ArticlePDF Available

Reliability of Assessing Hand Osteoarthritis on Digital Photographs and Associations With Radiographic and Clinical Findings

Authors:

Abstract and Figures

Objective To investigate the reliability and construct validity of an atlas for grading hand osteoarthritis (OA) on photographs in a separate younger community-dwelling population than the development cohort.Methods Participants were community-dwelling adults (ages ≥50 years) in North Staffordshire, UK with hand pain or hand problems in the last year who attended a research clinic. High-quality photographs were taken in a standardized position. A photographic atlas was used to score hand joints (second and third distal interphalangeal [DIP], second and third proximal interphalangeal [PIP], and first carpometacarpal [CMC] joints) and joint groups (DIP, PIP, and CMC joints) for OA on a 0–3 scale. Hand radiographs were graded for OA using the Kellgren/Lawrence (K/L) grading system. Clinical features (nodes, bony enlargement, and deformity) were determined by physical examination. Associations of photographic hand OA grades with radiographic OA and clinical features were determined to assess construct validity.ResultsIn total, 558 participants (mean age 64 years, 62% women) were included in the analyses. Reliability for scoring OA on the photographs was good (mean intrarater intraclass correlation coefficient [ICC] 0.77 and mean interrater ICC 0.71). At the joint level, photographic hand OA grade was positively associated with radiographic OA grade (Spearman's ρ = 0.19–0.57, P < 0.001) and the number of clinical features (Spearman's ρ = 0.36–0.59, P < 0.001). At the person level, individuals with higher global photographic OA scores had higher summed K/L scores and higher percentages meeting the American College of Rheumatology clinical hand OA criteria.Conclusion This photographic scoring system was reliable and a good indicator of hand OA in a separate younger community-dwelling population than the development cohort. This method of data collection offers researchers a feasible alternative to physical examination and radiography.
Content may be subject to copyright.
Reliability of Assessing Hand Osteoarthritis on
Digital Photographs and Associations With
Radiographic and Clinical Findings
MICHELLE MARSHALL,
1
HELGI JONSSON,
2
GUDRUN P. HELGADOTTIR,
3
ELAINE NICHOLLS,
1
DANIELLE VAN DER WINDT,
1
HELEN MYERS,
1
AND KRYSIA DZIEDZIC
1
Objective. To investigate the reliability and construct validity of an atlas for grading hand osteoarthritis (OA) on
photographs in a separate younger community-dwelling population than the development cohort.
Methods. Participants were community-dwelling adults (ages >50 years) in North Staffordshire, UK with hand pain or
hand problems in the last year who attended a research clinic. High-quality photographs were taken in a standardized
position. A photographic atlas was used to score hand joints (second and third distal interphalangeal [DIP], second and
third proximal interphalangeal [PIP], and first carpometacarpal [CMC] joints) and joint groups (DIP, PIP, and CMC joints)
for OA on a 0–3 scale. Hand radiographs were graded for OA using the Kellgren/Lawrence (K/L) grading system. Clinical
features (nodes, bony enlargement, and deformity) were determined by physical examination. Associations of photo-
graphic hand OA grades with radiographic OA and clinical features were determined to assess construct validity.
Results. In total, 558 participants (mean age 64 years, 62% women) were included in the analyses. Reliability for scoring
OA on the photographs was good (mean intrarater intraclass correlation coefficient [ICC] 0.77 and mean interrater ICC
0.71). At the joint level, photographic hand OA grade was positively associated with radiographic OA grade (Spearman’s
0.190.57, P<0.001) and the number of clinical features (Spearman’s
0.360.59, P<0.001). At the person level,
individuals with higher global photographic OA scores had higher summed K/L scores and higher percentages meeting
the American College of Rheumatology clinical hand OA criteria.
Conclusion. This photographic scoring system was reliable and a good indicator of hand OA in a separate younger
community-dwelling population than the development cohort. This method of data collection offers researchers a feasible
alternative to physical examination and radiography.
INTRODUCTION
Hand osteoarthritis (OA) is a highly prevalent condition
affecting many older adults (1). Individuals report signifi-
cant pain and interference with hand function in their
everyday lives and perceive their hand condition to be
serious (2). Despite this, compared with OA of the knee,
there is limited evidence on the epidemiology of hand OA
in different populations.
Currently, both clinical and radiographic criteria have
their advocates for use in large epidemiologic studies. The
Supported by the Medical Research Council UK (grant
G9900220) and Arthritis Research UK (grant 18174). NHS
service support costs were provided by Support for Sciences
funding secured from the North Staffordshire Primary Care
Consortium.
1
Michelle Marshall, PhD, Elaine Nicholls, MSc, Danielle
van der Windt, PhD, Helen Myers, PhD, Krysia Dziedzic,
PhD: Arthritis Research UK Primary Care Centre, Pri-
mary Care Sciences, Keele University, Staffordshire, UK;
2
Helgi Jonsson, MD, PhD: Landspitalinn University Hospital
and University of Iceland, Reykjavik, Iceland;
3
Gudrun P.
Helgadottir, MSc: University of Iceland, Reykjavik, Iceland.
