Background: This study identified whether Functional Index for Hand Osteoarthritis (FIHOA) is associated with pain, hand muscle strength, health-related quality of life, and radiographic severity in hand osteoarthritis (OA). Methods: We consecutively recruited 95 patients with hand OA. The FIHOA was used to assess questionnaire- based physical function in hand OA. Health-related quality of life was evaluated using EuroQol-5 dimension (EQ-5D). Radiographic changes of hand joints were measured by Kellgren-Lawrence (K-L) grade, which was determined based on total radiographic severity score and number of affected joints. Other measures included patient’s visual analogue scale (VAS) score for pain and performance-based function indexes such as grip and pinch strength. Statistical analysis was performed using Mann-Whitney U test, Spearman’s correlation analysis, and multivariate logistic regression analysis. Results: FIHOA score was negatively associated with grip and pinch hand strength and EQ-5D and positively correlated to VAS pain (p < 0.05 for all). There were significant differences of grip and pinch strength, VAS pain, EQ- 5D index, and EQ-VAS between two FIHOA groups (≤ 4 vs. > 4) (p < 0.05 for all). Multivariate logistic regression analysis showed that higher FIHOA score (FIHOA > 4) was related with increased VAS pain and with lower EQ-5D index (p = 0.008 and p = 0.013, respectively). There was no association between FIHOA score and measures of total radiographic severity score and number of affected joints. Conclusion: This study observes that FIHOA score is associated with patient-reported VAS pain, hand muscle strength indexes, and EQ-5D but not radiographic severity in hand OA. Keywords: Osteoarthritis, Hand, FIHOA, EQ-5D, VAS, Kellgren-Lawrence grade Background been frequently used in clinical trials [3, 4]. For assess- Hand osteoarthritis (OA) is a prevalent degenerative dis- ment of physical function based on a questionnaire for ease that leads to pain, joint deformity, functional dis- hand OA, outcome measures from the pain subscale of ability, and impaired quality of life [1, 2]. The clinical the Australian/Canadian (AUSCAN) Index , the phenotypes of hand OA seem to be heterogeneous Cochin hand functional disability scale , and the according to number and pattern of joint involvement. Functional Index for Hand Osteoarthritis (FIHOA)  The Outcome Measures in Rheumatology (OMERACT) have been used in clinical trials and have been shown to and the Osteoarthritis Research Society International be valid, reliable, and relevant. (OARSI) Task Force on Clinical Trials Guidelines have The FIHOA is a unidimensional questionnaire that is structurally different from the AUSCAN index, which * Correspondence: email@example.com measures pain, stiffness, and function dimensions [7, 8]. Division of Rheumatology, Department of Internal Medicine, Catholic A case-control study revealed that FIHOA score was grad- University of Daegu School of Medicine, 33, Duryugongwon-ro 17-gil, ually increased as the severity of hand OA increased . Nam-gu, Daegu 42472, Republic of Korea © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Kim et al. Advances in Rheumatology (2021) 61:19 Page 2 of 7 In a study that analyzed 18 patients with hand OA, Radiological assessment FIHOA score was found to be correlated with the degree Total radiographic severity scores were the sum of of radiological damage, but not synovial inflammation Kellgren-Lawrence (K-L) grade scores at a total of 20 based on magnetic resonance image (MRI) . Compat- joints such as 2nd – 5th distal interphalangeal (DIP) ible with previous studies [7, 8], Koutroumpas et al. con- joints, 2nd – 5th proximal interphalangeal (PIP) joints, firmed significant association between FIHOA and clinical thumb interphalangeal (IP) joint, and first carpometacar- assessment for erosive hand OA . In addition, FIHOA pal joint of both hands, which ranged from grade 0 to was noted to related with MRI-defined bone attrition in grade 80. The number of affected joints with any kind of 77 female patients