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Rheumatology Advance Access published online on August 1, 2007
Rheumatology, doi:10.1093/rheumatology/kem185
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© The Author 2007. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Finger joint pain in relation to radiographic osteoarthritis and joint location—a study of middle-aged female dentists and teachers

H. Ding, S. Solovieva, T. Vehmas, H. Riihimäki and P. Leino-Arjas

Centre of Expertise for Health and Work Ability, Finnish Institute of Occupational Health, Helsinki, Finland

Correspondence to: Päivi Leino-Arjas, MD, PhD, Musculoskeletal Disorders, Centre of Expertise for Health and Work Ability, Finnish Institute of Occupational Health, Topeliuksenkatu 41 a A, FIN-00250 Helsinki, Finland. E-mail: paivi.leino-arjas{at}ttl.fi


   Abstract
Top
 Abstract
Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Objectives. To investigate the associations of radiographic finger joint osteoarthritis (ROA), hand laterality (right/left) and anatomical location within the hand, with finger joint pain.

Methods. Radiographs of both hands of 295 female dentists and 248 female teachers were examined for the presence of osteoarthritis in each finger joint, using grades 0 = no OA, 1 = doubtful OA, 2 = mild OA, 3 = moderate OA, 4 = severe OA. Information on the occurrence of pain in each finger joint during the past 30 days and hand laterality was obtained by questionnaire.

Results. Compared with subjects with no ROA, the prevalence ratio (PR) of finger joint pain was 1.92 [95% confidence interval (CI) 1.61–2.34] among those with mild ROA and 5.34 (4.51–6.54) among those with at least moderate ROA, based on a multivariate log-binomial regression model. Pain was slightly more common in the right than in the left hand (1.27; 1.15–1.40). Compared with the little finger, more pain occurred in the thumb (2.67; 2.25–3.16), the index finger (1.76; 1.50–2.07) and the middle finger (1.47; 1.24–1.74). Further, pain was more common in the proximal interphalangeal (1.77; 1.56–2.00) and the distal interphalangeal (1.51; 1.29–1.76) joints than in the metacarpophalangeal joints. The strength of the association between ROA and finger joint pain increased with the severity of pain.

Conclusions. Our findings suggest that ROA, anatomic localization within the hand, and hand laterality have independent effects on finger joint pain.

KEY WORDS: Finger joint pain, Radiographic osteoarthritis, Hand use


   Introduction
Top
 Abstract
 Introduction
Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
The hands are essential for most occupational activities and those of the daily living. Disorders of the upper extremities are among the most frequent causes of disability [1–3] and often lead to long absence from work [4].

Osteoarthritis (OA) is regarded as a likely origin of joint pain [5]. It seems plausible to assume that the severity of radiographic OA (ROA) would be associated with pain. However, data supporting this are limited. A recent review by Dahaghin and colleagues [6] revealed that the strength of the association between radiographic hand OA and pain varies widely in the published studies.

The hands are complex multi-joint structures. The degree of involvement and loading of the various joints in occupational and daily activities may also influence the occurrence and location of pain in the hand. A biomechanical analysis of finger joint load showed that forces were greatest across the distal interphalangeal joints and that fine pinch grip resulted in greater loads than power grip [7]. Extensive research into the role of occupational factors in the development of low-back, neck–shoulder, forearm and wrist pain has been carried out [8]. However, evidence on the role of occupational activities in the aetiology of finger joint pain is lacking.

Dentistry is one of the few academic occupations with distinctive and continuous demands on the hands. The work performed by the right and the left hand (‘drill hand’ and ‘mirror hand’) differs in the proportion of static vs dynamic work [9]. Dentists heavily utilize the thumb, index and middle fingers in precision gripping, while the ring and little fingers are more static [10]. Without considering symptoms, the results of a recent study by our group suggest that dentists are more likely than teachers (an occupation within the same socio-economic grade but with lower hand loading) to have severe ROA in the thumb, index or middle fingers of the right hand [11].

The aim of this study was to investigate the associations of the severity of radiographic finger joint OA with finger joint pain in female middle-aged dentists and teachers, and to examine whether hand laterality (right vs left hand) or joint site within the hand influence finger joint pain.


   Materials and methods
Top
 Abstract
 Introduction
 Materials and methods
Results
 Discussion
 Acknowledgements
 References
 
Study samples
The subjects were identified through the registers of the Finnish Dental Association and the Finnish Teachers’ Trade Union (restricted to the teachers of theoretical subjects in secondary school). We randomly selected 436 women aged 45–63 yrs from both occupational groups using the place of residence as an inclusion criterion (Helsinki or its neighbouring cities). Of those who received the questionnaire (in 2002), 295 (67.7%) dentists and 248 (56.9%) teachers participated in a clinical examination between October 2002 and March 2003. Participation in the study was voluntary and based on informed consent.

