Hand problems in community-dwelling older adults: onset and effect on global physical function over a 3-year period
1Arthritis Research Campaign National Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, UK.
Correspondence to: E. Thomas, Arthritis Research Campaign National Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire ST5 5BG, UK. E-mail: e.thomas{at}keele.ac.uk
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Abstract |
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Objective. To determine the impact of the onset of hand problems on global physical functioning in community-dwelling older adults.
Methods. Three-year follow-up postal survey of a population sample of older adults (50 yrs and over) previously recruited to the North Staffordshire Osteoarthritis Project. Questionnaires at baseline and 3-yr collected data on joint pain in the past 12 months in the hands and lower limbs, and physical functioning [SF-36 subscale (PF-10)]. Onset of hand problems at 3 yrs was determined in two subgroups: (i) those free from hand problems and lower limb pain at baseline (n = 762) and (ii) those free from hand problems but with lower limb pain at baseline (n = 754). Changes in PF-10 scores from baseline to 3 yrs were examined in these two subgroups.
Results. Onset of hand problems was similar in the two subgroups (20.6 and 24.3% in those without and with baseline lower limb pain, respectively). Females had a higher onset than males but age had little influence. Significantly greater mean change in PF-10 scores was seen in those who reported hand problem onset compared with persons who remained free of hand problems; 8.47 vs 4.62 and 4.78 vs 1.08 in those without and with baseline lower limb pain, respectively.
Conclusions. The development of hand problems has a detrimental effect on global physical functioning even in the absence of concurrent lower limb problems. The assessment and effective treatment of hand problems could prove to be important components of maintaining function in the older adult with joint pain and OA.
KEY WORDS: Hand (regional rheumatism), Osteoarthritis (rheumatic diseases), Disability evaluation (psychological and social phenomena), Epidemiology (basic and clinical sciences), Primary care rheumatology (health services and practice)
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Introduction |
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Clinical OA can be considered as a syndrome of pain and restricted mobility in the joints of older people, variably associated with radiographic evidence of cartilage loss and bone changes [1]. It is the single most common cause of restricted activity in daily life in the older UK population [2–5]. The lower limb joints are the most disabling location for this syndrome, but OA of the hand is its most common form [3, 6]. Although there have been fewer studies of the impact of hand pain and hand OA on everyday life in older people, compared with studies of knee and hip OA, the evidence indicates that hand OA does contribute significantly to restricted activities associated with upper limb and hand function in this age group [7].
In planning approaches to primary and secondary prevention of the consequences of OA in older people, it is important to know what the most productive targets for intervention might be. Evidence for effective treatment, e.g. NICE OA guidelines [1], is frequently derived from studies at single joint sites. However, concurrent involvement of several joints is more common than OA restricted to a single site [8]. In cross-sectional studies, the disability attributable to chronic knee pain, for example, is greater in persons who have concurrent pain in multiple other sites [9].
We hypothesized that development of hand problems will significantly compromise a person's everyday capacity to function and participate in activities of daily living and that compromise will exacerbate the effect of existing lower limb pain on these daily activities.
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Patients and methods |
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This was a prospective postal survey (recruitment and 3-yr follow-up) of an older adult population using self-complete questionnaires. Both baseline and 3-yr follow-up surveys consisted of a two-stage process involving an initial health survey (HS) questionnaire and a subsequent more intensive regional pains survey (RPS) questionnaire. Ethical approval for all stages of the study was obtained from the North Staffordshire Local Research Ethics Committee and participants completed a consent form, according to the Declaration of Helsinki, on the baseline HS giving permission for the use of their data and for re-contact.
Baseline survey
Detailed methods of, and results from, the baseline survey have been presented previously [7, 10–12]. In summary, the population registers of three general practices from the North Staffordshire Primary Care Research Consortium were used as a sampling frame for an initial two-stage questionnaire survey to recruit a cohort of 7878 adults aged 50 yrs and over. Approximately 98% of the British population is registered with a general practitioner (GP), making GP lists an appropriate sampling frame for a population study [13].
