Abstract
Background
There is a paucity of literature that examines how patient-reported outcomes correspond to early radiographic progression of thumb carpometacarpal (CMC) osteoarthritis (OA). This study examines how Australian/Canadian Osteoarthritis Hand Index (AUSCAN) and Patient-Rated Hand and Wrist Evaluation (PRWHE) scores change over 36 months in subjects with early CMC OA.
Methods
Ninety-one subjects with symptomatic early thumb CMC OA were enrolled. Differences in AUSCAN and PRWHE scores were measured between subjects at baseline and at 18-month follow-up, and between the subjects at baseline and at 36-month follow-up. Radiographic progression was defined as an increase in modified Eaton Stage. Differences in AUSCAN and PRWHE scores were compared between these 2 groups in order to determine if radiographic progression was associated with a greater change in AUSCAN and PRWHE at 18- and 36-month follow-up.
Results
At 18- and 36-month follow-up visits, there were no significant differences in AUSCAN or PRWHE compared to baseline. Multivariable logistic regression analysis did not reveal any significant differences between subjects with radiographic progression to subjects without radiographic progression at 18-month follow-up. At 36-month follow-up, this analysis did demonstrate that subjects with evidence of radiographic progression had a significant increase in the PRWHE pain subscale.
Conclusion
AUSCAN and PRWHE scores were not found to significantly progress at 18-month and 36-month follow-up. However, when comparing the subset of subjects with and without radiographic OA, subjects with early CMC OA who had 1 stage of radiographic progression were found to have a significantly higher intensity of pain on the PRWHE pain subscale at 36-month follow-up.
Keywords: thumb arthritis, thumb carpometacarpal arthritis, patient reported outcomes, early arthritis, CMC, arthritis, diagnosis
Introduction
The prevalent ailment of thumb carpometacarpal (CMC) osteoarthritis (OA) causes functional disability. 1 Surgery for this joint represents the most common arthritis procedure in the hand. 1 Prevalence increases with age: 38% of women and 27% of men older than 75 years develop thumb CMC OA. 2 Patients present with symptoms that range from occasional basilar thumb aching and pain, to debilitating pain that limits functional maneuvers such as pinching, grasping, or twisting.1,3 The etiology of CMC OA is multifactorial. Risk factors that have been associated with CMC OA include advanced age, female sex, family history, ligamentous laxity, and obesity.1,3,4
The thumb CMC joint is a semi-constrained joint that allows a high degree of motion.1,5 Multiplanar motion challenges joint stability, and instability may predispose the joint to developing OA. Previous investigations have demonstrated that there are morphologic and kinematic differences between the arthritic CMC joint and the native joint.6-8 Additionally, pinch and grip strength testing have been demonstrated to be highly reliable as objective indices for measuring hand function in subjects with advanced CMC OA (Eaton Stage III-IV).9,10 McQuillan and colleagues examined the extent to which early symptomatic CMC OA impacts function by quantifying the association between declining pinch strength and early symptomatic OA after controlling for age, sex, and body mass index. 4 They evaluated 3 different pinch positions (key, tripod, and tip pinch) and reported that key pinch had the most robust association with early CMC OA, in which a 20% decrease in key pinch strength was associated with a 10% increase in OA diagnosis. 4 Coughlan and colleagues also assessed hand function in subjects with early CMC OA. 11 They compared gross grasp strength to cylindrical grasp strength in 90 subjects with early CMC OA. They reported that cylindrical grasp may serve as a more sensitive measure for detecting changes in subjects with early symptomatic CMC OA.
A paucity of literature exists that examines how patient-reported outcomes correspond to early radiographic progression of CMC OA. Recently, McQuillan and colleagues demonstrated that Australian/Canadian Hand Osteoarthritis Index (AUSCAN) and Patient-Rated Wrist and Hand Evaluation (PRWHE) are valid and consistent patient-reported outcome measures (PROMs) in subjects with early CMC OA.12,13 This study aimed to examine how these patient-reported outcome measures change over time in subjects with modified Eaton Stage 0 or 1. 14 Specifically, the purpose of this study is to (1) examine how AUSCAN and PRWHE scores change over 36 months in subjects with early CMC OA and (2) to compare AUSCAN and PRWHE scores in subjects with and without radiographic evidence of progression of CMC at 18 months and 36 months after enrollment of subjects. We hypothesized that deterioration of PROMs correlates with early radiographic progression.
