Rheumatology Advance Access originally published online on February 28, 2007
Rheumatology 2007 46(6):963-967; doi:10.1093/rheumatology/kem005
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The impact of musculoskeletal hand problems in older adults: findings from the North Staffordshire Osteoarthritis Project (NorStOP)
Primary Care Musculoskeletal Research Centre, Primary Care Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK
Correspondence to: Dr K. Dziedzic, arc Senior Lecturer in Physiotherapy, Primary Care Musculoskeletal Research Centre, Primary Care Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK. E-mail: k.s.dziedzic{at}keele.ac.uk
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Abstract |
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Objectives. Hand problems are common in older people, but their impact on everyday life is not clear. The aim of this study was to investigate the impact of hand problems in community-dwelling older adults and how this varies with age and gender.
Methods. Analysis was performed in 7878 subjects who responded to a baseline questionnaire. Participants defined as having hand problems were sent a second questionnaire, which included questions about hand pain and disability. Severe disability was defined as a score of 4 or more points on a validated hand and finger function scale. Estimates of 1-month period prevalence of hand pain and severe disability were calculated for the total responder population, by age and gender.
Results. 2113 persons with hand problems completed Stage 2 (78.6% response). One-year period prevalence of hand problems was 47% and estimated 1-month period prevalence of hand pain was 30.8%. These figures varied little with age. Severe hand-related disability affected 12.3% (95% confidence interval 11.3–13.3%) of this sample, was significantly more common in females than males, and increased in prevalence to the oldest age-groups.
Conclusions. Musculoskeletal hand problems are common in the population aged over 50 yrs. Most are painful, and have a significant impact on everyday life. Women and the very old appear especially vulnerable to the effect of hand problems on their daily activities.
KEY WORDS: Hand pain, Osteoarthritis, Hand problems, Disability, Older adults
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Introduction |
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TopAbstractIntroductionParticipants and methodsQuestionnairesResultsDiscussionAcknowledgementsReferences |
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Musculoskeletal diseases have a major impact on the health of the population [1, 2]. They are the commonest cause of disability and the most frequent reason for long-term absence from work [3–6]. In older people the dominant problem and the most frequent cause of pain and disability in this age-group is joint pain. The focus of attention in this age-group has been on the extent to which lower limb joint pain—usually attributed to osteoarthritis—limits mobility and physical activity. Less attention has been given to the hand despite the fact that it is one of the most common sites of pain and osteoarthritic change in this age-group [4, 5, 7]. Furthermore, recent population studies have highlighted the high prevalence of hand pain and disability in older people [8–10]. We report on a population survey of adults aged 50 yrs and over in North Staffordshire, England, which describes the patterns of hand problems (including pain and associated disability) with gender and age up to the oldest age-groups, and the related levels of health care use.
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Participants and methods |
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TopAbstractIntroductionParticipants and methodsQuestionnairesResultsDiscussionAcknowledgementsReferences |
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The design of the study was a two-stage cross-sectional postal survey of an older adult population sample using self-complete questionnaires. This survey was part of a larger study of joint problems in older people (NorStOP, the North Staffordshire Osteoarthritis Project). Ethical approval for all stages of the study was obtained from the North Staffordshire Local Research Ethics Committee.
Study population and setting
Full details of the study design and methods have previously been reported [11, 12]. Briefly, three general practices from the North Staffordshire Primary Care Research Consortium were recruited to the study. The sampling frame consisted of all adults aged 50 yrs and over registered with these three practices (n = 11 309). Questionnaires were mailed to participants (April 2002) and reminders were sent to non-responders after 2 and 4 weeks.
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Questionnaires |
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Stage 1—the Health Survey questionnaire
The first questionnaire included two questions about hand problems in the past 12 months: one enquired specifically about hand pain and the other about any other hand problem, giving the examples of hand stiffness and knobbly swellings on the fingers and thumbs. An adjusted response rate of 71.3% (n = 7878) to the Stage 1 Health Survey questionnaire was achieved [12]. Survey responders who answered positively to either of these two questions and gave permission for re-contact were mailed the Stage 2 questionnaire.
The Stage 1 questionnaire also collected information on demographic factors, and on general health using scores from two summary scales [Physical Component Summary (PCS) and the Mental Component Summary (MCS)] of the Medical Outcomes Survey SF 12 [13].
