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A Multidisciplinary Hand Clinic for Patients with Rheumatic Diseases: a Pilot Study

A Multidisciplinary Hand Clinic for Patients with Rheumatic Diseases: a Pilot Study
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   JHT R EAD FOR  C REDIT ARTICLE  # 065 A Multidisciplinary Hand Clinic for Patientswith Rheumatic Diseases: a Pilot Study F.J. van der Giesen, PT Department of Rheumatology, Leiden University MedicalCenter, The Netherlands R.G.H.H. Nelissen, MD, PhDP.M. Rozing, MD, PhD Department of Orthopaedics, Leiden University MedicalCenter, The Netherlands  J.H. Arendzen, MD, PhD Department of Rehabilitation, Leiden University MedicalCenter, The Netherlands Z. de Jong, MD, PhD Department of Rheumatology, Leiden University MedicalCenter, The Netherlands R. Wolterbeek, MSc Department of Medical Statistics, Leiden University Medical Center, The Netherlands T.P.M. Vliet Vlieland, MD, PhD Department of Rheumatology, Leiden University MedicalCenter, The Netherlands ABSTRACT : To describe the characteristics, management strate-gies and outcomes of patients with rheumatic diseases and com-plex hand function problems referred to a multidisciplinaryhand clinic. Assessments (baseline and after three months of follow-up) included sociodemographic and disease characteristicsand various hand function measures. The most frequently men-tioned impairments and limitations of the 69 patients enrolled inthe studypertainedtogrip,pain,gripstrength,andshakinghands.Fifty-six patients received treatment advice, conservative therapy( n ¼ 39), surgery ( n ¼ 12), or a combination of both ( n ¼ 5). In 38of 56 patients (68%) the recommended treatment was performed,and 33 completed the follow-up assessment. On average, patientsimproved, with an increase in grip strength and the MichiganHand Outcomes Questionnaire scores reached statistical signifi-cance. Two-thirds of patients with rheumatic conditions visitinga multidisciplinary hand clinic reportedly followed the treatmentadvice (recommendations), with an overall trend toward a benefi-cial effect on hand function. To further determine the added valueof a structured, multidisciplinary approach a controlled compari-son with other treatment strategies is needed. J HAND THER. 2007;20:251–61. Hand function problems are common in patientswith rheumatic diseases. It is estimated that thehands and wrists are affected in 80 e 90% of thepatients with rheumatoid arthritis (RA), 1 whereasthe hand is the most frequent site of involvement inosteoarthritis (OA). 2 Involvement of the hand isalso common in patients with psoriatic arthritis, 3 scleroderma, 4 and systemic lupus erythematosus(SLE). 5 Theimportanceofhandfunctioninrheumaticconditions is underlined by the fact that the ‘‘finehand use’’ domain is included in the recently devel-oped preliminary International Classification of Functioning, Disability, and Health (ICF) 6 Core Setsfor both RA and OA. 7,8 The ICF is aimed at providinga unified and standard language and framework forthe description of health and health-related states(Figure 1). Although the importance of hand functionproblemsin rheumatic diseases is generallyacknowl-edged, there is little evidence on how and when touseconservativeorsurgicalinterventionstooptimizehand function. 9 This lack of knowledge can be partlyexplained by the complexity of hand function prob-lems in many patients. Limitations in hand functionduring activities of daily living (ADL) are often ac-companied by a combination of multiple impair-ments on the ICF level of body functions or bodystructures, such as pain, stiffness, joint swelling,limited range of motion (ROM), joint destruction, ordeformities. Moreover, personal and environmentalfactors may play an important role in the occurrenceand impact of hand function problems. S CIENTIFIC /C LINICAL  A  RTICLES Correspondence and reprint requests to F.J. van der Giesen, PT,Leiden University Medical Center, Department of PhysicalTherapy, H0-Q, PO Box 9600, 2300 RC Leiden, The Netherlands;e-mail: <>.0894-1130/$ e see front matter  2007 Hanley & Belfus, an imprintof Elsevier Inc. All rights reserved.doi:10.1197/j.jht.2007.04.004  July e September   2007  251  To assist in the management of patients withcomplex, challenging hand function problems, mul-tidisciplinary handclinics have beenestablished overthe last decade. To date, the characteristics andoutcomes of patients with rheumatic diseases whoare being evaluated in such clinics are not known.Therefore,ouraimwastodescribe theclinicalprofile,management strategies and outcomes of patientswith rheumatic diseases who were referred to amultidisciplinary clinic for complex hand functionproblems. The