Material and Methods
Ninety-one subjects with symptomatic early CMC OA and early radiographic thumb CMC OA (modified Eaton Stage 0 or 1)14-16 were recruited at 2 institutions to participate in a prospective, longitudinal study that was designed to monitor the kinematics of the CMC as the degenerative disease progresses. Institutional review board approval was obtained at both institutions, and subjects were consented prior to data collection.
Subject screening included plain radiographs (anteroposterior, lateral, stress, and Robert’s views of the thumb) and a detailed clinical history. Subjects met the inclusion criteria if they reported pain or discomfort at the thumb CMC and radiographs demonstrated either modified Eaton Stage 0 or I CMC OA. Subjects were excluded if they reported a history of inflammatory arthritis, connective tissue disease, metabolic bone disease, radiographically evident OA in other joints of the wrist and trapezium, wrist and thumb fractures, ligamentous injury, and previous ipsilateral hand surgery. 4 Data were collected at baseline, 18 months, and 36 months. Subjects were withdrawn from the study if they underwent basilar thumb surgery. Eighty-five subjects completed testing at 18 months and 84 at 36 months. Radiographic progression was defined as an increase in modified Eaton Stage by a single stage from baseline (ie, Stage 0 or Stage 1). Subjects were categorized as subjects with radiographic progression or no radiographic progression.
In addition to radiographs, AUSCAN and PRWHE patient-reported outcome questionnaires were collected at each time point.12,13 AUSCAN is a validated instrument that has been utilized for hand and thumb OA studies.17-21 AUSCAN is a self-reported instrument that assesses hand pain, stiffness, and function/disability with 5-point scale (0 = none to 4 = extreme) questions about pain, stiffness, and physical function. 22 The total score ranges from 0 to 60, the function subscale ranges from 0 to 36, the pain subscale ranges from 0 to 20, and the stiffness subscale measures 0 to 4; a higher score corresponds to more severe pain, stiffness, and loss of function. PRWHE is a validated instrument that assesses patient hand and wrist function using 5 brief questions about pain and 10 questions about function, each question on a 10-point scale.12,23-25 The total score ranges from 0 to 100; 5 pain items account for 50 points and 10 functional items account for 50 points. Similar to AUSCAN, higher score corresponds to more severe pain and disability.
Statistical Analysis
Differences in AUSCAN and PRWHE scores were measured between CMC OA subjects at baseline and at 18-month follow-up, and between subjects at baseline and at 36-month follow-up using a paired 2-sample t-test. Differences in AUSCAN and PRWHE scores were compared between subjects with radiographic progression or no radiographic progression using a 2-sample t-test in order to determine if radiographic progression was associated with a greater change in AUSCAN and PRWHE at 18- and 36-month follow-up. Equality of variance was assessed using folded F statistic. Pooled variance was used when variance between groups was equal and Satterthwaite method was used in the case of unequal variance. Additionally, multivariable logistic regression was used to control for age, sex, and hand dominance in the comparison of the difference in these measures between OA subjects who progressed radiographically to those who did not at 18- and 36-month follow-up. Statistical significance was set at P < .05. All analyses were performed in SAS statistical software v9.4 (SAS Institute, Cary, NC).
Results
At 18- and 36-month follow-up visits, there were no statistically significant differences in AUSCAN or PRWHE compared to baseline (Tables 1 and 2). At 18 and 36 months, there were no significant differences in AUSCAN or PRWHE composite scores when comparing subjects with and without 1 stage of radiographic progression (Tables 3 and 4). Similarly, multivariable logistic regression analysis that controlled for age, sex, and hand dominance in the comparison of the difference in these measures between subjects who progressed by 1 stage radiographically to those who did not at 18-month follow-up did not reveal any significant differences (Table 5). However, at 36-month follow-up, subjects with evidence of radiographic progression did have a significant (mean difference of 1 point) increase in PRWHE pain subscale (Table 5).