Dr. Dziedzic has received consultancy fees, speaking fees,
and/or honoraria (less than $10,000 each) from the Euro-
pean League Against Rheumatism, the Osteoarthritis Re-
search Society International, and the National Institute for
Health and Clinical Excellence and was a coeditor of a book
about evidence-based rheumatology for physiotherapists
and occupational therapists, for which she receives royal-
ties.
Address correspondence to Michelle Marshall, PhD, Ar-
thritis Research UK Primary Care Centre, Primary Care
Sciences, Keele University, Keele, Staffordshire, ST5 5BG,
UK. E-mail: m.marshall@keele.ac.uk.
Submitted for publication July 19, 2013; accepted in re-
vised form October 22, 2013.
Arthritis Care & Research
Vol. 66, No. 6, June 2014, pp 828836
DOI 10.1002/acr.22225
© 2014 The Authors. Arthritis Care & Research is published by Wiley
Periodicals, Inc. on behalf of the American College of Rheumatology.
This is an open access article under the terms of the Creative Commons
Attribution License, which permits use, distribution, and reproduction in
any medium, provided the original work is properly cited.
ORIGINAL ARTICLE
828
radiographic criteria are frequently used to assess the pres-
ence and severity of hand OA, and although they are
widely available, the disadvantages include cost, radiation
exposure, and availability of trained readers (3,4). Further-
more, radiographic changes develop over a considerable
length of time, and thus are often underdiagnosed in the
youngest and often most symptomatic group of hand OA
patients, who constitute a potential future target group for
preventative treatment (5,6). The American College of
Rheumatology (ACR) criteria are a recognized method of
determining the presence of clinical hand OA by physical
examination (7), but among the main disadvantages are the
availability of expert examiners and the difficulty of stan-
dardizing assessments between multiple observers (8).
Hand photography offers the possibility of obtaining clin-
ical data in a standardized way, which, if it can be shown
to be reliable and a valid indicator of the severity of hand
OA, could offer a simple and cheap alternative, particu-
larly if data need to be collected in large samples and over
wide geographic areas (9,10).
Photography of the hands has been used in a few studies
to examine, and in some cases to diagnose, hand OA
(9,11–13). Early investigations suggested that the photo-
graphic method lacked sensitivity (9,14), indicating that
photographic assessment often missed the presence of
radiographic change, but with improved imaging quality
and the development of an atlas for scoring hand photo-
graphs, the method has shown promise (10,15). The atlas
was developed in a population-based study of older adults
(ages 69 years) in Reykjavik, Iceland (10). This study
found that the reading of hand photographs not only could
be standardized with reasonable intra- and interreader re-
liability, but also that the photographic grade of hand OA
was correlated with radiographic OA and clinical hand
OA (10,16,17), indicating that grades obtained from hand
photography may provide a valid indicator of hand OA
severity. However, while this system of diagnosing hand
OA has been shown to be useful in elderly Icelanders, its
performance in other younger populations, where more
individuals are likely to be in the process of developing or
have an early form of hand OA, is not known. The reli-
ability and validity of an instrument can vary between
settings and populations with different clinical character-
istics, and it is therefore important to assess these proper-
ties across populations and settings in order to confirm
the generalizability of photographic assessment of hand
OA (18).
The objectives of this study were to investigate the re-
liability of the Age, Gene/Environment Susceptibility–
Reykjavik (AGES-Reykjavik) atlas for diagnosing hand
OA from photographs and to assess its validity as an indi-
cator of OA severity by investigating associations with
radiographic and clinical features in a separate younger
community-dwelling population.
SUBJECTS AND METHODS
Study participants. The Clinical Assessment Study of
the Hand (CASHA) is a prospective observational cohort
study, in which all individuals ages 50 years from 2
general practice registers in North Staffordshire, UK were
invited to participate in a 2-stage postal survey. The gen-
eral practice register was used as a sampling frame because
97% of the population in the UK is registered with a
general practitioner (19). Participants were not required to
have consulted about their hand pain or hand problems.
Individuals who responded to the questionnaires, con-
sented to further contact, and indicated that they had
experienced hand pain or hand problems in the previous
12 months were invited to attend a research clinic at a
local rheumatology center. The research clinics consisted
of a standardized clinical interview, physical examination,
digital photographs of the hands, hand radiographs, and
anthropometric measurements (height and weight). Full
details of the study design and methods have been previ-
ously reported (20). The North Staffordshire Local Re-
search Ethics Committee approved this study (project
number 1430) and all participants provided written in-
formed consent.
Digital hand photography. Posterior photographs of
both hands were taken using a digital camera (Olympus
Camedia C-4040 Zoom; resolution 2,272 1,704 pixels).
The camera was placed in a fixed position at a distance of
15 inches above a gridded stand. Positioning for the pho-
tographs was standardized. The participants were seated
with the shoulder adducted and the elbow at 90°. The
hand was pronated and placed on a fixed point on the
gridded stand with the forearm, wrist, and fingers in a
straight line and the hand resting in a natural position, i.e.,
with the fingers and thumb not held closely together or
spanned.
Grading of the dorsal hand photographs was undertaken
by a single observer (HJ) using an established scoring sys-
tem for diagnosing and grading severity of hand OA (10).
