying on the waiting list for surgery. This group had 1 session with the therapist. Primary: - Pain at rest and after pinch and grip strength testing using the NRS (0-10)

Secondary: - Function measured with quickDASH (0-100) and MAP for activity limitations (1-4)

Intervention duration was 12 weeks. The results of our present study revealed that a multimodal occupational therapy intervention yielded significant beneficial shortterm effects on pain and hand function in patients with thumb base OA. These findings imply that patients with thumb base OA may benefit from therapy before considering surgical consultation.

C(n=18): Placebo Placebo cream, apply 2 times a day

Participants had 1 session with the therapist. Intervention duration was 4 weeks. 4 weeks Primary: - Pain directly after pinch grip testing measured with VAS (0-10) - Pain measured with the AUSCAN index - Function measured with the AUSCAN index Hand therapy treatment with appropriate orthoses, therapeutic exercise, and joint protection techniques significantly improve pain and function in individuals suffering from thumb base OA.

Author (year) Design Studies in- and country exclusion criteria Participant

Intervention and comparator characteristics (n= baseline number of participants) Follow-up Outcome measures Authors conclusion

Boustedt C (2009)10

Sweden CCT In: Referred by physician because of thumb base OA for joint protection program. Women with clinically or radiographically diagnosed HOA. Pain in the thumb base.

Ex: Rheumatoid arthritis or any rheumatic disease. Carpal tunnel syndrome. I A: 61 (40-76) F: 100%

C A: 61 (50-76) F: 100% I(n=30): Multimodal As the comparator group. In addition: - participants received two orthoses. Custom-made thermoplastic orthosis to wear at night. Prefabricated elastic orthosis to wear at all times during the day. - Exercises as learnt in the therapy session. 1 time a day. Advise to apply heat before exercising.

C(n=29): Education + exercise - Joint protection program with advice about pain, using alternate working methods, and assistive devices. - Hand exercises with paraffin dough during the therapy session. Apply heat before exercises. Exercises focused on ROM and strength of the hand intrinsic and thumb extrinsic musculature.

Use of medications was allowed. Both groups had 10 group therapy sessions over a period of 5 weeks. 6 weeks

1 year - Pain at night and pain on motion during the last week measured with the VAS (0-100) - Function measured with the DASH (0-100) The orthoses and exercise regimen added to a join protection program gives a greater improvement of pain and daily activities than the joint protection program alone.

Abbreviations: RCT= randomized controlled trial, CCT= controlled clinical trial, n= number, ex= exclusion, in= inclusion, multi=multimodal, I= intervention group, C= control group, G1= group 1, G2= group 2, G3= group 3, A= age, F= female, G= grade of radiographic osteoarthritis, ROM= range of motion, VAS= Visual Analogue Scale, FIHOA= Functional Index of Hand Osteoarthritis, AUSCAN= Australian/Canadian Hand Osteoarthritis Index, QuikDASH= Quick Disabilities of Arm Shoulder and Hand, GAT= Grip Ability Test, MAP= Measure of Activity Performance, DASH= Disabilities of Arm Shoulder and Hand. Age is reported as mean (sd) or mean (min-max). Grades of osteoarthritis are reported with KL or Eat. KL means graded by the Kellgrenn and Lawrence system, they are either reported as the grade (gr..) and their percentage or as KL median (IQR). Eat means graded by the Eaton-Littler classification and is reported as the grades (gr..) and their percentages.

Table 2 Quality appraisal of the studies included using the PEDro scale

Deveza (2021)30

Mcveigh (2021)29

Adams (2021)32

Tveter (2020)33

Merritt (2012)12

Boustedt (2009)10

= yes x = no 1. Eligibility criteria 2. Randomization

x

x

x

x

x

x 3. Allocation concealed

x

x 4. Similarity groups at baseline

x 5. Blinding subjects

x

x

x

x

x 6. Blinding therapists

x

x

x

x

x

x 7. Blinding assessor

x

x

x 8. Adequate follow-up

x

x 9. intention-to-treat analysis

x

x 10. between-group analysis 11. point estimates and variability Total

5/10

6/10

8/10

6/10

5/10

2/10 Quality

fair

good

good

good

fair

poor

Function All six studies reported on the outcome function. Two RCTs showed that function significantly improved in favor of the multimodal approach group in a time range from three to four months.30,33 One CCT reported a significant improvement in function in favor of the intervention group at six weeks.10 Three RCTs reported no significant differences in function improvement between the groups in a time range from four to twelve weeks.12,29,32 In these RCTs, the multimodal approach was compared with education and orthosis29, placebo cream12, education and exercise32, and education, exercise and a placebo orthosis32. The last comparison could be viewed as a multimodal approach.

Synthesis of results Pain Strong evidence was found for the positive effects of a multimodal approach on thumb pain in patients with thumb base OA compared to a control. This statement is based on three RCTs that scored four points or more on the PEDro scale.12,30,33 These are therefore qualified as high-quality RCTs.