with hand OA . However, there is a radiologic change was calculated for each subject lack of research data regarding FIHOA score and hand according to the K-L grading system. A single rheuma- muscle strength or quality of life in hand OA. The main tologist completing a training program (UH Jung) aim of this study is to determine association of FIHOA- provided radiographic digital images of hand joints from based functional status with pain, grip and pinch strength, the Korean College of Rheumatology. quality of life, and radiographic severity in hand OA. Muscle strength measurement Subjects and methods Measurement for grip strength in both hands was per- Study population formed with arms and elbows at right angles using a A total of 95 patients with Korean hand OA that met dynamometer (Jamar Hydraulic Hand Dynamometer, the American College of Rheumatology (ACR) classifica- Nottinghamshire, UK). Pinch strength for the first and tion criteria was recruited from the Rheumatology Clinic second fingers was measured by a pinch gauge (B&L En- and enrolled in this study from February 2019 to January gineering, Tustin, CA, USA). The mean values for grip 2020 . All patients showed radiographic changes at strength and pinch strength were presented after mea- more than one of both hand joints assessed according to surements on both hands. the Kellgren-Lawrence (K-L) grading system . This study excluded patients diagnosed with rheumatoid Statistical analysis arthritis, systemic lupus erythematosus, psoriatic Data are described as median (interquartile range [IQR]) arthritis, and gouty arthritis. for continuous variables and number (percentage [%]) for nominal variables. The Shapiro-Wilk test was applied Clinical information to test normality and showed a non-normal distribution. Demographic data were age (years), sex, body mass 2 The correlations between FIHOA score and clinical and index (BMI, kg/m ), systolic blood pressure (SBP, radiographic variables were measured by Spearman’s mmHg), diastolic blood pressure (DBP, mmHg), and correlation coefficient. The differences of variables symptom duration (months) at time of enrollment. between FIHOA ≤4 and FIHOA > 4 were calculated by Acute phase reactants, such as erythrocyte sediment rate Mann-Whitney U test. Multivariate logistic regression (ESR) and C-reactive protein (CRP), were measured. analysis was performed to identify clinical and radio- Pain was scored using a 100 mm Visual Analogue Scale graphic variables related to higher FIHOA score > 4 (VAS). The Functional Index for Hand Osteoarthritis along with the odds ratio (OR) and 95% confidence (FIHOA) questionnaire was assessed for hand physical interval (CI). A P value less than 0.5 was considered function scores from 0 to 30 and was composed of 10 statistically significant. Statistical analyses were doctor-administered questions with semi-quantitative performed by IBM SPSS Statistics 19.0 (IBM Corp., assessment on a 4-point Likert scale ranging from 0 to 3 Armonk, NY, USA). [7, 8]. This study used a Korean version of the FIHOA, which was validated in Korean patients with hand OA . FIHOA scores were divided into two groups based Results on four points (FIHOA ≤4 vs. FIHOA > 4) according to Baseline characteristics classification by an earlier study . Baseline characteristics of enrolled subjects are described in Table 1. The median age was 60.0 years (IQR 54.0– EuroQol-5 dimension (EQ-5D) measurement 66.0), and most subjects were female (n = 90, 94.7%). The Korean version of EQ-5D is a tool to measure The average values of grip strength and pinch strength health-related quality of life (HRQOL) . The EQ-5D were 20.0 (IQR 16.5–24.5) and 5.7 (IQR 4.8–6.5), consists of the EQ-5D index and the EQ-VAS. The EQ- respectively, and the median score of FIHOA was 65.0 5D index consists of five questions that ask about the (IQR 50.0–80.0). Radiographic changes were measured current state of health as mobility, self-care, usual as 6.0 (IQR 2.0–18.0) for total radiographic severity activities, pain/discomfort, and anxiety/depression. score and 