Five joints in each hand (second and third distal interpha-
langeal [DIP], second and third proximal interphalangeal
Significance & Innovations
The Age, Gene/Environment Susceptibility–Rey-
kjavik (AGES-Reykjavik) photographic atlas was
shown to be a reliable method of scoring hand
osteoarthritis (OA) and was associated with both
radiographic OA and clinical features.
This photographic hand OA atlas offers research-
ers a feasible alternative method of data collec-
tion, which may be of particular use for large
population-based studies, for studies covering
wide geographic or remote areas worldwide, and
for researchers wanting to assess widespread in-
volvement that includes hand OA in addition to
OA at other joint sites.
Diagnosing hand OA from photographic images
may be of benefit to clinicians providing remote
health care because digital images of hands could
be taken and sent to the clinician or an expert for
assessment.
Assessing OA on Digital Hand Photographs 829
[PIP], and first carpometacarpal [CMC] joints) were exam-
ined for the visual presence of hard tissue enlargement,
deformity, and nodes. Each joint was given a score on a
0–3 scale, with the assistance of a reference photo collec-
tion (10), where 0 normal with no evidence of OA; 1
mild, some evidence of OA but not fulfilling the criteria for
definite disease; 2 definite moderate OA; and 3 severe
OA. Joint groups across both hands (DIP, PIP, and CMC
joints) were also graded for overall involvement of OA
using the same 0–3 scale. Hand OA on the photographs
was defined as grade 2 for a joint or joint group. A global
hand OA score was calculated for each participant from
the aggregate of the joint group scores (range 0–9). The
reader was blinded to clinical and radiographic data. In-
trarater reliability was assessed by the reader (HJ) scoring
a random sample of photographs from 56 participants a
second time after an interval of 4 weeks. A second expe-
rienced observer (GPH), who was blinded to clinical and
radiographic data as well as the scores of the first reader,
also graded a random sample of photographs from 60
participants to determine interrater reliability.
Radiographic scoring. Dorsipalmar radiographs of the
hands and wrists were taken with separate exposures for
each hand according to a standardized protocol (20). A
single reader (MM), blinded to all questionnaires, clinical
assessment, and photographic data, graded all films for the
presence and severity of OA using the Kellgren/Lawrence
(K/L) grading system, written description (21). Standard-
ized scoring was completed for the second and third
DIP, second and third PIP, and first CMC joints in each
hand. A second reader, an academic rheumatologist, graded
50 pairs of hands and interrater reliability was found to
be very good for the presence of OA in an individual
joint (unweighted mean
0.79; 95% mean percentage
agreement).
Clinical features of OA. At the research clinics, a phys-
ical examination undertaken by trained physiotherapists
and occupational therapists determined the presence of
nodes, hard tissue (bony) enlargement, and deformity in
the second and third DIP and second and third PIP joints;
enlargement and deformity in the first CMC joint; and
swelling in the metacarpophalangeal joints. Participants
also reported the frequency of hand pain, aching, and
stiffness (no days, few days, some days, most days, or all
days), which, along with the presence of clinical features,
allowed ACR clinical hand OA criteria to be applied (7).
The assessors were not aware of the results of the photo-
graphic or radiographic scoring, both of which occurred
after the clinical assessment.
Exclusions. Participants were excluded from the analy-
ses if they did not have hand radiographs or digital pho-
tographs, or if general practice or local rheumatology med-
ical records or a musculoskeletal radiologist identified
them as having inflammatory arthritis (rheumatoid or
psoriatic arthritis). Additionally, individuals were ex-
cluded if there was an indication of possible inflammatory
arthritis or other serious pathology (scleroderma, neuro-
pathic changes, or severe contracture) on the digital hand
photographs, as determined by a consultant rheumatolo-
gist (HJ).
Statistical analysis. Statistical analysis was performed
using SPSS for Windows, version 14.0. All tests were 2-
tailed and a Pvalue of 0.05 was considered statistically
significant.
Figure 1. In this study, the associations of photographic hand osteoarthritis (OA)
with radiographic OA and clinical features were examined to explore the construct
validity of hand photography as an indicator of hand OA. An example of a hand
photograph and its corresponding radiographic image is shown.
830 Marshall et al
The reliability of scoring hand OA from photographs
was assessed using intraclass correlation coefficients
(ICCs) calculated for absolute agreement using a 2-way
random-effects model for single measures for the 10 hand
joints and the 3 joint groups for intra- and interrater reli-
ability. An ICC of 0.70 was considered to indicate good
reliability (22).
The associations of photographic hand OA with radio-
graphic OA and clinical features were examined to ex-
plore the construct validity of hand photography as an
indicator of hand OA (example in Figure 1). For each hand
joint and joint group, the frequency of 1) mild (K/L score
of 2) and moderate to severe (K/L score 3) radiographic
OA and 2) the number of clinical features present on the
hand examination were determined for each photographic
hand OA grade (range 0–3). The radiographic grade and
numbers of clinical features for a joint group were deter-
mined by the highest radiographic grade and greatest num-
ber of clinical features that were present in any of the
joints within a group, respectively. Spearman’s rank cor-
relation coefficients were calculated to assess the strength
and statistical significance of associations of photographic
hand OA score with radiographic OA and clinical features
at the joint and joint group level. Additionally, global hand
OA scores (range 0–9) were compared at the person level
using descriptive statistics to 1) summed K/L radiographic
scores for all 10 hand joints divided into quartiles and
2) the presence of clinical hand OA according to the ACR
criteria (where hand pain was present on most or all days)
(7), relaxed ACR criteria (where hand pain was present on
some, most, or all days), and the clinical features of hand
OA using the ACR criteria (not including the presence of
hand pain).
