If you have arthritis of the hand, even the simplest tasks-such as twisting open a jar or lifting a bag of groceries-can seem nearly impossible as a result of pain, stiffness, and weakness. A bounty of new evidence has led to updated recommendations from the European League Against Rheumatism (EULAR) on how to manage this chronic and painful condition. The new guidance, which was published online in August 2018 in the Annals of the Rheumatic Diseases, adds evidence to 2012 recommendations from the American College of Rheumatology (ACR).
When treating hand arthritis, EULAR stresses the importance of a multifaceted approach that includes nondrug strategies like exercise and orthotics, along with medication and sometimes surgery. The authors of the recommendations-a European task force made up of doctors, other healthcare professionals, and patients-say it’s important for people with hand arthritis to understand their disease and to be involved in making decisions about their own treatment.
The therapies you and your doctor ultimately choose should be individualized based on your symptoms, your age, the type of arthritis you have, and its impact on your day-to-day life.
Hand arthritis-the basics
The two most common types of arthritis that affect the bones and joints in the hands are osteoarthritis (OA) and rheumatoid arthritis (RA). OA is the more common of the two conditions and is characterized by pain and stiffness in the joints due to cartilage breakdown. It mainly affects older adults. Half of all women and about a quarter of men will deal with hand OA at some point in their lifetime.
OA typically affects three different parts of the hand: the carpometacarpal (CMC) joint at the base of the thumb, the distal interphalangeal (DIP) joint right below the fingertip, and the proximal interphalangeal (PIP) joint in the middle of the finger.
Rheumatoid arthritis is an autoimmune disease that occurs when the immune system mistakenly attacks the joints and other areas, producing inflammation. If RA is the cause of your hand pain, the joints most likely to be affected are the wrist joints; the index and middle metacarpophalangeal (MCP) joints, which are the large knuckles visible when the hands are clenched into a fist; and the PIP joints. RA typically doesn’t affect the DIP joints. About 80 percent of people with RA have arthritis in their hand joints. It usually affects both hands symmetrically.
A treatment strategy
Hand arthritis requires more than a single healthcare professional to treat. Several health professionals may be involved in your care, including your primary care doctor, a rheumatologist, a hand surgeon (an orthopedic surgeon who subspecializes in hands), and a hand therapist. Certified hand therapists are specialists trained in occupational and physical therapy practices. Their role is to evaluate and treat arthritis and other conditions of the hand. If you’ve lost strength, flexibility, and function from arthritis, a hand therapist can develop a program to help restore normal movement and improve your ability to accomplish your daily tasks.
For hand osteoarthritis, the best place to start is with nondrug/nonsurgical therapies, according to the EULAR recommendations. If conservative measures don’t relieve your symptoms, you can work your way up to medications and possibly surgery.
Rheumatoid arthritis almost always requires medication to stop disease progression. Nondrug therapies can help ease pain and stiffness, but prompt, aggressive treatment with disease-modifying antirheumatic arthritis drugs (DMARDs) has been shown to slow disease progression and limit joint damage, reducing the likelihood that your hand will have limited function or become permanently disfigured.
Using assistive devices such as jar openers, button hooks, faucet turners, and easy-grip kitchen tools can make everyday tasks easier. A hand, occupational, or physical therapist can teach you the best methods to protect your hands whether you have OA or RA.
Applying heat and cold is another simple intervention you can try at home. Research hasn’t confirmed that either one works for arthritis, but if a heating pad or cold pack gives you some relief, it won’t hurt to use one. To relieve RA’s morning stiffness, warm paraffin wax or other warming interventions often help.
When your hands are painful and stiff, exercising them might be the last thing you want to do. Yet strengthening the muscles and stretching the joints could help improve pain, stiffness, and grip strength-without the cost or potential side effects of medication, especially for OA. The typical exercise program for hand arthritis combines strengthening and stretching.