5.0 (IQR 2.0–9.0) for affected joint count. Kim et al. Advances in Rheumatology (2021) 61:19 Page 3 of 7 Table 1 Baseline characteristics of enrolled subjects sex, symptom duration, BMI, SBP, DBP, ESR, CRP, total radiographic severity score, or number of affected joints. Variables Results Age (year) 60.0 (54.0–66.0) Sex, female (n, %) 90 (94.7) Variables associated with high FIHOA score Symptom duration (month) 6.0 (1.0–73.0) Mean grip and pinch strength, patient VAS pain, EQ- 5D index, and EQ-VAS were associated with high BMI (kg/m ) 23.4 (21.5–24.9) FIHOA score in univariate regression analysis (Table 3). SBP (mmHg) 127.0 (115.0–135.0) Multivariate regression analysis after adjusting for con- DBP (mmHg) 74.0 (69.0–80.0) founding factors of age, sex, and symptom duration ESR (mm/hr) 14.0 (9.0–32.0) revealed that high FIHOA score was significantly linked CRP (mg/L) 0.6 (0.6–0.8) to patient VAS pain and EQ-5D index (p = 0.008 and Past history p = 0.013, respectively). Hypertension (n, %) 24 (25.3) Diabetes mellitus (n, %) 10 (10.5) Discussion Grip strength This study assessed the relationships of FIHOA score with other outcome measures including pain, grip and Mean 20.0 (16.5–24.5) pinch hand strength, and EQ-5D in hand OA. In Right 20.0 (16.0–25.0) addition, correlation between functional impairment and Left 22.0 (16.0–25.0) radiographic damage was also explored. We found that Pinch strength FIHOA score was associated with patient-reported pain, Mean 5.7 (4.8–6.5) hand strength, and quality of life based on the EQ-5D in Right 6.0 (5.0–6.8) hand OA. In addition, higher FIHOA score was associ- ated with higher VAS pain score and lower EQ-5D index Left 5.5 (4.8–6.5) and EQ-VAS. However, there was no relationship VAS pain 34.0 (20.0–52.0) between FIHOA score and radiographic outcome. FIHOA 65.0 (50.0–80.0) The outcome measures of hand OA include pain, hand EQ-5D index 0.82 (0.77–0.87) physical function, and quality of life [3, 4]. Among the EQ-VAS 65.0 (50.0–80.0) several hand OA-specific measures for physical disability Total radiographic severity scores (0–80) 6.0 (2.0–18.0) that have been developed, such as the AUSCAN Index , the Cochin hand functional disability scale , and Number of affected joints (0–20) 5.0 (2.0–9.0) the FIHOA , FIHOA score is a unidimensional meas- Data were described as median (Interquartile range) or number (%) Abbreviation: BMI body mass index; SBP systolic blood pressure; DBP diastolic ure for functional impairment of hand OA and is con- blood pressure; ESR erythrocyte sedimentation rate; CRP C-reactive protein; sidered a feasible and valid questionnaire commonly VAS visual analogue scale; FIHOA Functional Index for Hand Osteoarthritis; EQ- used in clinical study. Efforts have been made to verify 5D EuroQol-5 dimension Average value of the sum of right and left hand scores the association between FIHOA score and other mea- Based on Kellgren-Lawrence grade sures in OA. The Health Assessment Questionnaire (HAQ) , which is a rheumatoid arthritis-specific Comparison of variables according to FIHOA group questionnaire for health status, was significantly associ- There were no differences in age, sex, symptom duration, ated with FIHOA score in hand OA (r = 0.73) and phys- BMI, SBP, DBP, ESR, CRP, total radiographic severity ical function scale of AUSCAN (r = 0.80) . Similarly, score, and number of affected joints between the high and EQ-5D, which is a generic measure for health-related low FIHOA groups (p > 0.05 for all) (Table 2). Subjects quality of life , was also validated in patients with with high FIHOA score had lower grip and pinch hand knee OA, showing a negative relationship of the Korean strength, higher patient VAS pain score, and lower EQ-5D version of Western Ontario and McMaster Scale (KWO- index and EQ-VAS scores (p < 0.05 for all). MAC) with the EQ-5D index . There is a lack of data on the association between FIHOA score and EQ- Associations between FIHOA score and variables 5D in hand OA. As far as we know, this study is the first Analysis for variables related with FIHOA score showed