Table 1.
PRWHE and AUSCAN at Baseline, 18- and 36-Month Follow-Up.
| CMC OA patients |
Baseline (0 months) |
18 months |
36 months |
||||||
|---|---|---|---|---|---|---|---|---|---|
| Variable | N | Mean | SD | N | Mean | SD | N | Mean | SD |
| PRWHE Pain | 91 | 17.2 | 11.5 | 85 | 15.6 | 10.6 | 84 | 16.0 | 11.3 |
| PRWHE Function Specific | 91 | 13.0 | 13.4 | 85 | 10.8 | 12.1 | 84 | 11.1 | 12.3 |
| PRWHE Function Usual | 91 | 9.4 | 8.8 | 85 | 8.1 | 8.1 | 84 | 8.1 | 8.6 |
| PRWHE Total | 91 | 28.7 | 21.9 | 84 | 25.6 | 20.0 | 84 | 25.9 | 20.8 |
| AUSCAN Pain | 91 | 6.6 | 4.1 | 85 | 6.1 | 4.0 | 84 | 6.4 | 4.2 |
| AUSCAN Stiffness | 91 | 0.9 | 0.9 | 85 | 1.0 | 0.9 | 81 | 1.0 | 0.9 |
| AUSCAN Function | 91 | 10.8 | 7.7 | 85 | 9.6 | 6.6 | 84 | 10.2 | 7.5 |
| AUSCAN Total | 91 | 18.2 | 11.9 | 85 | 16.7 | 10.7 | 81 | 18.2 | 11.6 |
Note. CMC = carpometacarpal; OA = arthritis; PRWHE = Patient-Rated Wrist and Hand Evaluation; AUSCAN = Australian/Canadian Hand Osteoarthritis Index.
Table 2.
Comparison of PRWHE and AUSCAN at Baseline to PRWHE and AUSCAN at 18- and 36-Month Follow-Up.
| Comparison between baseline and follow-up | Variable | N | Mean | SD | % Change (from baseline) | P-value (T-test—comparison to baseline) |
|---|---|---|---|---|---|---|
| 18-month difference | PRWHE Pain | 85 | −1.4 | 10.2 | −8.10 | .21 |
| PRWHE Function Specific | 85 | −1.5 | 12.1 | −11.67 | .25 | |
| PRWHE Function Usual | 85 | −1.0 | 7.2 | −11.03 | .19 | |
| PRWHE Total | 84 | −2.3 | 18.0 | −7.94 | .25 | |
| AUSCAN Pain | 85 | −0.3 | 3.7 | −4.67 | .45 | |
| AUSCAN Stiffness | 85 | 0.1 | 0.8 | 14.36 | .16 | |
| AUSCAN Function | 85 | −0.8 | 6.2 | −7.26 | .25 | |
| AUSCAN Total | 85 | −1.0 | 9.7 | −5.46 | .35 | |
| 36-month difference | PRWHE Pain | 84 | −0.7 | 11.9 | −4.01 | .60 |
| PRWHE Function Specific | 84 | −1.1 | 13.7 | −8.14 | .48 | |
| PRWHE Function Usual | 84 | −0.8 | 9.1 | −8.33 | .43 | |
| PRWHE Total | 84 | −1.6 | 21.5 | −5.69 | .49 | |
| AUSCAN Pain | 84 | 0.1 | 4.1 | 0.73 | .92 | |
| AUSCAN Stiffness | 81 | 0.2 | 0.9 | 17.81 | .12 | |
| AUSCAN Function | 84 | −0.2 | 6.8 | −2.10 | .76 | |
| AUSCAN Total | 81 | 0.6 | 10.7 | 3.05 | .64 |
Note. PRWHE = Patient-Rated Wrist and Hand Evaluation; AUSCAN = Australian/Canadian Hand Osteoarthritis Index.