A 12-week program using these two components improved joint swelling, pain, strength, and function more than interventions like joint protection and splinting in people with RA, according to a 2015 study published in The Lancet. A hand or physical therapist can get you started and teach you how to correctly perform the exercises, which you can then do at home.
To reduce pain before you perform exercises, try soaking your hands in warm water or dipping then in warm paraffin wax. You may even want to try performing some exercises with your hands submerged in warm water or while you’re in a heated pool. This is a gentle way to exercise joints and muscles. The buoyancy of the water supports and lessens stress on the joints, enabling you to move your hands more easily. Water may also act as resistance to help build muscle strength.
Hand orthotics are splints and other wearable aids made from plastic, neoprene, and other materials. They stabilize and support the weakened parts of your hand while you go about your daily routine. These devices may be most helpful for people who have arthritis at the base of the thumb.
Research shows thumb-base orthotics reduce pain and improve function, especially if you wear them for long periods-three months or more. It’s not clear which materials are best, or when the ideal time is to wear them (for example, only during certain activities, all day, or at night). However, it’s important to have orthotics fitted to you by your doctor. The more comfortable the device is, the more likely you’ll be to wear it.
Topical and oral drug therapy
If nondrug treatments don’t provide enough relief, you can try medication. EULAR recommends starting with topical nonsteroidal anti-inflammatory drugs (NSAIDs), which may work as well as oral pain relievers but without most of the side effects.
Over-the-counter (OTC) capsaicin cream (Capzasin-HP, Zostrix, others) is another topical medication for arthritis. It’s made from a chili pepper extract that acts as a counterirritant, essentially distracting you from your pain. Common side effects are burning or stinging at the application site, which can make this treatment somewhat unpleasant.
The most commonly used oral pain relievers are acetaminophen (Tylenol) and NSAIDs like aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve). The type of drug your doctor recommends depends on the intensity of your pain and the potential side effects of the medication. The drug with the fewest potential side effects is usually tried first.
Acetaminophen is the initial drug of choice for osteoarthritis because it’s just as effective as most NSAIDs and less likely to cause side effects like stomach irritation. However, acetaminophen can cause liver problems if taken in high doses or with alcohol. It’s easy to inadvertently get harmful amounts, since acetaminophen is found in many headache and cold and flu remedies and other OTC drugs. It can also interact with certain other medications, such as warfarin (Coumadin), and there’s evidence that it may be hard on the kidneys.
Oral NSAIDs can be used for both forms of arthritis. Taking these medicines for two to four weeks can improve hand pain and function, but they come with risks like gastrointestinal bleeding, ulcers, and kidney and heart problems. These side effects may be especially concerning for people who have other coexisting health conditions such as heart or kidney disease or bleeding risks. If you do take NSAIDs, use the lowest effective dose for the shortest possible period.
Medical treatment is typically recommended for rheumatoid arthritis. DMARDs such as methotrexate or adalimumab can help reduce inflammation and slow joint damage.
Steroid injections reduce inflammation, which makes them useful for treating inflammatory diseases like arthritis. An injection into an inflamed interphalangeal joint might help relieve pain and swelling, but steroids don’t seem to help with OA at the base of the thumb.
Glucosamine and chondroitin
Glucosamine and chondroitin sulfate are two natural components in cartilage and are among the most popular supplements used to treat arthritis. However, their effectiveness hasn’t been confirmed by research, and there isn’t enough evidence to justify taking glucosamine for hand arthritis. If you already take these supplements and find they help, continue with them, but consider stopping for a while to see if there’s a difference.
Because surgery is invasive, you shouldn’t consider it unless you’ve exhausted all other options. If your pain continues despite several attempts at treatment and arthritis is impacting your quality of life, then it’s time to consult with an orthopedic surgeon who specializes in hand problems.
It’s important to have a thoughtful discussion with your doctor or surgeon about risks and potential benefits before deciding whether to undergo a procedure. It can take up to three months to return to your normal activities after surgery. Undergoing rehabilitation can help you regain movement in the joint after surgery.