to find FIHOA score to be negatively related with EQ- that the score was negatively associated with mean grip 5D index and EQ-VAS, and patients with high FIHOA and pinch hand muscle strengths, EQ-5D index, and score showed a trend toward a lower EQ-5D index but EQ-VAS (Fig. 1). In contrast, FIHOA score was posi- not EQ-VAS in hand OA. Based on these observations, tively related with patient VAS pain. However, there functional impairment might be linked to health-related were no relationships between FIHOA score and age, quality of life in hand OA. Kim et al. Advances in Rheumatology (2021) 61:19 Page 4 of 7 Table 2 Comparison of variables according to FIHOA FIHOA ≤4(n = 49) FIHOA > 4 (n = 46) p values Age (year) 61.0 (54.6–67.5) 59.0 (54.0–63.3) 0.367 Sex, female (n, %) 46 (93.9) 44 (95.7) 0.530 Symptom duration (month) 24.0 (1.0–96.0) 4.0 (1.0–30.0) 0.120 BMI (kg/m ) 23.4 (21.3–24.0) 23.8 (21.5–25.9) 0.295 SBP (mmHg) 126.0 (114.0–135.0) 127.5 (119.5–135.5) 0.690 DBP (mmHg) 74.0 (69.0–80.0) 75.5 (69.5–80.3) 0.463 ESR (mm/hr) 14.0 (9.0–27.3) 14.0 (8.0–20.5) 0.376 CRP (mg/L) 0.6 (0.6–0.8) 0.6 (0.6–1.3) 0.295 Grip strength Mean 23.0 (19.3–25.0) 18.0 (13.9–22.3) < 0.001 Right 22.0 (18.0–27.5) 18.0 (14.0–22.5) 0.004 Left 23.0 (10.0–26.0) 17.5 (12.8–23.0) < 0.001 Pinch strength Mean 6.3 (5.3–7.1) 5.4 (4.0–6.4) < 0.001 Right 6.3 (5.1–7.3) 5.5 (3.5–6.5) 0.001 Left 6.0 (5.0–7.0) 5.5 (3.9–6.0) 0.002 VAS pain 22.0 (10.0–36.5) 48.5 (34.0–71.0) < 0.001 EQ-5D index 0.87 (0.82–0.91) 0.82 (0.7–0.86) < 0.001 EQ-VAS 70.0 (57.5–80.0) 50.0 (49.5–70.0) < 0.001 Total radiographic severity scores 6.0 (2.5–21.0) 8.5 (2.0–17.3) 1.000 Number of affected joints 5.0 (2.0–12.0) 5.5 (2.0–9.0) 0.917 Data were described as median (Interquartile range) or number (%) Abbreviation: BMI body mass index; SBP systolic blood pressure; DBP diastolic blood pressure; ESR erythrocyte sedimentation rate; CRP C-reactive protein; VAS visual analogue scale; FIHOA Functional Index for Hand Osteoarthritis; EQ-5D EuroQol-5 dimensio Average value of the sum of right and left hand scores Based on Kellgren-Lawrence grade Fig. 1 Correlation of FIHOA with VAS pain, hand strength, and EQ-5D. Abbreviation: VAS, visual analogue scale; FIHOA, Functional Index for Hand Osteoarthritis; EQ-5D, EuroQol-5 dimension Kim et al. Advances in Rheumatology (2021) 61:19 Page 5 of 7 Table 3 Determination of variables related with high FIHOA score Univariate regression Multivariate regression Variables OR 95% CI p values OR 95% CI p values Age (year) 0.978 0.934–1.025 0.362 0.940 0.864–1.022 0.149 Sex, female (n, %) 0.697 0.111–4.372 0.700 1.919 0.128–28.793 0.637 Symptom duration (month) 0.995 0.988–1.001 0.111 0.988 0.976–1.001 0.078 BMI (kg/m ) 1.060 0.900–1.226 0.535 ESR (mm/hr) 0.974 0.939–1.009 0.146 CRP (mg/L) 1.137 0.856–1.512 0.375 Mean grip strength 0.871 0.803–0.945 0.001 0.907 0.794–1.037 0.152 Mean pinch strength 0.525 0.368–0.748 < 0.001 0.803 0.445–1.448 0.466 Patient VAS 1.066 1.038–1.096 < 0.001 1.044 1.011–1.079 0.008 EQ-5D index 0.000 0.000–0.001 < 0.001 0.000 0.000–0.069 0.013 EQ-VAS 0.947 0.921–0.974 < 0.001 0.970 0.931–1.011 0.149 Total radiographic severity scores 0.996 0.963–1.030 0.815 Number of affected joints 0.988 0.913–1.070 0.773 Abbreviation: BMI body mass index; ESR erythrocyte sedimentation rate; CRP C-reactive protein; VAS visual analogue scale; EQ-5D EuroQol-5 dimension It has been previously demonstrated that FIHOA score The VAS pain scale is frequently used to assess was relatively well associated with radiographic damages in patient-reported pain in OA. Some studies have investi- hand OA [9, 10, 20, 21]. In assessment of correlation gated whether physical function measures such as between hand functional limitation by AUSCAN function FIHOA and AUSCAN indexes are associated with VAS and FIHOA score and radiographic damage, FIHOA score pain [11, 18]. A cross-sectional study revealed that was better correlated with radiographic structural changes FIHOA score was significantly associated with VAS pain than was the AUSCAN index . FIHOA scores revealed and AUSCAN