What management strategies can help alleviate symptoms of stiffness and occasional pain in a patient with bilateral hand arthritis?

Management of Bilateral Hand Arthritis with Stiffness and Occasional Pain

For patients with bilateral hand arthritis experiencing stiffness and occasional pain, a comprehensive approach including exercises, orthoses, topical treatments, and oral medications should be implemented, with education on ergonomic principles and activity pacing as foundational elements.

Non-Pharmacological Interventions (First-Line)

Education and Ergonomics

• Education on joint protection principles, ergonomic techniques, and activity pacing should be offered to every patient 1
• Teach patients to:
  • Use larger/stronger joints for tasks when possible
  • Avoid prolonged gripping or pinching activities
  • Take regular breaks during hand-intensive activities
  • Use assistive devices for opening jars, bottles, and other challenging tasks 1

Exercise Program

• Hand exercises should be performed regularly to improve function, increase muscle strength, and reduce pain 1, 2
• Recommended exercise regimen:
  • Range of motion exercises: gentle finger and thumb flexion/extension, opposition movements
  • Strengthening exercises: squeezing soft objects, using therapy putty of appropriate resistance
  • Frequency: 2-3 times daily, 10-15 repetitions per exercise 2
• Benefits include small but significant improvements in pain (5% reduction), function (6% improvement), and joint stiffness (7% reduction) 2

Orthoses/Splints

• Thumb base orthoses should be considered for symptom relief, especially for patients with thumb base involvement 1
• Long-term use (at least 3 months) is recommended for maximum benefit 1
• Can be worn during activities that aggravate symptoms or at night to reduce morning stiffness 1

Heat Therapy

• Local application of heat (paraffin wax baths, hot packs) before exercise can provide temporary relief 1
• Heat therapy has stronger evidence (77% recommendation) compared to ultrasound (25% recommendation) 1

Pharmacological Interventions

Topical Treatments (First-Line)

• Topical treatments are preferred over systemic treatments due to safety considerations 1, 3
• Topical NSAIDs (particularly diclofenac gel) should be the first pharmacological treatment choice 1
• Capsaicin cream can be applied 3-4 times daily to affected joints 3
  • Patients should wash hands thoroughly after application unless treating the hands themselves

Oral Medications (Second-Line)

• Acetaminophen (up to 4g/day) should be used as the first oral analgesic due to its efficacy and safety profile 1, 4
• NSAIDs should be considered for a limited duration at the lowest effective dose when acetaminophen is insufficient 1
  • Consider cardiovascular, gastrointestinal, and renal risks
  • In patients with increased gastrointestinal risk, use non-selective NSAIDs with a gastroprotective agent or a COX-2 inhibitor
  • In patients with increased cardiovascular risk, COX-2 inhibitors are contraindicated and non-selective NSAIDs should be used with caution 1

Supplements

• Chondroitin sulfate may be used for pain relief and functional improvement 1
  • Effects are small but may be beneficial with low toxicity

Advanced Interventions for Refractory Symptoms

Intra-articular Injections

• Glucocorticoid injections are not generally recommended for hand OA but may be considered for painful interphalangeal joints 1
• Most beneficial for inflammatory flares rather than chronic symptoms

Surgical Options

• Surgery should be considered only when other treatments have failed to provide sufficient pain relief 1
• Options include:
  • Trapeziectomy for thumb base OA
  • Arthrodesis or arthroplasty for interphalangeal joint OA 1

Treatment Algorithm

1. Start with non-pharmacological approaches:

   • Education on joint protection and ergonomics
   • Daily hand exercises (range of motion and strengthening)
   • Heat therapy before exercises
   • Thumb base orthoses if indicated

2. Add topical treatments:

   • Topical NSAIDs (first choice)
   • Capsaicin cream as an alternative

3. If insufficient relief, add oral medications:

   • Acetaminophen (up to 4g/day)
   • Short-term NSAIDs at lowest effective dose if acetaminophen is insufficient
   • Consider chondroitin sulfate

4. For persistent symptoms:

   • Consider intra-articular glucocorticoid injections for painful interphalangeal joints
   • Surgical consultation if conservative measures fail

Monitoring and Follow-up

• Regularly assess pain levels, hand function, and range of motion
• Evaluate adherence to exercise program and proper use of orthoses
• Adjust treatment plan based on response and any adverse effects