Function No evidence was found for the positive effects of a multimodal approach on function in patients with thumb base OA compared to a control. This statement is based on five RCTs,12,29,30,32,33 all of high quality according to van Peppen et al.23 Only two out of five RCTs showed significant positive results on the outcome function.30,33 This is less than 50% of the total number of studies found within the same category of methodological quality and study design. It should be noted that the three RCTs that did not find significant differences in improvement between the groups all had different control groups.12,29,32

Discussion The aim of this systematic review was to investigate the effect of a multimodal hand therapy approach consisting of education, exercises, and wearing an orthosis on thumb pain and function in patients with thumb base OA. The findings demonstrate a strong level of evidence for the multimodal approach providing a more significant improvement in pain in patients with thumb base OA than a control. There is no evidence for a multimodal approach providing a more significant improvement in function in patients with thumb base OA than a control. This is the first systematic review to focus solely on the effect of a multimodal approach consisting of education, exercises, and wearing an orthosis on thumb pain and function. Two other systematic reviews on the effect of different types of conservative management on pain and function in thumb base OA made a statement about multimodal approaches.5,8 The first review, published in 2015, concluded there was low-quality evidence that a multimodal approach provided no significant improvement in pain or function.5 This conclusion is not in line with this review in which a high level of evidence. These different findings can be explained by differences in study populations and the inclusion of more recent studies. The second systematic review that made a statement about the effect of a multimodal approach was published in 2016 and reported moderate to high evidence that a multimodal therapy intervention had beneficial effects on pain in patients with thumb base OA.8 This is in line with our conclusion that there is a strong level of evidence. One of the limitations of this review is that selection and information bias might have occurred since primary study screening and data extraction was done by one person. Secondly, the use of medications was not set as an exclusion criterion, even though this might have influenced the outcomes on thumb pain and function.2 Thirdly, I chose to report the multimodal approach as a single construct consisting of education, exercises, and providing an orthosis. There was, however, a lot of variation within the exact content of the therapy and this might have influenced the results in this review. Deveza et al. for example advised carrying out the exercises three times a week,30 whereas Mcveigh et al. advised carrying out the exercises three times a day.29 I, moreover, chose to compare the between-group difference in change of a multimodal approach with a control, in which the control consisted of all different sorts of therapy, placebo, or no treatment. A major drawback of this type of comparison is when comparing a multimodal approach with, for example, a bimodal approach and there are no significant between-group changes in the outcomes, this does not necessarily mean there is no effect of the multimodal approach. Adams et al. for example,32 compared a multimodal approach with education, exercises, and a placebo splint and did not find any significant between-group differences. They, however, found improved function and pain from baseline to 12 weeks across all the treatment groups. Mcveigh et al. compared the multimodal approach with education and an orthosis and found no significant between-group differences.29 Yet, they showed significant improvements in pain and function at six weeks and six months within both of the treatment groups. The findings in this review that there is a strong level of evidence for the multimodal approach providing a more significant improvement in pain but not in function, might therefore be too simplistic. A limitation of the studies included in the review is they used all sorts of different outcome measures, such as the Numerics Rating Scale (NRS) for pain or the Australian/ Canadian Osteoarthritis Hand Index (AUSCAN) subscale for pain. Measurements were moreover performed under different circumstances. Pain for example was measured under unknown circumstances,29,30, at rest,33 after pinch testing,12,33 at night and on motion,10 and under different circumstances.12,32 The main reason for conducting this review was that most hand therapists use a combination of education, exercises, and an orthosis as their primary treatment for thumb base OA in their daily clinical practices. Yet, there was insufficient evidence to support this. This systematic review demonstrates strong evidence for a multimodal approach providing significant improvements in pain in patients with thumb base OA compared to a control group. However, it might be even more important to know about the clinical relevance of the changes. Two out of four studies that found a significant positive effect on pain reported clinical importance.30,33 The first study reported that the significant change in pain was not superior to the minimal clinical important difference (MCID).30 Their MCID was a change of 20 points on a visual analog scale (VAS) that ranges from 0-100. The second study reported a change of 33% as a minimal important change. It showed that 44% of the participants in the multimodal approach group had a clinically meaningful change in pain at rest, and 42% had a clinically meaningful change in pain following grip testing.33 On the contrary, this was 22% and 22% in the control group. The differences between the groups in terms of a clinically meaningful change were significant.33 The remaining two studies showing significant improvement in pain did not report on clinical importance.10,12 However, when applying the abovementioned criteria of a 33% change or a change of 20 points on the VAS, both studies seem to meet a clinically meaningful change in favor of the intervention group.

Future research is needed to study the different parts of the multimodal approach. The positive effect of wearing an orthosis in thumb base OA has been shown.3,4 However, this is not the case for education and exercises as single interventions. The recommendation on providing education

is based on two RCTs that were conducted in patients with general HOA instead of thumb base OA.6,7 Thumb base OA, however, has major differences compared to HOA.44 The thumb, for example, is an unstable saddle joint with four articulations, whereas the finger joints are hinged joints with only two articulations. Therefore, future research should focus on the effect of education and training in ergonomic principles for thumb base OA instead of general HOA. Additional research is also needed on different types of exercises and their parameters. Future RCTs should examine the effect of a dynamic stability program and a more generalized thumb strengthening program on thumb pain and function in patients with various stages of severity of thumb base OA.45,46 In these studies, attention should be given to exercise parameters such as the number of repetitions. Once these future studies are completed and theories have emerged on why and how the single interventions work, these interventions could be clustered into a multimodal approach consisting of education, exercises, and an orthosis. One last point to consider is that when the three interventions show a positive effect by themselves, it does not necessarily mean they provide even better results when combined in a multimodal approach.47 This was also shown by Adams et al. who found that adding a thumb orthosis to education and exercises shows no beneficial effect on reducing pain and improving function.32 It might therefore also be interesting to gain a broader insight into the effects of a hand therapy approach in which two of the three interventions are combined.

Conclusion The present study shows that there is evidence that a multimodal approach consisting of education, exercises, and wearing an orthosis provides significant improvements in pain but not in function in patients with thumb base OA compared to a control intervention.

Conflicts of interest statement The author declares that there are no conflicts of interest in relation to the work presented.

AUTHOR Sharon Nijkamp,handtherapeut Isala Zwolle en fysiotherapiewetenschapper in opleiding Email: s.nijkamp@students.uu.nl

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