Stage 2—the Regional Pains Survey questionnaire
Participants were asked about the duration of their hand problems, hand dominance and history of injury or surgery to the hand, as well as questions about lower limb pain. Subscales of the Arthritis Impact Measurement Scales 2 (AIMS2) were used to measure the health status of individuals [14]. The AIMS2 was designed as a self-administered tool for use in either a clinical or home-based setting [14]. It has been used in a variety of settings in the US, including with osteoarthritis sufferers, and has been evaluated in UK population- and clinic-based studies of musculoskeletal hand problems [15]. In a systematic review of measures to evaluate outcome measures for hand problems in older people in the general population [16] the AIMS2 was one of the most highly rated across four criteria examined.
Scores for each AIMS2 subscale were calculated by summing the individual items, and normalizing them so that the potential range of scores is 0–10 where higher scores indicate most problems [14].
Hand pain
Participants were asked whether they had experienced any recent pain, specifically ‘in the past month any ache or pain that lasted for one day or longer in your hands’. If so, participants were asked to give the precise location of this recent hand pain using a hand drawing. These hand drawings were then scored using a standard transparent template to define pain in all or any of three regions of each pair of hands: the fingers, the thumb region and the palm or back of the hand. The drawings were also scored for laterality of pain (bilateral, unilateral). The pain subscale of the AIMS2 questionnaire [14] was used to assess pain severity and a subgroup of participants with ‘severe’ pain, i.e. those with scores in the top 25% of the observed distribution, was defined.
Hand function
Disability was measured in terms of hand and arm function. Hand function was measured using the AIMS2 hand and finger function subscale, which asks five questions on different every day tasks (writing, buttoning, turning a key, tying a knot, opening a new jar). Arm function was measured using the AIMS2 upper limb function subscale, which asks five questions on daily tasks for example, putting on a pullover, reaching shelves above head height. A subgroup of participants with ‘severe’ functional problems, i.e. those with scores in the top 25% of the observed distribution of the hand and finger function subscale, was defined.
Global impact of hand problems
The single item Impact AIMS2 subscale was completed [14]. This asks participants how their hand problem affects them, compared with other people of the same age.
Hand aesthetics
Hand aesthetics was measured using the 4-item appearance subscale of the Michigan Hand Outcomes Questionnaire (MHQ) [17]. The MHQ was developed as a hand-specific outcomes instrument containing six distinct scales: (i) overall hand function, (ii) activities of daily living, (iii) pain, (iv) work performance, (v) aesthetics and (vi) patient satisfaction with hand function. The scales have been shown to be reliable and valid [17]. Each item asks participants to rate different aspects of the appearance of their hands in the past month with answers on a 5-point Likert scale (‘Strongly agree’ = 1 to ‘Strongly disagree’ = 5). After reversing the scoring for one item, the scores for the four items are summed and then normalized so that the potential range of scores is 0–100 where higher scores indicate better self-reported appearance.
Health care and medication use
Details regarding self-reported health care consultations and treatments for their hand problems in the previous 12 months were obtained using an amended version of the Knee Pain Screening Tool (KNEST) [18]. The list of health care professionals included general practitioner (GP), physiotherapist, occupational therapist, hospital specialist, acupuncturist, osteopath and chiropractor. Participants were also asked to report whether they had had any medication, operations, or injections for their hand problems. A single question on frequency of use of medication (AIMS2 medication subscale) was also included, and scored using the protocol of Meenan et al. [14].
Analysis
Estimates of the 1-yr period prevalence of hand problems were calculated from responses to the Stage 1 Health Survey questionnaire. Overall prevalence and prevalence by gender and age-specific strata (50–59, 60–69, 70–79, 80+ yrs) are presented. One-month period prevalence of hand pain and severe hand disability were estimated by applying Stage 2 data, within age and gender strata, to the population mailed in Stage 1. We assumed that Stage 1 responders with hand problems who did not complete the Stage 2 questionnaire, had the same likelihood of hand pain and of severe hand disability as persons who did complete Stage 2. In order to determine the validity of this assumption, we explored demographic differences between responders and non-responders to the Stage 2 questionnaire. As the prevalence figures incorporated some estimated data, confidence intervals for these prevalence estimates were calculated using weighted logistic regression [19].
Using responders to the hand section of the Stage 2 Regional Pains questionnaire as the denominator population of persons with hand problems, summary data of characteristics and severity were calculated by gender and age-group.
All analysis was carried out in Stata 7.0.
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Results |
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TopAbstractIntroductionParticipants and methodsQuestionnairesResultsDiscussionAcknowledgementsReferences |
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Among responders to the Stage 1 Health Survey questionnaire, the proportion of people who reported hand problems during the previous year was 47.6% (n = 3749), most of them (n = 3449; 91%) having hand pain. This 1-yr period prevalence of any hand problem was significantly higher in females (53.4%) than males (40.2%) [difference (%) = 13.1%; 95% confidence interval (95% CI): 10.9–15.3%] but showed only a small increase in prevalence with increasing age in both males and females, which was not statistically significant (Table 1).
