Prolonged, severe morning stiffness frequent in patients with hand osteoarthritis
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Key takeaways:
- Prolonged morning stiffness is frequent in patients with hand OA.
- Patients with prolonged stiffness report more pain and less physical function.
Morning stiffness lasting longer than 60 minutes is frequent in patients with hand osteoarthritis, and is linked to greater pain, lower function and decreased quality of life, according to data published in Osteoarthritis and Cartilage.
“Short duration morning stiffness on the other hand is regarded as a symptom of osteoarthritis (OA) and short morning stiffness is included in the tree format of clinical ACR classification criteria of hip OA and classical format ACR classification of knee OA,” L.A. van de Stadt, MD, of the department of rheumatology at Leiden University Medical Center, in the Netherlands, and colleagues wrote.
“Studies describing the characteristics of stiffness or morning stiffness in patients with OA are few and mostly concern clinical trials using morning stiffness as outcome measurement,” they added. “Although in patients with hand OA, the presence of stiffness is considered a core symptom that can result in functional disability and probably diminished quality of life, knowledge about the characteristics of stiffness and morning stiffness in patients with hand OA is lacking.”
To investigate morning stiffness in patients with hand OA, van de Stadt and colleagues analyzed data from the Hand OSTeoArthritis in Secondary Care study. Patients were enrolled in the cohort between 2009 and 2015 upon OA diagnosis by the treating rheumatologist. Patients were excluded from the analysis if another ailment, such as rheumatoid arthritis, psoriatic arthritis, psoriasis or secondary OA, was present and could explain morning stiffness, the researchers wrote.
Van de Stadt and colleagues collected demographic and clinical information, including a Dutch-language version of the Australian and Canadian hand OA index assessment. In addition, patients provided responses to a morning stiffness questionnaire in which they were asked to identify the specific joints that were stiff in the morning. Patients were followed for 8 years, including annual questionnaire responses, and underwent two visits each year.
The analysis included 519 patients. Of those, 17% reported “prolonged” morning stiffness while 30% described their morning stiffness as “mild,” according to the researchers. Additionally, 37% of included patients reported that their stiffness was “intermediate,” while 18% defined their stiffness as “severe” and 4% described their stiffness as “extreme.” Compared with those who did not have prolonged stiffness, patients who demonstrated longer periods of morning stiffness described having higher levels of pain, lower physical function, and reduced quality of life scores.
“Prolonged morning stiffness of more than 60 minutes can be present in patients with hand OA and is associated with more pain, worse physical function and a lower quality of life,” van de Stadt and colleagues wrote. “Its presence should not preclude a diagnosis of hand OA.”
Perspective
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David E. Bacha, MD, FACP, FACR
Rheumatologists are constantly on the lookout for clinical pearls, secrets and helpful hints that can be applied in day-to-day practice. Through the years, textbooks such as A Clinician’s Pearls and Myths in Rheumatology and Rheumatology Secrets, as well as salient journal articles and reports have provided clinically useful information. This brief report, published in Osteoarthritis and Cartilage, offers some useful points to consider when evaluating patients with arthritis of the hands.
Clinically, patients with osteoarthritis typically have morning stiffness that lasts less than 30 minutes. Guidelines from the NIH and Care Excellence note that osteoarthritis is characterized by no morning stiffness, or morning stiffness that lasts less than 30 minutes. In contrast, prolonged morning stiffness — generally greater than 60 minutes — might suggest inflammatory arthritis.
The main implication of this article is that there is an atypical subset of patients with hand osteoarthritis who can be confused with inflammatory arthritis. This subset of patients tends to have more severe radiographic disease and may have more profound symptoms, including morning stiffness.
Although it may not reach the level of a clinical pearl or secret, the results of the study provide helpful information that clinicians can use in practice. Pragmatically, the findings in this article are a reminder that diagnostic acumen relies on considering a constellation of signs and symptoms rather than relying too heavily on one diagnostic clue.
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