The HS questionnaire
The survey collected data on gender and date of birth to ensure the correct person had responded to the questionnaire. Current or most recent job title was used to determine the individual's socio-economic classification [14, 15]. Global physical function was assessed using the physical function scale (PF-10) from the Medical Outcomes Survey Short Form-36 (SF-36), a questionnaire validated for use in postal surveys [16]. The PF-10 is comprised of 10 questions that ask about limitation with different aspects of physical functioning. Each item has three response options (‘limited a lot’, ‘limited a little’ and ‘not limited’) and the items are totalled to obtain a score from 0 to 100 with 100 representing no physical function problems.
The presence of hand problems in the past 12 months was collected using two screening questions: 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. Three similar screening questions collected information about the presence of lower limb pain in the past 12 months: pain in or around the hips, the knees or the feet.
Those responding positively to any of the five screening questions regarding pain in the past 12 months on the HS questionnaire, i.e. hand, hip, knee or foot pain or hand problems, and giving permission for re-contact were mailed the RPS questionnaire.
The RPS questionnaire
The survey contained separate detailed sections for each of the problem/pain areas, but also repeated the five screening questions completed on the HS questionnaire.
Definition of baseline groups for follow-up
Information from the HS and RPS questionnaires was combined to define a group of participants ‘free from hand problems’—participants who responded negatively to the two hand-related screening questions on the HS questionnaire, confirmed by negative responses to the same questions on the RPS questionnaire for those eligible to receive this questionnaire. This definition considered the consistency of responses across the two questionnaires and any participant with missing or contradictory responses on the two questionnaires was excluded from the main analysis.
A similar approach was applied to the hip, knee and foot baseline data to form two groups: one group ‘free from lower limb pain’, i.e. no hip, knee or foot pain, and one with ‘lower limb pain’, i.e. a positive response to any of the hip, knee or foot screening question on the HS questionnaire, confirmed by a positive response to the equivalent question on the RPS questionnaire.
Three-year follow-up survey
A second, follow-up survey was carried out 3 yrs later in all participants who gave permission for follow-up at baseline and were still eligible for follow-up after checks by the GP for exclusions (for example, severe psychiatric, terminal illness or death). All eligible participants were sent a HS questionnaire, similar to that used at baseline, in which the same five screening questions regarding hand problems and lower limb pain were repeated. As at baseline, responses to the screening questions were used to define hand problem status, i.e. either ‘free from hand problems’ or ‘with hand problems’, and lower limb pain status, i.e. either ‘free from lower limb pain’ or ‘with lower limb pain’ at 3 yrs.
Statistical analysis
This analysis focused on the cohort of respondents who were defined as being ‘free from hand problems’ at baseline, and who completed and returned the 3-yr follow-up survey. Two separate subgroups of this cohort were formed for analysis: (i) those ‘free from hand problems’ and ‘free from lower limb pain’ at baseline and (ii) those ‘free from hand problems’ but ‘with lower limb pain’ at baseline.
Onset of hand problems, defined as the subsequent presence of hand problems reported in the 3-yr HS questionnaire, was studied separately in the two subgroups. Onset was reported as simple numbers and percentages, both overall, and by gender and age groups (age at baseline: 50–69 yrs, 70 yrs and over). Onset was compared across the two subgroups, overall and in gender and age groups, by calculating percentage differences and 95% CIs.
Change in PF-10 scores (baseline–3 yr) was calculated and the distribution of the change scores was confirmed as normal. For each of the two subgroups of the analysis cohort, mean difference in change scores, with a 95%CI, was computed between those who did and did not report the onset of hand problem at the 3-yr follow-up survey, both overall and comparing across gender and age group. Gender and age group (50–69 yrs, 70 yrs and over) adjusted differences in the PF-10 score, in each of the two subgroups, were calculated using linear regression to establish whether any differences seen were explained by difference in gender and age group.
All analyses were carried out in Stata 7.0.
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Results |
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Of the 7878 respondents to the baseline HS questionnaire, 3761 were defined as ‘free from hand problems’ at baseline. Of these, 2278 (60.6%) were mailed a 3-yr HS questionnaire, as they had given permission and were eligible to be re-contacted after the GP check for exclusions, to which 1901 responded. After adjusting for exclusions occurring during the mailing process, this represented a response of 84% in those eligible for follow-up. Of these 1901 responders, 1516 could be ascribed lower limb baseline status, follow-up hand status and PF-10 scores at baseline and follow-up could be calculated. This final sample of 1516 thus represents 40.3% of the original cohort of older persons free of hand problems at baseline, and 66.5% of those who were eligible to receive a follow-up questionnaire.