description of the organization of theclinic can be used for comparison by cliniciansinvolved with this patient group, such as handtherapists, occupational therapists, physical thera-pists, surgeons, rheumatologists, and rehabilitationspecialists. Moreover, the systematic evaluation of complex hand function problems and their outcomesafter comprehensive treatment will help to set theagenda for future research in this area. PATIENTS AND METHODS Study Design This observational study was conducted at the daypatient clinic of the Department of Rheumatology of the Leiden University Medical Center in TheNetherlands. This clinic is a tertiary referral centerand offers multidisciplinary team care for patientswith rheumatic diseases, 10 including two specificmultidisciplinary programs: a vocational rehabilita-tion program 11 and a multidisciplinary hand clinic.All 69 consecutive patients referred to the multidisci-plinary hand clinic between January 2002 and April2004 were enrolled in the present study. TheMedical Ethical Committee of the Leiden UniversityMedical Center approved the study, and all patientsgave written informed consent. The Multidisciplinary Hand Clinic The multidisciplinary hand clinic serves patientswith rheumatic diseases and complex hand functionproblems, defined as a problem in hand function thatcannot be solved by a single intervention or a singlehealth professional. Referrals were made by rheuma-tologists and orthopedic surgeons. At referral, radi-ographs of the hands and wrist were ordered, exceptwhen recent radiographs (less than six months) wereavailable. The multidisciplinary team involved anorthopedic surgeon, a rehabilitation specialist, arheumatologist, an occupational therapist, and aphysical therapist.Patients visited the hospital twice for assessmentand treatment advice (recommendations). At theinitial visit a standardized, comprehensive analysisof hand function was made by a physical therapist,who was the coordinator of the team, a rheumatolo-gist and an occupational therapist, in succession. Aspart of the occupational therapy assessment a videowas made of the patient performing specific ADLwithin the framework of the Sequential OccupationalDexterity Assessment (SODA), 12 recording handfunction problems.At the second visit, the coordinator, with the entiremultidisciplinary team and the patient present,reviewed a synopsis of the clinical assessments,including the video and the radiographs. Theorthopedic surgeon and rehabilitation specialist un-dertook additional history and physical examination,and subsequently a multidisciplinary treatment planwas proposed and discussed with the patient.Treatment could consist of conservative or surgicaltherapy or a combination of both. If an interventionwas instituted, a follow-up appointment for a formalassessment after three months was scheduled. Clinical Assessments A rheumatologist, a trained physical therapist(F.J.v.d.G.), and five trained occupational therapistsperformed all clinical assessments in connection withthe hand function clinic. The principal investigator(F.J.v.d.G.) trained all evaluating occupational thera-pists in the performance of the clinical measure-ments, i.e., the joint count, the SODA and themeasurements of grip strength and joint ROM.Training sessions for calibration were repeated withevery occupational therapist every three months. Sociodemographic and Disease Characteristicsand General Health Status Sociodemographic data included gender, age, paidemployment, and status of living (living alone orliving with spouse and/or family). In addition, therheumatological diagnosis and the disease durationin years were recorded. Health condition(disorder or disease)Body functionsand StructuresActivities ParticipationEnvironmentalFactorsPersonalFactors  FIGURE 1.  The model of the International Classificationof Functioning, Disability and Health (ICF). This modelshows the relationship between the different ICF compo-nents. Each component consists of chapters and each chap-ter consists of categories. The patient perceived problemscan be located within the component ‘‘Body functionsand Body structures’’ and ‘‘Activities and Participation’’. 252  JOURNAL OF HAND THERAPY   General health status was measured by means of the RAND (Research and Development) 36-ItemHealth Survey, 13 which includes 35 items coveringeight dimensions of health status (physical function-ing, social functioning, role limitations caused byphysical health problems, role limitations caused byemotional health problems, pain, mental health, vi-tality,andgeneralhealthperception)andoneitemas-sessing changes in perceived health over the last 12months. Each dimension generates a score from 0 to100, with higher scores indicating better health. TheRAND can be converted to two summary scales:the physical and mental component summary scales.The RAND includes the same items as the MedicalOutcomes Study Short-Form and although the scor-ing procedures are somewhat different, the effectsof these on final scores are minimal. 