What is the recommended management for bilateral hand degenerative changes?

Management of Bilateral Hand Osteoarthritis

Begin immediately with patient education on joint protection principles, ergonomic modifications, and self-management strategies, combined with a structured hand exercise program—these non-pharmacological interventions form the foundation of treatment for all patients with hand osteoarthritis regardless of severity. 1

Initial Non-Pharmacological Management (First-Line for All Patients)

Education and Joint Protection

• Provide comprehensive education on the disease course, self-management principles, and all available treatment options at the initial visit. 1, 2
• Train patients in ergonomic principles, activity pacing, and proper use of assistive devices to minimize joint stress during activities of daily living. 1, 2
• Evaluate the patient's ability to perform ADLs and provide specific assistive devices as needed. 2

Exercise Program

• Prescribe exercises targeting both range of motion and muscle strengthening for all affected joints—this has Level 1a evidence with Grade A recommendation. 1, 2
• Tailor exercises specifically: thumb base exercises differ from interphalangeal joint exercises and must be individualized to the affected joint pattern. 2
• Exercises should specifically aim at improving joint mobility, muscle strength, and thumb base stability. 2

Orthotic Management

• For thumb base (carpometacarpal) osteoarthritis: prescribe either neoprene or rigid orthoses for long-term use (minimum 3 months) to achieve optimal symptom relief. 1, 2
• Custom-made orthoses are strongly preferred over prefabricated options to ensure proper fit and improve patient compliance. 2
• For DIP and other interphalangeal joint involvement: orthoses may be considered but have conditional rather than strong recommendation. 1, 2
• Critical pitfall: Splinting effectiveness requires consistent use for at least 3 months; shorter periods show minimal benefit. 2

Thermal Modalities

• Apply local heat (paraffin wax or hot packs) before exercise sessions for symptomatic relief—this has 77% recommendation strength. 1, 2
• Heat therapy is significantly more evidence-supported than therapeutic ultrasound (25% recommendation strength). 1, 2

Pharmacological Management (Stepwise Approach)

First-Line Pharmacological Treatment

• Topical NSAIDs are the first-choice pharmacological treatment due to superior safety profile compared to systemic medications. 1, 2
• Topical NSAIDs are particularly appropriate for mild-to-moderate pain affecting only a few joints. 2
• For patients ≥75 years old: use topical rather than oral NSAIDs due to safety concerns. 1, 2

Second-Line: Oral Analgesics

• If topical treatments provide inadequate relief, add acetaminophen (paracetamol) up to 4g/day as the oral analgesic of first choice. 2
• Oral NSAIDs should be used only at the lowest effective dose and for the shortest duration necessary. 1, 2
• For patients with increased gastrointestinal risk: prescribe either non-selective NSAIDs plus gastroprotective agent OR a selective COX-2 inhibitor. 2

Alternative Pharmacological Options

• Chondroitin sulfate may be used for pain relief and functional improvement (Level 1b evidence, Grade A). 1
• Topical capsaicin may be considered as an alternative topical treatment. 2, 3
• Tramadol may be considered for patients with inadequate response to other analgesics. 2

Intra-Articular Corticosteroid Injections

• Do NOT routinely use intra-articular glucocorticoid injections in hand OA. 1
• Exception: Consider intra-articular long-acting corticosteroid for painful interphalangeal joint flares, especially in the trapeziometacarpal joint. 1, 2

Treatments to AVOID

Do not prescribe conventional or biological disease-modifying antirheumatic drugs (DMARDs)—this has Level 1a evidence against their use. 1, 2

• Do not use therapeutic ultrasound (insufficient evidence of benefit). 1
• Do not prescribe bisphosphonates, colchicine, hydroxychloroquine, or methotrexate for hand OA. 1
• Avoid long-term oral NSAIDs due to gastrointestinal, cardiovascular, and renal adverse effects. 2

Surgical Intervention (When Conservative Management Fails)

Surgery should be considered only when patients have structural abnormalities with marked pain/disability AND other treatment modalities have failed to provide adequate pain relief. 1, 2

Specific Surgical Procedures by Location

• For severe thumb base (carpometacarpal) OA: trapeziectomy is the procedure of choice. 1, 2
• For interphalangeal OA: arthrodesis or arthroplasty should be considered. 1
• Evidence shows that combination surgical procedures (e.g., trapeziectomy plus ligament reconstruction) offer no advantage over single procedures but have higher complication rates. 1

Follow-Up Strategy

Long-term follow-up should be adapted to individual patient needs, with ongoing reinforcement of education and self-management principles at each visit. 1

Key Clinical Pitfalls to Avoid

• Do not delay non-pharmacological interventions: Education, exercises, and orthoses should begin immediately, not after pharmacological treatments fail. 1
• Do not prescribe short-term splinting: Orthoses require minimum 3-month consistent use for benefit. 2
• Do not use the same exercise protocol for all joints: Thumb base exercises differ fundamentally from interphalangeal joint exercises. 2
• Do not overlook patient age when prescribing NSAIDs: Patients ≥75 years require topical rather than oral formulations. 1, 2