RESULTS
Study population. Following exclusions for the absence
of hand radiographs (n 4) or digital photographs (n
22), definite inflammatory arthritis (n 28) and possible
inflammatory arthritis (n 8), or other serious patholo-
gies (scleroderma [n 1], neuropathic changes [n 1],
and severe hand contracture [n 1]), data from 558
participants were included in the analyses. The descrip-
tive characteristics of the study population are shown in
Table 1.
The frequency of each grade of hand OA and the prev-
alence of photographic hand OA (grade 2) in this
study population are shown in Supplementary Table 1
(available in the online version of this article at http://
onlinelibrary.wiley.com/doi/10.1002/acr.22225/abstract).
The highest prevalence of OA as determined on the digital
hand photographs was in the DIP joints on each hand,
followed by the first CMC and PIP joints. The same pattern
of involvement was seen for the overall joint groups.
Reliability. Overall, the reliability of grading digital
hand photographs on an ordinal scale (range 0–3) was
found to be good; the mean ICCs for the 10 individual
joints were 0.77 for intrarater reliability and 0.71 for inter-
rater reliability (Table 2). For each joint, the ICCs for in-
terrater reliability tended to be slightly lower than those
for intrarater reliability, except for the left second PIP and
Table 1. Descriptive characteristics of the
study participants*
All participants
(n 558)
Women 61.6 (344)
Age range, years 51–91
Age, mean SD years 64.2 8.2
BMI, mean SD kg/m
2
28.2 4.8
Attended higher education 16.2 (89)
Manual occupational class 52.3 (274)
Right-handed 90.8 (504)
Hand pain or problems in the last month 85.8 (479)
Thumb pain during activity in the last
month
53.0 (296)
Duration of hand symptoms
1 year 10.3 (53)
1–5 years 42.3 (218)
5–10 years 22.5 (116)
10 years 24.9 (128)
Clinical hand OA
ACR criteria 29.6 (165)
Relaxed ACR criteria† 51.0 (284)
Radiographic OA
K/L score 2in1 joint 76.5 (427)
K/L score 3in1 joint 35.8 (200)
* Values are the percentage (number) unless indicated otherwise.
BMI body mass index; OA osteoarthritis; ACR American
College of Rheumatology; K/L Kellgren/Lawrence grading sys-
tem.
† Relaxed ACR criteria are when there is pain on some, most, or all
days rather than most days or all days in the ACR criteria.
Table 2. Intrarater and interrater reliability for scoring
of hand osteoarthritis on a 0–3 scale on digital
hand photographs by joint and joint group*
Intrarater ICC Interrater ICC
Right
DIP3 0.87 0.77
DIP2 0.85 0.82
PIP3 0.89 0.82
PIP2 0.74 0.61
CMC1 0.45 0.73
Left
DIP3 0.91 0.82
DIP2 0.79 0.77
PIP3 0.88 0.64
PIP2 0.36 0.52
CMC1 0.98 0.55
Joint group
DIP joints 0.83 0.71
PIP joints 0.83 0.77
CMC1 joints 0.93 0.72
* Intraclass correlation coefficients (ICCs) were calculated for abso-
lute agreement using a 2-way random-effects model for single mea-
sures. DIP3 third distal interphalangeal joint; DIP2 second DIP
joint; PIP3 third proximal interphalangeal joint; PIP2 second
PIP joint; CMC1 first carpometacarpal joint.
Assessing OA on Digital Hand Photographs 831
right first CMC joints, where intrarater reliability was
lower.
Associations with radiographic and clinical features.
For each joint and joint group, the percentage of individ-
uals with radiographic OA increased from grade 0 through
to grade 3 of photographic hand OA scores (Figure 2). Of
the hand joints and joint groups classed as having photo-
graphic grade 3 hand OA, 90% had radiographic OA, the
majority of which was moderate to severe OA (K/L score
3). However, for those categorized as having photo-
graphic grade 2, the amount of radiographic OA present in
the joints and joint groups varied greatly from 26–91%.
Similarly, for each joint and joint group, the percentage
of individuals with 1 clinical features as determined on
the hand examination increased with photographic grade
of hand OA (Figure 2). In hand joints and joint groups
categorized with photographic grade 2, 74% had 1
clinical features, and in those with photographic grade 3,
all (100%) had 1 features. Statistically significant asso-
ciations were found for each joint and each joint group
between photographic hand OA score and 1) K/L score
(range 04) and 2) number of clinical features present
(range 0–3) (Table 3).