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Figure 1 details response rates for Stages 1 and 2 questionnaires. Responders who completed the hand questions in Stage 2 were more likely than non-responders in Stage 2 to be female [difference (%) = 7.1%; 95% CI = 2.6–11.7%] and to have significantly better mental health scores (SF-12 MCS mean difference = 1.22; 95% CI = 0.05–2.39), but there was no difference in the mean age and physical health status (SF-12 PCS mean difference = –0.78; 95% CI = –2.01, 0.45).
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The remainder of the analysis will focus on this subgroup of 2113 participants who reported hand problems in Stage 1 and completed Stage 2. The preliminary analysis was carried out separately in males and females and where no differences were observed the results are presented for the genders combined. The median lifetime duration of hand problems in this population was 6 yrs (interquartile range = 2–12 yrs), and the proportion with dominant right hand was 90% and with a history of injury to the hand was 26%.
Hand pain
Table 2 shows the characteristics of hand pain in this sample. Bilateral hand pain was more common than unilateral pain.
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The mean (S.D.) AIMS2 pain score among all those with hand problems was 4.03 (2.5). The mean score increased with age in both males and females. The proportion of participants classified with severe pain increased with age in females but not in males.
Hand function
Summary scores for hand function among Stage 2 responders are presented in Table 2. The mean (S.D.) AIMS2 hand and finger function score was 2.42 (2.5) and arm function score was 1.44 (2.1). The proportion of responders with severe functional limitations was significantly higher in females than males [29.3% compared with 18.3%, difference (%) = 11.0%; 95% CI = 7.3–14.6%] and increased with age, significantly so only in females (females-
2 = 40.93, P < 0.0001; males-2 = 4.41, P = 0.22).
Global impact of hand problems
Neither gender nor age influenced the AIMS2 Impact subscale score (Table 2).
Hand aesthetics
The Michigan aesthetics scores were significantly lower in females than males (mean difference = 9.8; 95% CI = 7.8–11.8) indicating lower levels of satisfaction with appearance in females (Table 2). The level of satisfaction significantly decreased with age in females (F3,1245 = 17.08; P < 0.0001), but not in males (F3,730 = 1.52; P = 0.21).
Health care use
Frequency of medication use was associated with severity of functional limitation (Table 3) with daily medication four times more likely to be reported by those with severe functional limitation (2 = 354.3; P < 0.0001). The proportion of responders reporting consultations for their hands in the previous 12 months was significantly higher in those with severe compared with non-severe functional limitation (2 = 116.7; P < 0.0001). The commonest health care item used was a doctor's prescription for medication (25% overall; 46% severe functional limitation, 17% non-severe), with all other options reported by fewer than 10% of participants, percentages being greater in those with severe, compared with non-severe functional limitation.
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Population prevalence
Key characteristics measured in Stage 2 were related back to the initial sample of Stage 1 survey responders. The estimated 1-month period prevalence of hand pain in the general population aged 50 yrs and over was 30.8% (95% CI = 29.5–32.1%) and of severely disabling hand problems was 12.3% (95% CI = 11.3–13.3%).
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Discussion |
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TopAbstractIntroductionParticipants and methodsQuestionnairesResultsDiscussionAcknowledgementsReferences |
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We have confirmed that hand problems, including hand pain, are common in the older population and that their overall prevalence does not increase substantially across the older age-groups. Most hand pain, even in our youngest age group of 50–59 yrs, was reported as being bilateral and persistent (more than 3 months in the past year). However, we have shown, using hand-specific measures of disability and pain severity and by ensuring sufficient numbers of people in the oldest age-groups, that the impact of these problems increases substantially with age into the oldest age-groups, and is more marked in women.
Whether the impact is measured in terms of pain severity, the number of painful areas in the hand, the degree of difficulty with hand-related tasks, or the extent of distress from the appearance of the hands, the proportion of people affected increases with age from 50–59 yrs up to 80+ yrs, notably in women. Furthermore, only a minority of sufferers are seeking or using health care for their hand problems.
Most participants with hand problems had hand pain. Our estimated 1-month period prevalence of hand pain in the general population aged 50 yrs and over was 
30%. There have been other recent population studies of the prevalence of hand pain, with prevalence estimates of pain varying from 12 to 21% [8–10]. Differences in prevalence estimates are likely to be due to the different instruments applied to measure hand pain and the differences in the age range and other characteristics of the populations studied. Our study also confirms Dahaghin et al.'s [9] finding that female gender was associated with more frequent hand pain overall, but older age was not. However, our study adds a different perspective to this picture by showing that the extent and severity of pain both increase in a clear trend into the 80+ yrs, and this trend is more marked in women.
