Treating Specific Hand Disorders: What Works?Specialists such as hand surgeons and hand therapists treating hand disorders will be interested in the results of this study. Researchers from the Netherlands took the time to review studies published and listed in PubMed (search engine for the U.S. government's record of publications in the National Library of Medicine). They confined themselves to four specific hand disorders: 1) trigger finger, 2) Raynaud's phenomenon, 3) Dupuytren's disease, and 4) De Quervain's disease.
Taking the time to review the evidence collected so far on the treatment of these conditions is an important activity. How else will the worker bees in the trenches know what is working and what's not for patients with these problems? Having each clinician involved in the treatment of these hand disorders search PubMed for studies, analyze those studies, and come up with a summary of the evidence supporting or refuting treatment techniques just isn't going to happen. Everyone is too busy treating the patients!
But this kind of information is very useful and important. In any review of the literature like this one, the authors must come up with words that help them search for articles on the topic of interest. In this case, it was fairly easy to choose the names of the four conditions as the primary search words.
Once the articles of interest are found, it's necessary to examine them closely to decide whether or not the study has merit. Is the design of each study and are the methods used of high enough quality to count on the results as reliable and true evidence to support that particular methodology? The authors of this review include a list of the six categories of questions they considered when looking at each study.
They limited their search to randomized controlled trials (RCTs). Patients in such studies are assigned to a group without knowing which group they are in. A double blind RCT means the clinicians treating the patients don't know who the real patients are and who is getting the placebo treatment versus the real treatment.
For each of the six categories, they came up with a list of questions to help assess the quality of each study. For example, they asked if the patient, clinician, and person who assessed the results were truly blinded to the treatment? They looked to see if patients in the groups being compared to one another were similar before treatment began. How was the data handled for patients who dropped out of the study? Every possible source of bias was examined carefully.
In the end, what they found was that the number of published RCTs for any of these hand conditions was very low -- usually only one or two for each one. That's not enough to argue that one treatment was clearly better than another. At best they could say that a lack of evidence points to the need for more RCTs for these four hand disorders. The authors reminded us that a lack of evidence is NOT the same as evidence that the treatment doesn't work or should/should not be used.
The four hand conditions included in this study form a distinct group of musculoskeletal complaints of the arm, neck, or shoulder, also known as (CANS). There are all kinds of treatments out there for CANS. Physical therapy, pharmacotherapy (prescription drugs), steroid injections, and surgery top the list. But the question must be asked: which one (or combination of treatment) works best for each of the four common conditions.
If physical therapy is successful, why is it? Is there a particular modality or two approaches used together that help? There's a wide range of tools available from ultrasound and laser therapy to joint manipulation, soft tissue mobilization, and exercise. Here's what they found so far. Let's take the conditions one at a time.
Trigger finger (or trigger thumb) causes swelling and painful movement when straightening out the affected finger. The sheath or lining around the tendon is involved. The name trigger finger refers to the fact that when the finger unlocks, it pops back suddenly, as if releasing a trigger on a gun.
More than one finger may be affected at a time, though it usually affects the thumb, middle, or ring finger. The triggering is usually worse in the morning, or while gripping an object. Steroid injections might be useful in the treatment of this condition, but there was only one (very small) study that compared steroid injections with a placebo injection, so more study is needed in this area.
Raynaud's phenomenon (RP) is a change in color (white, blue, red) of the fingers and/or toes often accompanied by pain. The cause is a spasm of the blood vessels triggered by emotional stress or extremes in temperature (hot or cold). Scientists have investigated the use of medications such as calcium channel blockers (to lower the blood pressure by keeping the blood vessels open), special thermoflow gloves to keep the hands warm in the cold, acupuncture, and low-level laser therapy.
Evidence was strongest in favor of the calcium channel blockers with laser therapy coming in second. For behavioral therapy with biofeedback (for temperature control) and the use of supplements like Ginkgo Biloba, there was limited evidence to support their effectiveness with Raynaud's.
Dupuytren disease describes a condition with one or more fingers (usually the ring and little fingers) stuck in a flexed position. It is named after a surgeon (Dr. Dupuytren) who described an operation to correct the problem back in the 1800s. There were only four randomized controlled trials centered on treatment of this condition. Those all had to do with surgery, type of incision made, and postoperative procedures to control swelling. There was no evidence that any one particular approach worked best or had the most positive effects.
De Quervain's disease is an inflammation or a tendinosis of the sheath or tunnel that surrounds two tendons that control movement of the thumb. It was also named after a physician, a Swiss surgeon Fritz de Quervain who first wrote about it in the late 1800s.
Studies of cortisone injections (with or without antiinflammatory drugs) and splinting did not show either one to be effective in treating the symptoms of this condition. Wearing a splint reduced pain for some patients but it didn't last. As soon as the splints were removed and the thumb moved, the pain came right back. Injections seem to help, as two-thirds of the group was better three weeks later. But that was the same result as in the placebo group.
All of these studies had different periods of treatment and follow-up, but most were of short duration. That doesn't answer the question of whether or not any of these modalities has long-lasting effects. That's important from a cost-effective point-of-view.
There are always questions raised about pursuing treatment that isn't going to make a long-term difference. If there is a benefit, is it reducing the frequency (how often it happens), the severity or intensity of symptoms, or duration (how long the symptoms last)?
Research on any given problem takes time and thought. There are many variables and factors to consider in conducting high-quality research looking for evidence to support specific treatment approaches. The authors of this review point out the obvious: there is a big need for some decent research in the area of effective treatment for painful conditions of the hand.
Marienke van Middelkoop, PhD, et al. Effectiveness of Interventions of Specific Complaints of the Arm, Neck, or Shoulder (CANS). Musculoskeletal Disorders of the Hand. In The Clinical Journal of Pain. July-August 2009. Vol. 25. No. 6. Pp. 537-552.
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