Global photographic hand OA scores (range 0–9), trun-
cated into 5 categories (0, 1, 2, 3, and 4) given the small
number of individuals with higher grades, were compared
to quartiles of radiographic summed K/L scores for the 10
hand joints (0, 1–4, 5–9, and 10). Higher K/L summed
scores were seen more often in those with higher global
hand OA scores (Table 4). Global photographic hand OA
scores were also compared with clinical OA at the person
level. A higher percentage of those classified as having
ACR clinical hand OA were represented in those with
Figure 2. Photographic hand osteoarthritis (OA) grades and the frequency of radiographic OA
and clinical features. A, For each joint and joint group, the percentage of individuals with radio-
graphic OA increased from grade 0 through to grade 3 of photographic hand OA scores. B, For each
joint and joint group, the percentage of individuals with 1 clinical features as deter-
mined on the hand examination increased with photographic grade of hand OA. LDIP3 left
third distal interphalangeal joint; LPIP3 left third proximal interphalangeal joint; LDIP2 left
second DIP joint; LPIP2 left second PIP joint; LCMC1 left first carpometacarpal joint;
RCMC1 right first CMC joint; RPIP2 right second PIP joint; RDIP2 right second DIP
joint; RPIP3 right third PIP joint; RDIP3 right third DIP joint; K&L Kellgren/Lawrence
grade.
832 Marshall et al
grades 3 and 4 global hand OA scores (Figure 3). In
addition, when using the relaxed ACR criteria (where
hand pain was reported on few days or more in the last
month rather than on most days or more) and the clinical
features of hand OA using the ACR criteria excluding the
hand pain question, the percentage of individuals meeting
the criteria increased as the grade of global hand OA in-
creased (Figure 3).
DISCUSSION
This study investigated the reliability of a published at-
las for grading the presence of hand OA on high-quality
digital photographs in a separate younger population from
that in which it was developed. We found the photo-
graphic scoring system for hand OA to be reliable for
scoring both individual joints and overall joint groups, in
terms of both inter- and intrarater reliability. We found
photographic hand OA scores to be associated with both
the presence and severity of radiographic OA and clinical
features of hand OA, confirming the construct validity of
the atlas.
Reproducibility of scoring OA on hand photographs has
previously been examined (10,13,14). In the same popula-
tion as the current study, Nicholls et al (14) found only fair
agreement (
0.340.45) for interrater reliability and
moderate agreement (
0.460.57) for intrarater reliabil-
ity. However, some of the raters in this pilot study were
inexperienced in assessing clinical hand OA features, and
the presence of nodes, bony enlargement, and deformity
was assessed individually rather than globally. In contrast,
Stankovich et al (13) found excellent intrarater reliability,
with ICCs 0.94 for the presence of nodes in the DIP joint
group, and Jonsson et al (10) found good reproducibility
using a global assessment of features, with intrarater ICCs
of 0.81–0.95 and interrater ICCs of 0.780.89. In the cur-
rent study, the intra- and interrater reliability was slightly
lower than that reported in the AGES-Reykjavik study.
However, this was probably due to using ICCs for single
measures, which obtained estimates of reliability for a
single rater, and results in values that are lower than those
obtained for average-measures ICCs. The single-measures
ICC is considered to be more appropriate to estimate intra-
and interrater reliability for future studies that will not
repeat the same degree of testing with multiple raters on
multiple occasions (23).
A number of previous studies have tested the diagnostic
accuracy of examining OA features on hand photographs
using radiography as the reference standard for hand OA,
and have reported inconsistent findings (9–11). It is ques-
tionable whether radiography is an adequate reference
standard for hand OA, given the known discordance be-
tween clinical and radiographic features of OA, with ra-
diographic definitions of OA producing higher prevalence
estimates compared with clinical definitions (24,25).
Therefore, in the current study, we decided to focus on
construct validity by investigating associations of photo-
graphic hand OA scores with radiographic OA and clinical
features of hand OA. In our study population, those with at
least moderate (grade 2) photographic hand OA in each
joint or joint group displayed a stronger association with
clinical features than with radiographic OA. This was also
seen in a previous study by Jonsson et al (10) in the AGES-
Reykjavik Study. The strength of associations obtained for
construct validity between photographic hand OA and
Table 3. Associations of OA on digital hand
photographs and radiographic OA and the number of
clinical features by joint and joint group*
Photographic
hand OA (range
0–3) and K/L
radiographic OA
(range 0–4)
Photographic
hand OA (range
0–3) and number
of clinical features
(range 0–3)
Right
DIP3 0.47 (P0.001) 0.59 (P0.001)
DIP2 0.45 (P0.001) 0.58 (P0.001)
PIP3 0.32 (P0.001) 0.41 (P0.001)
PIP2 0.19 (P0.001) 0.36 (P0.001)
CMC1 0.38 (P0.001) 0.36 (P0.001)
Left
DIP3 0.40 (P0.001) 0.59 (P0.001)
DIP2 0.42 (P0.001) 0.59 (P0.001)
PIP3 0.27 (P0.001) 0.43 (P0.001)
PIP2 0.37 (P0.001) 0.40 (P0.001)
CMC1 0.57 (P0.001) 0.51 (P0.001)
Joint group
DIP joints 0.50 (P0.001) 0.54 (P0.001)
PIP joints 0.29 (P0.001) 0.38 (P0.001)
CMC1 joints 0.47 (P0.001) 0.44 (P0.001)
* Values are the Spearman’s rho. OA osteoarthritis; K/L Kellgren/
Lawrence; DIP3 third distal interphalangeal joint; DIP2 second
DIP joint; PIP3 third proximal interphalangeal joint; PIP2
second PIP joint; CMC1 first carpometacarpal joint.