pain subscale (r = 0.51 and r = 0.79, larger physical disability in patients with erosive OA respectively) . It has been reported that tenderness compared to those with non-erosive hand OA . In on palpation was significantly related to FIHOA score addition, number of radiographic remodeled joints was . Consistently, our study confirmed a close correl- markedly associated with FIHOA score in erosive OA. ation between FIHOA score and VAS pain. In addition, Number of joints with radiographic damage was shown to high FIHOA score was positively dependent on VAS be a predictor of functional impairment (β =0.54, 95% CI pain. This suggests that FIHOA score reflects to some 0.24–0.84, p < 0.01). Compatible with these studies, radio- extent the pain in hand OA patients, although this rela- graphic severity determined by the Kellgren-Lawrence scale tionship should be validated in a larger study population. was significantly associated with FIHOA score [9, 10]. Performance-based physical function tools such as However, this study observed lack of association between pinch and grip strength for measurement of physical radiographic outcomes such as total radiographic severity function of hands have been used in clinical studies of score and number of affected joints and FIHOA score. hand OA . Substantial evidence of a negative associ- Similarly, Roux et al. showed that FIHOA score was not ation of grip or pinch strength with AUSCAN function associated with number of OA joints with K-L grade ≥ 2, subscale has been noted [5, 18, 26]. Interestingly, Moe Verbruggen score, or osteophytes in Kallman score . et al. demonstrated a negative relationship between Ultrasound is a musculoskeletal imaging tool with many mean grip strength and FIHOA score (r = − 0.58) . advantages over radiography in reliable and reproducible Compatible with earlier data, the present study also detection of intra- and extra-articular structural abnor- found significant negative association between FIHOA malities, such as joint effusion, synovitis, bone erosions, score and two hand strength measures. This provides and therapeutic monitoring in arthritis . There is a adequate evidence that there is comparable equivalence close relationship between radiographic features and between questionnaire- and performance-based instru- ultrasound findings . However, FIHOA and AUSCAN ments in evaluating physical function of hand OA scores were not associated with ultrasound findings patients. [11, 24]. Important clinical questions about the rela- There are some limitations in this study. First, the tionship between functional impairment and diverse results of this study originated from cross-sectional ob- imaging tests, including conventional radiography, servation. Analysis of the causal relationships between should be confirmed in large studies. FIHOA scores and clinical features, hand strength, and Kim et al. Advances in Rheumatology (2021) 61:19 Page 6 of 7 radiologic findings is needed in prospective studies. Received: 5 October 2020 Accepted: 8 March 2021 Second, the patient reported FIHOA index does not evaluate the relevance of AUSCAN function subscale and Cochin hand function scale. The clinical, physical, References 1. Marshall M, Watt FE, Vincent TL, Dziedzic K. Hand osteoarthritis: clinical and radiographic measures related to FIHOA score in phenotypes, molecular mechanisms and disease management. Nat Rev hand OA need to be verified using other hand function Rheumatol. 2018;14(11):641–56. https://doi.org/10.1038/s41584-018-0095-4. tools such as AUSCAN and Cochin hand function scale. 2. Zhang W, Doherty M, Leeb BF, Alekseeva L, Arden NK, Bijlsma JW, Dincer F, Dziedzic K, Hauselmann HJ, Kaklamanis P, Kloppenburg M, Lohmander LS, In addition, most of the patients in this study consisted Maheu E, Martin-Mola E, Pavelka K, Punzi L, Reiter S, Smolen J, Verbruggen of women. Women have higher incidence and preva- G, Watt I, Zimmermann-Gorska I, ESCISIT. 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Advances in Rheumatology – Springer Journals
Published: Mar 19, 2021