14 WechosetheRANDbecausethisquestionnairehas been validated in a Dutch population. 13  Joint Swelling and Deformities Based on a 28 joint count, 15  joint swelling of themetacarpophalangeal joints (MCP; 10 joints), theproximal interphalangeal joints (PIP; eight joints)and the interphalangeal joints of the thumbs (IP;two joints) was assessed in a yes/no format for every joint, with the total joint swelling score for the handsranging from 0 to 20. The presence of deformities(Boutonnie`re deformity, swan-neck deformity and/or ulnar deviation of MCP joints) was listed on a bi-nary scale for each finger or thumb. In addition, thepresence of tendon ruptures and Heberden nodulesor RA nodules was recorded.  Assistive Devices and Splint Usage Possession of assistive devices or splints for hand,finger, or wrist function was noted. For that purpose,the assessor read out a list of 27 frequently usedassistive devices and asked with each device whetherthe patient had the device and if so, whether it wasused on a regular basis. Primary Hand Function Problems The patient’s individual problems and challengesregardinghandfunction wereobtainedbymeansofasemistructured interview. All impairments, limita-tions, or restrictions were categorized and labeledafterward according to the ICF 6 (see ICF Appendix).Furthermore, patients were asked to rank the threelimitations and/or problems that were most trou- bling to them. At the follow-up assessment, patientswere asked to rate the changes regarding their mainproblembymeans ofa5-point Likert-scale (1 ¼ muchimproved, 2 ¼ improved, 3 ¼ not changed,4 ¼ worsened, 5 ¼ much worsened). Range of Motion The ROM of the wrist (sum of palmar and dorsalflexion)andfingerjoints(palmarflexion)wasassessedwith a goniometer according to the method of theAmerican Academy of Orthopaedic Surgeons. 16 Forthe thumb, palmar flexion of the MCP and IP jointsROM were summed. All scores regarding wrist andfinger joint ROM were calculated separately for theleftandrightaswellasaveragedfortheleftandright. Grip Strength Grip strength was measured with a Jamar dyna-mometer. 17 Patients were sitting on a chair withshouldersandwristinneutralpositionandtheelbowin 90 8 flexion. They were asked to squeeze the dyna-mometer as hard as possible and were vocallyencouraged. Patients performed the test twice witheach hand; the higher score was recorded. The scorewas calculated separately for the left and right aswell as averaged over the left and right. Pain and Stiffness Hand pain during rest and motion and handstiffness were measured by means of a 10-cm hori-zontal visual analog scale for the left and right handseparately, with the left anchor representing no painor no stiffness at all and the right anchor the maximalpain or stiffness, respectively. An average score overthe left and right was calculated.  Hand Function Hand function was assessed by means of theSODA, 12 the hand and finger function domain of the Dutch Arthritis Impact Measurement Scales(AIMS-2) 18 and the Michigan Hand OutcomesQuestionnaire (MHQ). 19 With the SODA, the patient performed 12 stan-dardized tasks, some bimanual and some one-handed, representing all major grips such as pinchgrip, cylindrical grip, and writing grip. The assessorscored whether it was possible to perform the task inthe standardized way, the effort that the activity tookand the pain the patients experienced when perform-ing the task. The combination of the possibility toperform the tasks and the effort formed the SODAscore, ranging from 0 to 108, with a higher numberrepresenting better hand function. The pain patientsexperienced when performing the tasks formed theSODA pain score, ranging from 0 to 12, with a higherscore indicating more pain. The SODA has beenshown to be reliable, valid, and responsive to clinicalchanges in patients with RA. 12,20,21 The Dutch AIMS-2 is a questionnaire specificallydesigned to assess health status in subjects with RA.It consists of 12 domains, of which only the domain  July e September   2007  253  ‘‘hand and finger function’’ was used in this study.The domain consists of five questions, with the finalscore ranging from 0 to 10, with higher scores indi-cating worse hand function.The MHQ is a 37-item questionnaire covering sixdomains: overall hand function, ADL, pain, workperformance, aesthetics, and patient satisfaction withhand function. The latter four of these domains werescoredfor the right and left hand separately. The totalscore (average of all domains) ranges from 0 to 100,with higher scores indicating better hand function. ADutch version has previously been validated in 22patients with various hand conditions, includingnine RA patients. 