Table 3.
PRWHE and AUSCAN at Baseline, 18- and 36-Month Follow-Up for Subjects With Radiographic Progression and Those Without Radiographic Progression.
| Baseline (0 months) |
18 months |
36 months |
|||||||
|---|---|---|---|---|---|---|---|---|---|
| N | Mean | SD | N | Mean | SD | N | Mean | SD | |
| Radiographic progression | |||||||||
| PRWHE Pain | 52 | 18.4 | 12.0 | 52 | 16.7 | 10.6 | 52 | 18.3 | 12.3 |
| PRWHE Function Specific | 52 | 13.6 | 14.0 | 52 | 12.5 | 12.8 | 52 | 14.3 | 13.9 |
| PRWHE Function Usual | 52 | 9.0 | 9.0 | 52 | 8.4 | 7.9 | 52 | 10.0 | 10.0 |
| PRWHE Total | 52 | 30.2 | 22.6 | 52 | 27.6 | 20.4 | 52 | 30.9 | 23.3 |
| AUSCAN Pain | 52 | 7.2 | 4.1 | 52 | 6.8 | 3.9 | 52 | 7.3 | 4.5 |
| AUSCAN Stiffness | 52 | 1.0 | 0.9 | 52 | 1.0 | 0.9 | 51 | 1.3 | 0.9 |
| AUSCAN Function | 52 | 11.4 | 7.4 | 52 | 10.5 | 6.2 | 52 | 11.8 | 8.3 |
| AUSCAN Total | 52 | 19.6 | 11.7 | 52 | 18.3 | 10.1 | 51 | 20.7 | 12.9 |
| No radiographic progression | |||||||||
| PRWHE Pain | 30 | 13.3 | 10.1 | 29 | 12.2 | 8.3 | 30 | 13.0 | 7.8 |
| PRWHE Function Specific | 30 | 9.7 | 11.5 | 29 | 6.7 | 6.4 | 30 | 6.4 | 6.6 |
| PRWHE Function Usual | 30 | 8.4 | 8.6 | 29 | 6.3 | 7.1 | 30 | 5.4 | 4.2 |
| PRWHE Total | 30 | 22.5 | 19.7 | 29 | 18.8 | 13.5 | 30 | 19.0 | 11.9 |
| AUSCAN Pain | 30 | 4.8 | 3.4 | 29 | 4.6 | 3.2 | 30 | 5.2 | 3.0 |
| AUSCAN Stiffness | 30 | 0.6 | 0.7 | 29 | 0.9 | 0.8 | 30 | 0.6 | 0.7 |
| AUSCAN Function | 30 | 8.8 | 7.4 | 29 | 7.3 | 5.5 | 30 | 8.1 | 4.6 |
| AUSCAN Total | 30 | 14.2 | 10.9 | 29 | 12.7 | 8.1 | 30 | 13.9 | 7.4 |
Note. PRWHE = Patient-Rated Wrist and Hand Evaluation; AUSCAN = Australian/Canadian Hand Osteoarthritis Index.
Table 4.
Comparison of Subjects With Radiographic Progression to Those Without Radiographic Progression From Baseline.