Table 4. Mean and frequency of summed radiographic scores for different grades of global photographic hand OA*
Global photographic
hand OA score
(range 0–9)
Summed K/L score
(range 0–40), mean SD
Summed K/L radiographic score (range 0–40), % (no.)
0(n132) 1–4 (n 149) 5–9 (n 130) >10 (n 120)
0(n226) 2.9 3.5 39.4 (89) 35.8 (81) 19.0 (43) 5.8 (13)
1(n100) 5.0 4.3 19.0 (19) 37.0 (37) 29.0 (29) 15.0 (15)
2(n82) 6.1 5.2 20.7 (17) 22.0 (18) 37.8 (31) 19.5 (16)
3(n48) 8.7 7.1 14.6 (7) 18.8 (9) 27.1 (13) 39.5 (19)
4(n75) 16.6 8.8 0 5.3 (4) 18.7 (14) 76.0 (57)
* Percentages are in rows and show the proportion of summed radiographic quartiles for each global photographic hand OA grade. OA osteoarthritis;
K/L Kellgren/Lawrence.
Assessing OA on Digital Hand Photographs 833
clinical hand OA (Spearman’s
0.360.59) was greater
than that obtained in a previous study (26) examining
correlations of clinical OA with radiographic changes (r
0.180.52), which was comparable to the correlations in
the present study between photographic and radiographic
hand OA (Spearman’s
0.190.57). Stronger associa-
tions were expected because we assessed similar con-
structs when comparing clinical hand OA features deter-
mined by a physical examination with the same features
assessed visually on digital photographic images. Clinical
and radiographic features of OA may represent slightly
different presentations of OA that may not always coexist
or that occur at slightly different time points, particularly
in early OA. Despite the weaker associations, radiographic
OA was present in almost all hand joint and joint groups
with severe (grade 3) photographic hand OA.
Lower photographic hand OA grades showed a wider
range of K/L scores compared with higher photographic
grades. This might have occurred for several reasons. First,
in early OA, some individuals may present with clinical
features and some with mild radiographic OA, and it is
possible that at this early stage, clinical features and ra-
diographic changes may not always coexist in the same
joint. However, once the disease has become more estab-
lished, individual hand joints are more likely to be af-
fected by both clinical features of OA and radiographic
changes. Second, it is possible that there is a time lag
between clinical features of hand OA being detected
through a hand examination and being able to clearly
observe them on a photographic image, thereby leading to
some disparity between photographic and radiographic
OA, particularly in early OA. Despite this, trends in the
data showed that as photographic hand OA grade in-
creased, there were corresponding increases in the radio-
graphic OA scores.
The assessment of OA on digital hand photographs of-
fers researchers a potential alternative for collecting clin-
ical hand OA data. It has the advantage of being a simple
and cheap method that can be undertaken by a single
centralized researcher trained in the photographic proto-
col. This method may be of particular benefit if the data
collection is taking place over a wide geographic area or if
recruitment is occurring in remote areas, and therefore
may especially be of use in studies wishing to examine the
effects of race and ethnic origin on the prevalence of OA,
which to date have shown some interesting disparities
(27–29). Training different individuals to carry out a stan-
dardized photographic protocol to capture images would
be easier than trying to standardize multiple observers
determining the presence of clinical features on a hand
Figure 3. Global photographic hand osteoarthritis (OA) scores were compared with clinical OA at
the person level. A higher percentage of those classified as having American College of Rheuma-
tology (ACR) clinical hand OA were represented in those with grades 3 and 4 global hand OA
scores (A). When using the relaxed ACR criteria (where hand pain was reported on some days or
more in the last month rather than on most days or more) (B) and the ACR clinical hand OA features
excluding the hand pain question (C), the percentage of individuals meeting the criteria increased
as grade of global hand OA increased.
834 Marshall et al
examination. A photographic method of assessing and di-
agnosing hand OA also has potential for use in studies of
OA at other joint sites, such as the knee, hip, or foot.
Researchers may be interested in assessing more wide-
spread involvement that includes nodal hand OA, but
time, cost, radiation exposure, and availability of expert
examiners limit the possibility of radiography or standard-
ized clinical assessments of the hand. Additionally, the
method of diagnosing hand OA from photographic images
may be of benefit to clinicians providing remote health
care, particularly those providing consultations at a dis-
tance from their patients. Photographs of hands could be
taken and sent to the clinician or an expert for their as-
sessment. Photographic images also offer the benefit of
providing a permanent record of an individual’s hands at
a specific time point and can be revisited for other features
at a later date, if necessary, or compared to future images.
The global scoring of joint groups, which can also provide
an overall hand OA score, showed good reliability and
construct validity with radiographic summed score and
the ACR criteria for clinical hand OA. This was particu-
larly the case when global photographic hand OA scores
were compared to the ACR clinical hand OA features
without the inclusion of the pain question.