Table 1 presents comparisons of baseline data between the four responder groups, i.e. all those free from hand problems (n = 3761), those eligible for follow-up at the start of the 3-yr HS mailing (n = 2278), those responding to the 3-yr HS questionnaire (n = 1901) and those with complete data for this analysis (n = 1516). The age and gender make-up of these four groups were very similar. Those mailed the 3-yr HS questionnaire were more likely to be in a non-manual occupation, and report higher levels of physical function but were more likely to report lower limb pain at baseline compared with those who were not mailed the questionnaire. However, these characteristics were not associated with response to the 3-yr HS questionnaire or with having complete data for analysis. We have used the group with full data (n = 1516) as our study cohort for the analyses in this article.
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In this cohort of 1516 participants free from hand problems at baseline, 762 were also free from lower limb pain at baseline (50.3%) whilst 754 had baseline lower limb pain (49.7%). Onset of hand problems at 3 yrs occurred in 340 of the 1516 (22.4%). Onset was similar in the two subgroups [157 (20.6%) and 183 (24.3%) in those without and with baseline lower limb pain, respectively]. Onset in females was not different across the subgroups. However, males with no lower limb pain at baseline had a statistically significant lower likelihood of reporting hand pain onset at 3 yrs than those males with lower limb pain at baseline [percentage difference (95% CI): –6.9% (–12.4%, –1.4%)]. Onset in the younger age group was similar in the two subgroups but was statistically significantly lower in the older age group with no lower limb pain at baseline [–10.5% (–18.6%, –2.1%)]. A similar pattern was seen in the age groups within females and males (Table 2).
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As expected, baseline PF-10 scores were lower (i.e. worse function) in the subgroup of 754 persons with lower limb pain at baseline than in the 762 with no lower limb problems. There was, however, a subsequent deterioration in PF-10 scores at 3-yr follow-up in both subgroups (Table 3). Among the 762 persons free from both hand and lower limb problems at baseline, mean (S.D.) change in PF-10 scores at 3 yrs was 5.41 (16.3). This figure was significantly greater in those who reported onset of hand problems at the 3-yr follow-up compared with persons who remained free of hand problems [8.47 vs 4.62; mean difference in change scores (95% CI): 3.85 (1.00, 6.71)]. This greater deterioration in those with hand pain onset was seen for both genders (statistically significant in males) and both age groups (statistically significant in those aged 50–69 yrs). The mean difference in PF-10 change score altered little after adjusting for gender and age, hence the greater deterioration in the PF-10 scores in those reporting the onset of hand pain was independent of influences of gender and age.
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Among the 754 persons who at baseline were free from hand problems but who did have lower limb joint problems, the mean 3-yr reduction in PF-10 score was 1.98 (18.5). This figure was significantly larger in persons who reported hand problems onset at the 3-yr follow-up compared with those who did not [4.78 vs 1.08; mean difference 3.70 (0.64, 6.77)]. Again, this greater deterioration in those with hand pain onset was seen for both genders (statistically significant in males) and both age groups. The mean difference in PF-10 change score and was maintained after adjustment for gender and age, suggesting a deterioration in physical function that is independent of gender and age effects.
One critical question is whether the decline in PF-10 scores in people who had lower limb pain at baseline and who went on to develop hand problems at 3 yrs may simply be attributed to the progressive effect of the concurrent lower limb problems. We therefore repeated the PF-10 analysis in the subgroup of respondents with lower limb pain at baseline who also reported lower limb pain at 3-yr follow-up, i.e. those who reported lower limb pain at both time points. This analysis yielded very similar results to the full analysis (data not shown).
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Discussion |
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This analysis of a cohort of older persons drawn from the population who were free of hand problems at the start of a 3-yr follow-up period has confirmed our hypothesis that the onset of hand problems adds to the impact of existing lower limb joint pain on global physical functioning. The analysis has, however, also established that the development of hand problems has a detrimental effect on global physical functioning even in the absence of concurrent lower limb problems and this was found to be statistically significant. The additional decline in PF-10 score over and above that observed in the groups who did not develop hand problems was similar in size in the groups with and without baseline lower limb joint pain. However, those with lower limb joint pain already had limited global physical function and the development of hand problems added further to this limitation.