| Change over time | Variable | No radiographic progression |
Radiographic progression |
P-value (T-test) | ||||
|---|---|---|---|---|---|---|---|---|
| N | Mean difference | SD | N | Mean difference | SD | |||
| 18-month difference | PRWHE Pain | 39 | −2.2 | 9.7 | 46 | −0.7 | 10.7 | .4895 |
| PRWHE Function Specific | 39 | −3.3 | 9.8 | 46 | −0.0 | 13.7 | .2023 | |
| PRWHE Function Usual | 39 | −2.4 | 6.8 | 46 | 0.2 | 7.5 | .1007 | |
| PRWHE Total | 38 | −4.3 | 16.1 | 46 | −0.6 | 19.4 | .3557 | |
| AUSCAN Pain | 39 | −0.8 | 4.0 | 46 | 0.1 | 3.4 | .2615 | |
| AUSCAN Stiffness | 39 | 0.2 | 0.6 | 46 | 0.1 | 1.0 | .6027 | |
| AUSCAN Function | 39 | −1.3 | 5.7 | 46 | −0.3 | 6.7 | .4657 | |
| AUSCAN Total | 39 | −2.0 | 9.3 | 46 | −0.1 | 10.0 | .3742 | |
| 36-month difference | PRWHE Pain | 30 | −0.3 | 12.2 | 52 | −0.1 | 11.2 | .9235 |
| PRWHE Function Specific | 30 | −3.3 | 13.7 | 52 | 0.7 | 13.7 | .2057 | |
| PRWHE Function Usual | 30 | −3.0 | 8.7 | 52 | 1.0 | 8.9 | .0551 | |
| PRWHE Total | 30 | −3.5 | 22.3 | 52 | 0.7 | 20.4 | .3835 | |
| AUSCAN Pain | 30 | 0.4 | 3.5 | 52 | 0.2 | 4.1 | .7859 | |
| AUSCAN Stiffness | 30 | 0.0 | 1.0 | 51 | 0.3 | 0.9 | .228 | |
| AUSCAN Function | 30 | −0.7 | 7.2 | 52 | 0.4 | 6.6 | .4677 | |
| AUSCAN Total | 30 | −0.3 | 10.8 | 51 | 1.1 | 10.6 | .5683 | |
Note. PRWHE = Patient-Rated Wrist and Hand Evaluation; AUSCAN = Australian/Canadian Hand Osteoarthritis Index.
Table 5.
Multivariable Logistic Regression, Adjusted for Age, Gender, Dominant Arm—Comparison of Subjects With Radiographic Progression to Those Without Radiographic Progression.
| P-value | Odds ratio estimates |
R 2 | |||
|---|---|---|---|---|---|
| Point estimate | 95% Wald confidence limits | ||||
| 18-month progression | |||||
| PRWHE Pain | .6313 | 1.011 | 0.968 | 1.056 | 0.03 |
| PRWHE Function Specific | .2259 | 1.024 | 0.986 | 1.064 | 0.0448 |
| PRWHE Function Usual | .131 | 1.054 | 0.984 | 1.129 | 0.0563 |
| PRWHE Total | .4057 | 1.011 | 0.986 | 1.036 | 0.0315 |
| AUSCAN Pain | .2996 | 1.066 | 0.945 | 1.204 | 0.03 |
| AUSCAN Stiffness | .7677 | 0.924 | 0.547 | 1.56 | 0.0283 |
| AUSCAN Function | .4491 | 1.028 | 0.957 | 1.106 | 0.034 |
| AUSCAN Total | .376 | 1.021 | 0.975 | 1.07 | 0.0365 |
| 36-month progression | |||||
| PRWHE Pain | .03 | 1.054 | 1.005 | 1.105 | 0.104 |
| PRWHE Function Specific | .1589 | 1.029 | 0.989 | 1.07 | 0.0687 |
| PRWHE Function Usual | .6778 | 1.012 | 0.958 | 1.068 | 0.0456 |
| PRWHE Total | .0842 | 1.022 | 0.997 | 1.047 | 0.0816 |
| AUSCAN Pain | .6467 | 0.972 | 0.862 | 1.097 | 0.046 |
| AUSCAN Stiffness | .2988 | 1.327 | 0.778 | 2.263 | 0.0604 |
| AUSCAN Function | .6044 | 1.019 | 0.95 | 1.093 | 0.0467 |
| AUSCAN Total | .716 | 1.008 | 0.964 | 1.054 | 0.0491 |
Note. PRWHE = Patient-Rated Wrist and Hand Evaluation; AUSCAN = Australian/Canadian Hand Osteoarthritis Index.