There are a few limitations that should be considered
when interpreting the results from these analyses. The
oblique positioning of the thumb when the hands were
pronated and placed palms down made the first CMC joint
harder to assess and grade for photographic hand OA. This
may explain the lower interrater reliability for the left first
CMC joint and lower intrarater reliability for the right first
CMC joint; however, the inter- and intrarater reliability for
the overall CMC joint group was good. It is possible that
additional views with the hands supinated may be useful
to help capture features in this joint. All individuals in this
population cohort had hand pain or hand problems in the
previous 12 months. While individuals with inflammatory
arthritis and scleroderma were excluded, other hand con-
ditions (such as carpal tunnel syndrome, Dupuytren’s con-
tracture, and trigger finger) may have been present, with or
without the co-occurrence of hand OA. When there were
indications of other conditions visible on the photographs
that would have affected the photographic grading, as
determined by the main assessor (HJ) who is an experi-
enced rheumatologist, these individuals were excluded
from the analyses. Therefore, we believe that the presence
of these other hand conditions did not strongly influence
the findings of this study. Additionally, nodes and hard
tissue (bony) enlargement were assessed as separate fea-
tures in the interphalangeal joints; however, we acknowl-
edge that nodes are a form of hard tissue enlargement. At
times, it may be difficult to differentiate between the 2
features, and in some instances, nodes may have been
categorized as bony enlargement or vice versa (30). The
analysis of clinical features in this study was based on the
total number of clinical features present; any misclassifi-
cation between the two was unlikely to have altered the
findings of this analysis. In addition, for the assessment of
the ACR hand OA criteria, the presence of either bony
enlargement or nodes was used to represent hard tissue
enlargement, required to be present in 2 of the 10 se-
lected joints and 2 DIP joints.
The AGES-Reykjavik photographic scoring system for
hand OA has been shown to be reliable and a valid indi-
cator of hand OA as assessed by radiographic and clinical
features, and its use in the current study confirmed the
adequate properties of this scoring system in a separate,
younger community-dwelling population of individuals
with hand pain or problems. This method of data collec-
tion offers researchers a feasible alternative to physical
examination and may be of particular use in large studies
and studies covering wide geographic or remote areas.
ACKNOWLEDGMENTS
The authors would like to acknowledge the contributions
of Professor Peter Croft, Professor Elaine Hay, Dr. Laurence
Wood, Dr. Elaine Thomas, Dr. Rachel Duncan, Charlotte
Purcell, Professor Chris Buckland-Wright, and Professor
Iain McCall for aspects of the conception and design
of the study and the acquisition of data. Dr. Jacqueline
Saklatvala, Carole Jackson, Julia Matheson, Janet Wisher,
Sandra Yates, Krystina Wallbank, and Jean Bamford from
the Department of Radiography, Haywood Hospital, have
contributed specifically to the acquisition of radiographs.
The authors would also like to thank the administrative
and health informatics staff at the Arthritis Research UK
Primary Care Centre at Keele University, as well as the
staff and patients of the participating general practices.
AUTHOR CONTRIBUTIONS
All authors were involved in drafting the article or revising it
critically for important intellectual content, and all authors ap-
proved the final version to be published. Dr. Marshall had full
access to all of the data in the study and takes responsibility for
the integrity of the data and the accuracy of the data analysis.
Study conception and design. Marshall, Jonsson, Helgadottir,
van der Windt, Myers, Dziedzic.
Acquisition of data. Marshall, Jonsson, Helgadottir, Myers,
Dziedzic.
Analysis and interpretation of data. Marshall, Jonsson, Nicholls.
REFERENCES
1. Wilder FV, Barrett JP, Farina EJ. Joint-specific prevalence of
osteoarthritis of the hand. Osteoarthritis Cartilage 2006;14:
953–7.
2. Dziedzic K, Thomas E, Hill S, Wilkie R, Peat G, Croft PR. The
impact of musculoskeletal hand problems in older adults:
findings from the North Staffordshire Osteoarthritis Project
(NorStOP). Rheumatology (Oxford) 2007;46:963–7.
3. Bellamy N, Tesar P, Walker D, Klestov A, Muirden K, Kuhnert
P, et al. Perceptual variation in grading hand, hip and knee
radiographs: observations based on an Australian twin regis-
try study of osteoarthritis. Ann Rheum Dis 1999;58:766–9.
4. Hart DJ, Spector TD. Definition and epidemiology of osteoar-
thritis of the hand: a review. Osteoarthritis Cartilage 2000;8:
S2–7.
5. Salaffi F, Carotti M, Stancati A, Grassi W. Radiographic as-
sessment of osteoarthritis: analysis of disease progression.
Aging Clin Exp Res 2003;15:391–404.
6. Cibere J. Do we need radiographs to diagnose osteoarthritis?
Best Pract Res Clin Rheumatol 2006;20:27–38.
7. Altman R, Alarcon G, Appelrouth D, Bloch D, Borenstein D,
Brandt K, et al. The American College of Rheumatology cri-
Assessing OA on Digital Hand Photographs 835
teria for the classification and reporting of osteoarthritis of the
hand. Arthritis Rheum 1990;33:1601–10.
8. Hennekens CH, Buring JE. Epidemiology in medicine. Boston:
Little, Brown and Company; 1987. p. 278–9.
9. Stern AG, Moxley G, Sudha Rao TP, Disler D, McDowell C,
Park M, et al. Utility of digital photographs of the hand for
assessing the presence of hand osteoarthritis. Osteoarthritis
Cartilage 2004;12:360–5.