The greatest difference in hand onset between the two baseline lower limb pain groups was in the older men—those with no lower limb pain at baseline had an onset rate that was approximately a third of that seen in men in the same age group who did report lower limb pain at baseline, i.e. 11 compared with 29%. This large difference was responsible for the significantly lower onset figures in those with no lower limb pain seen in the older age group (17 compared with 27%) and in males (16 compared with 23%). We suggest that this interesting finding may be partly explained by a healthy survivor effect, i.e. those aged 70 yrs and over with no recent lower limb pain and, of course, no hand pain, may be at lower risk of developing it than those who report pain in the lower limb pain region. This pattern was much more obvious in males than females which may be a reflection of the greater propensity of females to report hand problems in general [7, 17] as well as specific hand conditions, e.g. carpal tunnel [18].
For this analysis we made the decision to use a measure of global physical function, i.e. the PF-10 [16], rather than one specific to the hand, e.g. the AUSCAN [19] or the AIMS2 [20]. We felt that if a greater deterioration in this generic measure was shown to occur in those developing hand pain, over those remaining free from hand pain, this would make a more convincing argument for the importance of hand pain on everyday life than if we looked at a measure of function that was hand specific.
Pain frequently co-exists with chronic disease in older adults and can lead to increasing difficulties with physical functioning [21]. The decline in physical function seen in all subgroups, including those free of both hand and lower limb problems at baseline and follow-up, is in line with similar declines observed in other cohorts of older people [22, 23] and is likely to represent a measure of overall age-related physical function decline. It is also possible that this is a regression to the mean phenomenon if people who withdrew, died or did not respond at follow-up, were those with worse scores at baseline. However, there is no evidence from our comparative data at baseline that this was so.
The cohort used in the main analysis emerged from baseline and follow-up responders who had full data on the relevant parameters. Given that the main comparisons here concern internal analyses, the selective characteristics of baseline non-response are unlikely to have affected the analyses presented here. Of more concern is the follow-up attrition. However, there was little difference in baseline characteristics between those who were or were not subsequently included in the analysis cohort, and so bias affecting the main results is unlikely. There is, however, one clear selection issue apparent from the data. Although the design assumed that we could study the influence of new onset hand problems on physical function by starting off with persons free of hand problems, it is clear that prior to the onset of the hand problem, persons ‘destined to develop’ hand problems are already more compromised in terms of their global physical function than those ‘destined to remain free of hand problems’. This means that other influences are already present in addition to hand problems. However, the consistency of size of effect of hand problem onset in the two subgroups (those with and without lower limb pain) despite the substantially lower baseline physical function score in the lower limb pain group, suggests that this selection effect does not undermine the central conclusion that hand problem onset per se is linked with decline in global measure of physical function.
Wyrwich et al. [24] have suggested that a difference of at least 5–7 points is needed on the PF-10 before it can be considered a meaningful change, which could be achieved by gaining one more item of limitation at either the ‘a little’ or ‘a lot’ level. Whilst our data show a significantly worse decline for all those who develop hand problems, any clinically important change in the score, at least by Wyrwich's definition, seems to be limited to the subgroup free from hand problems at baseline.
The implications of our findings relate to the lack of poor attention paid to hand problems in the clinical literature. If worsening and progression of global physical function decline is going to be tackled, then our work suggests that it is important to tackle hand problems as well as lower limb problems, and this is particularly so in those whose physical function is already compromised because of lower limb problems. Deterioration of hand function in older adults is due to a combination of structural and neurological changes, which are often accompanied by the co-existence of OA [25]. It is plausible that the addition of hand problems may disturb any equilibrium in function reached by persons with lower limb joint pain. It is known that weaker grip strength is associated with reduced health-related quality of life generally in older men and women, even after allowing for age, physical activity and known comorbidity, and may reflect a link between muscle sarcopaenia and generalized frailty [26].
The perspective to be encouraged is that assessment and effective treatment of hand problems could prove to be important components of maintaining function in the older adult with joint pain and OA, rather than seeing each site-specific pain as a separate problem in its own right.
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Acknowledgements |
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The authors would like to thank the administrative and health informatics staff at Keele University's Arthritis Research Campaign National Primary Care Centre and the doctors, staff and patients of the three participating general practices.
Funding: This work was 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.S.D. was supported by a grant from the Arthritis Research Campaign. The funders of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report.
Disclosure statement: The authors have declared no conflicts of interests.
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