Discussion
Our study aimed to examine how AUSCAN and PRWHE scores change over 36 months in subjects with early CMC OA, and to compare AUSCAN and PRWHE scores in subjects who demonstrated 1 stage of radiographic evidence of progression of CMC OA to those who did not at 18 months and 36 months after enrollment of subjects. This study found that at 18 and 36 months, there were no significant differences in AUSCAN and PRWHE composite scores, and that these scores did not correlate with radiographic progression in subjects with early CMC OA at 18-month follow-up. However, when examining the subset of subjects with and without radiographic OA at 36-month follow-up, subjects with early CMC OA who had 1 stage of radiographic progression were found to have a significant higher intensity of pain on the PRWHE pain subscale, as compared to their baseline values.
There are several limitations to this investigation. First, we examined 2 validated PROMs, AUSCAN, and PRWHE. We did not examine and thus do not know whether other PROM instruments exist which are capable of detecting the early subjective impact of OA progression, subjects with early CMC OA. Second, we defined radiographic progression in early disease as progression of a single modified Eaton stage. The progression by stage, especially in early disease, has not previously been a focus of CMC OA literature. The rate and severity of change in function and pain may potentially differ in progression between stages. For instance, Eaton 0 to 1 may have very little functional change compared to those progressing from Eaton 1 to 2. Third, the sample size of this study was powered to detect biomechanical changes over the 36-month period, so a larger sample size may have yielded significant changes in the PROMs.
Similarly, the CMC literature that includes PROM evaluation focuses on advanced arthritis. MacDermid and colleagues compared the validity of AUSCAN and PRWHE in subjects with advanced CMC OA reporting that they are valid assessments of pain and/or disability of hand OA. 23 In contrast, our study focuses on early CMC OA based on clinical symptoms, and baseline no or minimal radiographic changes. Comparison of these AUSCAN and PRWHE scores at 18-month and 36-month follow-up to the baseline revealed that subjects with early CMC OA who had 1 stage of radiographic progression were found to have a significant higher intensity of pain on the PRWHE pain subscale at 36-month follow-up. Sivieron and colleagues examined the longitudinal progression of hand OA, with no interventions, and reported that a 4-point worsening over 1 year in the total AUSCAN was the most reliable estimate of a minimal clinically important difference (MCID). 26 The differences in this cohort of thumb OA, even at 3-years, were well within this value, thus an MCID for thumb OA with these PROMs remains elusive.
Studies that have examined the relationship between radiographic progression of CMC OA with patient reported outcome measures have yet to identify an association between them. Botha-Scheepers and colleagues examined the relationship between radiographic progression of CMC OA and AUSCAN. 20 They evaluated prospective longitudinal data from 189 participants with hand arthritis. Of these participants, 31.4% (n = 54) had thumb CMC OA. At 2-year follow-up, they found no association of radiographic progression with deterioration of the pain or function subscales of AUSCAN. The cohort of subjects included in the study had general hand osteoarthritis limiting the generalizability of their results to subjects with isolated CMC OA.
Our study supports that radiographic progression as measured over 36 months is limited to correlating with a single subscale of the PRWHE. Patients with early CMC OA who had 1 stage of radiographic progression were found to have a significantly higher intensity of pain on the PRWHE pain subscale at 36-month follow-up. We will follow our cohort of symptomatic subjects to completion of the 72-month study that will examine correlations in clinical measurements to imaging parameters in an effort to elucidate a predictive indicator of thumb CMC OA progression.
Footnotes
Author’s Note: This investigation was performed at the Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Rhode Island Hospital and the Department of Orthopedic Surgery, Stanford School of Medicine.
Ethical Approval: This study was approved by our institutional review board.
Statement of Human and Animal Rights: Institutional Review Boards approved this study.
Statement of Informed Consent: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Informed consent was obtained from all patients for being included in the study.
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under Award Number R01 AR059185. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Ethical review committee statement: This investigation was approved by the Lifespan and Stanford University IRB committees.
ORCID iD: Joseph A. Gil 
https://orcid.org/0000-0002-0117-1026
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