The Hospital District of Helsinki and Uusimaa Ethics Committee for Research in Occupational Health and Safety approved the study proposal.

Radiography
Both hands of the participants were radiographed. The radiographs were evaluated by an experienced radiologist who was blinded to the occupation, age and all health data of the subjects. Each distal interphalangeal (DIP), proximal interphalangeal (PIP), thumb interphalangeal (IP) and metacarpophalangeal (MCP) joint of both hands was graded separately using reference images and a modified Kellgren and Lawrence scoring system [11]: grade 0 = no OA; grade 1 = doubtful OA; grade 2 = mild OA; grade 3 = moderate OA; grade 4 = severe OA. The intra-observer reliability (the weighted {kappa}-coefficients) of the readings varied from 0.59 to 1.00.

Mild radiographic OA (ROA) for each joint was defined as a reading of grade 2, and at least moderate ROA as a reading of grade ≥3. We used a 3-class variable of the severity of ROA (0–1 = no findings, 2 = mild ROA, ≥3 = at least moderate ROA). A radiographic sum score was calculated as the sum of ROA grades of the different joints.

Finger joint pain
Information on finger joint pain was collected by a self-administered questionnaire. The participants were asked to mark on a diagram of both hands in which joints they had felt ‘pain or sensitivity to movement’ (here called pain) during the past 30 days. They were also asked to mark the intensity of pain: 0 = no pain, 1 = mild, 2 = moderate, 3 = severe. Finger pain was categorized as 0 = no pain and ≥ 1 = pain or 0 = no pain, 1 = mild pain, 2–3 = at least moderate pain. A pain sum score was calculated as the sum of pain (0–3) grades of the different joints.

Statistical analyses
The prevalence of pain was calculated for each finger joint separately. The differences between dentists and teachers in the prevalence of pain in hand joint groups and in the fingers were compared using Fisher's exact probability test.

Hierarchical logistic regression analyses for repeated measurements with finger joint pain as the dependent variable were used to evaluate the strength of the association of ROA severity, age (yrs), occupation, hand laterality and anatomical joint site (finger, joint group) with finger pain. This technique calculates the relations between ROA and pain of each joint as the unit of analysis, but accounts for the correlation between the joints within the individual. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were estimated in a generalized linear model with a logarithmic link function and binomial distribution for the residual [12]. We used the PR instead of odds ratio (OR) as a measure of the size of an effect [13].

The SPSS (version 12.1) and SAS (version 8.2) programs were used.


   Results
Top
 Abstract
 Introduction
 Materials and methods
 Results
Discussion
 Acknowledgements
 References
 
Prevalence of finger joint pain
The prevalence of pain in the different fingers during the past 30 days varied between 2.4 and 20.3% in the right hand and between 1.0 and 14.9% in the left hand (Table 1). The prevalence of any finger joint pain was 10.8% among the dentists and 10.1% among the teachers (Table 2).


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  		TABLE 1. Prevalence of any pain during the past month in each finger joint among dentists and teachers

 

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  		TABLE 2. Prevalence (%) of mild or at least moderate pain during the past month, by finger joint group and finger among dentists and teachers

 
Association between radiographic OA and pain
The pain sum score statistically significantly correlated with the number of joints affected by ROA (r = 0.28, P = 0.0005) and the radiographic sum score (r = 0.26, P = 0.0005).

In multivariate log-binomial regression analysis combining data on all finger joints a graded relationship of the severity of ROA with pain was evident. Allowing for the effect of age and occupation, the PR of pain was 1.70 (95% CI 1.44–2.01) for mild ROA and 5.17 (4.34–6.16) for at least moderate ROA compared with subjects with no ROA (Table 3). Inclusion of the variables related to the anatomical location (hand laterality, joint group and finger), the association between the severity of ROA and pain increased somewhat. Finger joint pain was independently associated also with hand laterality, finger and joint group. Pain was slightly more common in the right than in the left hand (1.27; 1.15–1.40). Compared with the little finger, more pain occurred in the thumb (2.67; 2.25–3.16), the index finger (1.76; 1.50–2.07) and the middle finger (1.47; 1.24–1.74). Further, pain was more common in the PIP (1.77; 1.56–2.00) and the DIP (1.51; 1.29–1.76) joints than in the MCP joints.