There is more consistency in estimates of the prevalence of significant hand disability in older people across the recent population studies [8–10]. We estimated the 1-month period prevalence of severe hand disability in the general population aged 50 yrs and over to be 12%. This figure is consistent with those reported by Dahaghin et al. [9] and Walker-Bone et al. [10]. Dahaghin et al. [9] reported a general association of disability with female gender and age over 70 yrs. We have added to this picture by showing that the severity of specific hand-related disability including cosmetic concerns, increases in a trend across the age-groups and into the 80+ yrs, particularly in women.
Our participants represent a sample of those with hand problems in the population, most of whom (78%) reported that they had not consulted their GP about their hand problems within the last 12 months. In those not visiting their GP the proportion of people who do perceive a need for healthcare for their hand problem is unknown and warrants further investigation. Among those participants who had severe hand disability, only 38% had consulted their general practitioner and only 3% had consulted an occupational therapist. However, there is clear evidence that the impact of these problems is not trivial. The mean AIMS2 pain score was 4.03. This figure is similar to that observed in clinic patients who have osteoarthritis and who are likely to have more severe disease [14], underlining the extent and severity of pain arising from common hand problems such as osteoarthritis in the community.
Levels of disability related to common hand problems in the general population are, like pain, comparable with those found in clinic attenders with hand osteoarthritis [14].
This was the first population survey to include an assessment of satisfaction with hand appearance using a subscale of the Michigan Hand Outcomes Questionnaire. Aesthetic damage is recognized as a major concern for women with osteoarthritis [7] although it is rarely measured. Satisfaction with hand appearance reduced with increasing age in women but not in men, and thus is part of the increased impact of hand problems in the older age groups of women.
The implication of our study is that hand problems may play an increasingly important role in determining disability from middle years onwards, more so in women. The relatively low use of health care may reflect either the lack of effective treatments or the perception that health care cannot help [6] or a lack of awareness of available treatments, e.g. [20]. Equally, participants in our study may not feel their symptoms warrant treatment, or that hand pain is an inevitable part of later life. In this study, the impact measured by the single item ‘how does your hand problem affect you, compared to other people of the same age?’ does not increase with age which suggests that when older adults compare themselves to their peers, their own hand problems may not appear any worse.
Studies in patients with chronic knee problems suggest that there is a culture of assuming that ‘it is all due to age’ and that little can be done. And yet our novel finding that the specific limitations associated with the hand and the negative effect of the appearance of hands both continue to increase with age. We can also see that the majority of people even up to the oldest ages do not have severe hand problems, which suggests that the perception of it being ‘all due to age’ needs to be changed.
In this study, we have not considered clinical and diagnostic subcategories of those with hand problems. It is likely that most older people with hand pain in the general population have clinical osteoarthritis, even if it has not been labelled as such, but it may be that the impact of the problem varies with the severity of disease. The purpose of this study was to investigate the general impact of hand problems in a UK population sample of adults over 50 yrs and how this varies with age and gender, regardless of the specific cause of the problem.
A strength of this study was the high response rate which was enhanced by reminder letters. Maximizing the response rate tends to reduce the possibility of selection bias which, in turn, can enhance the generalizability of study findings. However, the generalizability of our study findings may be limited by a number of factors. Our population was recruited from the registers of three general practices in North Staffordshire. At the time of the survey the age and gender structure of the registered population at the three practices was similar to that of North Staffordshire and of England and Wales. However, it is possible that other important determinants of the occurrence of hand problems will vary from one region or country to another. These include cultural background, threshold for reporting disabling pain, and expression of need for health care.
Our survey has shown that such hand problems in a general population of adults of 50 yrs and over are common, painful and have a significant influence on many dimensions of health, including daily activities and cosmetic perceptions. Women and the very old appear especially vulnerable to the effect of hand problems on their everyday lives. The prevalence of significant hand problems in older people has implications for the treatment and prevention of pain and disability in this age group in primary care and the community.
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Acknowledgements |
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This study is supported financially by a Programme Grant awarded by the Medical Research Council, UK (grant code: G9900220) and Support for Science funding secured by the North Staffordshire Primary Care Research Consortium for NHS service support costs. K.D. was supported by a grant from the Arthritis Research Campaign. The authors would like to thank the administrative and health informatics staff at Keele University's Primary Care Sciences Research Centre and the doctors, staff, and patients of the three participating general practices. We would also like to thank Professor Elaine Hay for comments on the draft manuscript and Professor Deborah Symmons for the hand pain manikin template. We would like to thank the anonymous reviewers for their helpful comments.
The authors have declared no conflict of interest.
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