22 Statistical Analysis Data are presented as medians with ranges orinterquartile ranges or means with standard devia-tion for continuous data, and numbers and percent-agesforcategoricaldata.Comparisonsofthebaselinecharacteristics between the group of patients whounderwent treatment and were available for follow-up and the group of patients who were not availablefor follow-up were done by means of the Mann-Whitney test or chi-square test where appropriate.Mean differences between baseline and follow-upscores of clinical outcome measures of hand functionwere calculated with a 95% confidence interval. Inaddition,the Wilcoxon ranktest wasused tocompare baseline and follow-up data. In the case of treatmentofonehand,andtheavailabilityofseparatescoresforthe right and left hand, additional change scores andWilcoxon rank tests were computed for the treatedhand only. Change scores of patients who underwentconservative therapy, surgical therapy, or a combina-tion were compared by means of a one-way analysisof covariance (ANCOVA), with baseline scores usedas the covariates. For all analyses, the level of signif-icancewassetat0.05,andalltestsweretwosided.Allanalyses were performed using the StatisticalPackage for Social Sciences (SPSS) version 11.0(SPSS inc. Chicago, IL). RESULTS All 69 consecutive patients referred to the multi-disciplinary hand clinic between January 2002 andApril 2004 participated in the study. The sociodemo-graphic and disease characteristics of the total group( n ¼ 69) are presented in Table 1. In addition, Table 1 shows the baseline characteristics of the group of patients who underwent treatment and were avail-able for follow-up separately ( n ¼ 33).With respect to the characteristics of the totalgroup, the majority of the population was female,with most of the patients having RA and aconsiderable disease duration (median 15.1 years).The median number of swollen MCP, PIP, or IP jointsper subject was 2 (range 0 e 14). Fifty (73%) patientshad one or more deformities. Thirty-one (45%) pa-tients had one or more boutonnie`re deformities (me-dian number of boutonnie`re deformities per subject:1 [range 1 e 5]), 32 (46%) patients had one or moreswan-neck deformities (median number of swan-neck deformities per subject: 3 [range 1 e 8]) andulnar deviation in one or more finger was presentin 35 patients (51%) (median number of fingers withulnar deviation per subject: 7 [range 1 e 8]). Tendonruptures, Heberden nodules, and RA nodules were TABLE 1.  Characteristics of 69 Patients with RheumaticDiseases Referred to a Multidisciplinary Hand Clinic(Total Group) Total groupEvaluated groupn ¼ 69 n ¼ 33 Sex (m/f) 15/54 5/28Age, years; med (range) 60.0 (21 e 84) 57.3 (21 e 80)Paid employment; no. (%) 14 (20) 7 (21)Living alone; no. (%) 17 (25) 7 (21) Diagnosis; no. (%) Rheumatoid arthritis 55 (80) 28 (85)Osteoarthritis 5 (7) 1 (3)Psoriatic arthritis 4 (6) 2 (6)Systemic lupuserythematosus3 (4) 1 (3)Mixed connective tissuedisease1 (1) 1 (3)Spondylarthropathy 1 (1) 0 (0)Disease duration, years; med(range)15.1 (0.2 e 51.0) 17.1 (0.2 e 43.0) RAND e 36 (0 e 100), med (range) Mental componentsummary scale,  n ¼ 6068.9 (15.1 e 100.0) 71.2 (23.8 e 94.0)Physical componentsummary scale,  n ¼ 6037.4 (4.3 e 87.5) 38.1 (16.9 e 87.5) Joint swelling (MCP þ PIP þ IP,0 e 20); med (range)2 (0 e 14) 2 (0 e 14)Boutonnie`re deformity; no. (%) 31 (45) 15 (46)Swan-neck deformity; no. (%) 32 (46) 16 (49)Ulnar deviation; no. (%) 35 (51) 12 (36)Tendon ruptures; no. (%) 21 (30) 7 (21)Heberden nodules; no. (%) 2 (3) 1 (3)RA nodules; no. (%) 6 (9) 4 (12)No. of assistive devices inpossession; med (range)6 (0 e 13) 6 (0 e 13) Splint possession; no. (%) Wrist splint(s) 31 (45) 16 (49)Thumb (CMC) splint 1 (1) 1 (3)Swan-neck splint(s) 14 (20) 6 (18)MCP ¼ metacarpophalangeal joint; PIP ¼ proximal interphalan-geal joint; IP ¼ interphalangeal joint; CMC ¼ carpometacarpal joint.Characteristics of the 33 patients in whom the advised treatmentwas executed and who were available for follow-up (evaluatedgroup) are presented separately. 