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  		TABLE 3. Multivariate log-linear binomial models of the severity of joint-wise radiographic osteoarthritis (ROA), hand laterality and anatomical location within the hand as determinants of any finger joint pain during the past month among dentists and teachers

 
Assuming that on average the activities performed by a dentist's right hand and a teacher's left hand have the largest difference in the produced mechanical loads on finger joints, we estimated the PR of pain in the right hand of the dentists, with the left hand of the teachers as reference. Allowing for the effect of the other factors, the dentists had a 1.7-fold (95% CI 1.34–2.19) increased rate of pain in the right hand as compared with the left hand of the teachers.

The multivariate log-binomial regression analysis was repeated for pain graded as a trichotomy. The strength of the association between ROA and finger joint pain increased with the severity of ROA and the severity of pain (Table 4). The PRs of mild pain were 1.93 (1.54–2.41) for mild ROA and 4.92 (3.77–6.43) for at least moderate ROA, and the PRs of at least moderate pain were 2.21 (1.58–3.10) for mild ROA and 11.73 (8.95–15.38) for at least moderate ROA. Pain was also independently associated with hand laterality and finger. The strength of the associations increased, again, with increasing severity of pain.


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  		TABLE 4. Multivariate log-linear binomial models of the severity of joint-wise radiographic osteoarthritis (ROA), hand laterality and anatomical location within the hand as determinants of mild or at least moderate finger joint pain during the past month among dentists and teachers

 

   Discussion
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
Acknowledgements
 References
 
Our study among middle-aged women in two occupations showed a graded association of finger pain, assessed joint-wise during the past month, with the severity of radiographic finger OA, correspondingly assessed by joint. Among subjects with mild ROA, the risk of pain was increased about 2-fold and among those with at least moderate ROA about 5-fold, compared with subjects with no ROA. The severity of finger joint pain was also clearly dependent on ROA severity.

Although the approaches to classification of hand-related symptoms vary widely between studies, our findings are in line with previously existing studies on the severity of ROA and hand pain [14–19]. In samples of the Northern England population aged 15 yrs and over, a moderate association of ever-felt pain with the severity of hand ROA was found when examined in clusters of DIP, PIP and MCP joints [14]. Among subjects of the Framingham cohort that were aged 70 yrs and over, pain and ROA were studied joint-wise similarly to our approach [18] and the presence of pain was visibly dependent on the ROA grade. In addition, our study showed a relationship between the severity of ROA and the severity of pain. Other studies have examined the association of any ROA with hand or finger pain. In a Tasmanian study of hand OA patients and their families, sum scores of ROA in the carpometacarpal and in the DIP joints were moderately associated with overall hand pain [17]. The Rotterdam study [19] found a weak association between ROA in the hand and the 1-month prevalence of hand pain in subjects aged 55 yrs and over. In the nationally representative Mini-Finland study, finger pain was associated with ROA in any finger joint (OR 1.38) and with symmetrical DIP joint ROA (1.68) [20]. It seems that the severity of ROA is relevant as to the strength of the association between ROA and finger pain.

In the present study, the 1-month prevalence of finger joint pain varied from 1.0% (the left little MCP) to 20.3% (the right thumb MCP). Our prevalence estimates come rather near to the few previously published data on overall hand pain. In a large population survey of the residents from the urban area in the North-West of England, the 1-month prevalence of hand pain among women aged 45–64 yrs was 19% [21]. Dahaghin et al. [19] reported a 1-month hand pain prevalence of 17% among the elderly.

We found that the rate of finger joint pain was higher in the right hand than in the left, in the thumb, index and middle fingers compared with the little finger, and in the PIP and DIP joints compared with the MCP joints. These new findings suggest that hand loading factors could be involved in the genesis of finger joint pain, either via increased tissue damage or increased awareness of pain. Tissue damage leads to an inflammatory response which in turn induces peripheral sensitization [22].

Dental personnel were reported to have a high risk of developing musculoskeletal symptoms [23]. The occurrence of complaints of the hand was associated with work-related physical load among dentists [24]. We found a smaller difference in pain occurrence between the dentists and teachers than was expected. Being cross-sectional, our study may have been subject to the so called healthy worker effect, a health-based selection process to remain employed [25]. This may have flattened the contrast in finger joint pain between the two occupations.

In conclusion, we found evidence for a clear graded association of the severity of ROA with finger joint pain among middle-aged women. Our findings on the importance of anatomical location for pain occurrence suggest that biomechanical factors related to the differential use of the hands and their joints may also play a role in the development of finger joint pain, independent of ROA.

Formula


   Acknowledgements
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
References
 
The authors are most grateful to Katariina Luoma, DSMedSci (Department of Radiology, Peijas Hospital, Helsinki University Central Hospital, Finland), for performing the second readings of the hand radiographs for reliability analysis. The study was financially supported by the Finnish Work Environment Fund grant 101334.

The authors have declared no conflicts of interest.


   References
Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 

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Submitted 16 May 2007; Accepted 14 June 2007


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