254  JOURNAL OF HAND THERAPY   present in 21 (30%), two (3%), and six (9%) patients,respectively. Among the patients who had defor-mities, the median number of boutonnie`re defor-mities was 1 (range 1 e 5), the median number of swan-neck deformities was 3 (range 1 e 8) and themedian numberof fingers with ulnar deviation was 7(range 1 e 8). A tendon rupture was present in 21 of the 69 patients (30%).Thirty-one patients (45%) had wrist splints and 14patients (20%) had finger splints. Sixty-two patients(90%) used one or more of the listed assistive devicesrelated to hand function. Assistive devices that weremost frequently used were: an extended water tap( n ¼ 42, 61%), an enlarged pen grip ( n ¼ 30, 44%), andan elongated shoehorn ( n ¼ 30, 44%).A comparison of the baseline characteristics of thegroup of patients who underwent treatment and wasavailable for follow-up and the group who did notundergo treatment, showed no significant differ-ences. An exception was the proportion of patientswith one or more digits with ulnar deviation, whichwas significantly lower in the group of patients withtreatment and follow-up (chi-square test; p ¼ 0.02).Table 2 shows the problems patients were facingfrom their own perspective as categorized accordingto the ICF 6 (see ICF Appendix). With respect to thedomain denoted as Body functions and structures,patients clearly distinguished two types of problems,with the following common descriptions: 1) grip: theability to position the fingers and thumb around anobject with the intention to pick up, grab or holdthat object; and 2) grip strength: the ability to applyforce to an object while using a specific grip. Withinthe domain Body functions and structures, impairedgrip ( n ¼ 48, 70%), pain in the hand and/or wrist( n ¼ 40, 58%), and reduced grip strength ( n ¼ 24,35%) were the problems most frequently mentioned.The items that were most frequently perceived as aproblem in the domain Activities and participationwere: shaking hands ( n ¼ 21, 30%), cleaning activities( n ¼ 20, 30%), and participation in leisure activities( n ¼ 19, 28%).With respect to comparisons of problems betweenpatients who underwent treatment and were avail-able for follow-up versus the patients who did notundergotreatment, proportions of patients were onlydifferent with respect to the activity ‘‘buying grocer-ies’’ (p ¼ 0.03, chi-square test).The treatment advices are presented in Table 3. Of the 69 patients referred to the multidisciplinary handclinic, nine (13%) were reassured, four (6%) receivedtreatment advice that was not specifically related tothe hands (e.g., local treatment for shoulder or el- bow), and 56 (81%) received hand-related treatmentadvice.Twelve of the 56 patients (21%) received advicepertaining to surgical intervention only, 39 of 56patients (70%) received advice regarding one ormore conservative interventions only (occupationaltherapy and/or physical therapy and/or pharmaco-logical treatment) and five of 56 patients (9%)received advice for a combination of surgicalintervention and one or more conservative interven-tion(s). Of the 44 who received advice on one or moreconservative interventions, the advice included oc-cupational therapy in 33 patients (38 different mo-dalities), physical therapy in 15 patients (16 proposedtreatment modalities), and pharmacologicaltreatment in 15 patients (15 proposed treatmentmodalities). Totals add up to over 44 because insome subjects multiple conservative interventions ortreatment modalities were recommended. TABLE 2.  Perceived Hand Function Problems in 69 Pa-tients with Rheumatic Diseases Referred to a Multidis-ciplinary Hand Clinic (Total group) and in 33 Patients inwhom the Advised Treatment was Executed and Whowere Available for Follow-up (Evaluated Group) Total group(n ¼ 69)Evaluated group(n ¼ 33)Body functions and body structures, no. (%) Impaired grip (s730) 48 (70) 24 (72)Pain (b280) 40 (58) 18 (55)Decreased grip strength (b730) 24 (35) 13 (39)Hand stiffness (b780) 11 (16) 5 (15)Need for general information # 5 (7) 2 (6)Sensibility problems (b265) 3 (4) 1 (3)Cosmetic problems (b180) 2 (3) 1 (3)  Activities and participation, no. (%) Self-careDressing and undressing(d540)15 (22) 7 (12)Using cutlery (d550) 14 (20) 6 (18)Holding glasses and cups(d560)12 (17) 6 (18)Washing and dryingthemselves (d510)10 (15) 2 (6)Using toilet paper (d530) 8 (12) 3 (9)Domestic life, no. (%)Cleaning activities (d640) 20 (30) 6 (18)Preparing meals (d630) 11 (16) 6 (18)Buying groceries (d620) 10 (15) 8 (24)*Community, social and civic life, no. (%)Participation in hobbies(d920)19 (28) 11 (33)Participation in sports(d920)15 (22) 6 (18)Communication, no. (%)Shaking hands (d3602) 21 (30) 11 (33)Writing (d360) 16 (23) 7 (21)Using keyboard and mouse(d360)6 (9) 4 (12)Handling a telephone(d360)5 (7) 2 (6)*p , 0.05, chi-square test, comparison of patients who underwenttreatment and were available for follow-up ( n ¼ 33) and patientswho did not ( n ¼ 36). # Not definable in ICF.Numbers in parentheses refer to ICF codes.  July e September   2007  255
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