10. Jonsson H, Helgadottir GP, Aspelund T, Sverrisdottir JE,
Eiriksdottir G, Sigurdsson S, et al. The use of digital photo-
graphs for the diagnosis of hand osteoarthritis: the AGES-
Reykjavik study. BMC Musculoskelet Disord 2012;13:20.
11. Acheson RM, Collart AB, Greenberg RH, Clemett AR. New
Haven survey of joint disease: photographs and other vari-
ables in screening for arthritis of the hands. Am J Epidemiol
1969;90:224–35.
12. Hirsch R, Guralnik JM, Ling SM, Fried LP, Hochberg MC.
The patterns and prevalence of hand osteoarthritis in a pop-
ulation of disabled older women: the Women’s Health and
Aging Study. Osteoarthritis Cartilage 2000;8:S16–21.
13. Stankovich J, Sale MM, Cooley HM, Bahlo M, Reilly A,
Dickinson JL, et al. Investigation of chromosome 2q in osteo-
arthritis of the hand: no significant linkage in a Tasmanian
population. Ann Rheum Dis 2002;61:1081–4.
14. Nicholls E, Dziedzic K, Vohora K, Myers H, Marshall M,
Duncan R, et al. Reliability of digital images for scoring clin-
ical features of hand osteoarthritis [abstract]. Osteoarthritis
Cartilage 2006;14:S122.
15. Helgadottir GP, Sverrisdottir JE, Eiriksdottir G, Harris T,
Gudnason V, Jonsson H. Diagnosing hand osteoarthritis from
digital photographs: a reproducible scoring system [abstract].
Osteoarthritis Cartilage 2007;15:C195.
16. Helgadottir GP, Eliasson GJ, Jonsson A, Sigurdsson S,
Eiriksdottir G, Aspelund T, et al. Comparison of photographs,
clinical examination and radiographs for the assessment of
hand osteoarthritis [abstract]. Osteoarthritis Cartilage 2007;
15:C186.
17. Jonsson H, Helgadottir GP, Eliasson GJ, Jonsson A, Sigurdsson
S, Eiriksdottir G, et al. Hand joint pain in the elderly in
relation to hand osteoarthritis severity assessed by digital
photographs, clinical examination and radiographs [abstract].
Ann Rheum Dis 2008;67:235.
18. Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW,
Knol DL, et al. The COSMIN checklist for assessing the meth-
odological quality of studies on measurement properties of
health status on measurement instruments: an international
Delphi study. Qual Life Res 2010;19:53949.
19. Bowling A. Research methods in health. Buckingham: Open
University Press; 1997. p. 1946.
20. Myers H, Nicholls E, Handy J, Peat G, Thomas E, Duncan R,
et al. The Clinical Assessment Study of the Hand (CAS-HA):
a prospective study of musculoskeletal hand problems in the
general population. BMC Musculoskelet Disord 2007;8:85.
21. Lawrence JS. Osteo-arthrosis. In: Lawrence JS, editor. Rheu-
matism in populations. London: William Heinemann Medical
Books; 1977. p. 98–155.
22. Streiner DL, Norman GR. Health measurement scales: a prac-
tical guide to their development and use. 4th ed. New York:
Oxford University Press; 2008. p. 177–81.
23. De Vet HC, Terwee CB, Mokkink LB, Knol DL. Measurement
in medicine: a practical guide. Cambridge: Cambridge Univer-
sity Press; 2011. p. 103–11.
24. Hannan MT, Felson DT, Pincus T. Analysis of the discor-
dance between radiographic changes and knee pain in osteo-
arthritis of the knee. J Rheumatol 2000;27:1513–7.
25. Pereira D, Peleteiro B, Araujo J, Branco J, Santos RA, Ramos E.
The effect of osteoarthritis definition on prevalence and inci-
dence estimates: a systematic review. Osteoarthritis Cartilage
2011;19:127085.
26. Caspi D, Flusser G, Faber I, Ribak J, Leibovitx A, Habot B,
et al. Clinical, radiologic, demographic, and occupational as-
pects of hand osteoarthritis in the elderly. Semin Arthritis
Rheum 2001;30:321–31.
27. Nelson AE, Golightly YM, Renner JB, Schwartz TA, Kraus VB,
Helmick CG, et al. Differences in multijoint symptomatic os-
teoarthritis phenotypes by race and sex: the Johnston County
Osteoarthritis Project. Arthritis Rheum 2013;65:373–7.
28. Kalichman L, Li L, Batsevich V, Malkin I, Kobyliansky E.
Prevalence, pattern and determinants of radiographic hand
osteoarthritis in five Russian community-based samples. Os-
teoarthritis Cartilage 2010;18:803–9.
29. Nevitt MC, Xu L, Zhang Y, Lui LY, Yu W, Lane NE, et al. Very
low prevalence of hip osteoarthritis among Chinese elderly in
Beijing, China, compared with whites in the United States:
the Beijing Osteoarthritis Study. Arthritis Rheum 2002;46:
1773–9.
30. Myers HL, Thomas E, Hay EM, Dziedzic KS. Hand assessment
in older adults with musculoskeletal hand problems: a reli-
ability study. BMC Musculoskelet Disord 2011;12:3.
836 Marshall et al
... In 2012, the Age, Gene/Environment Susceptibility -Reykjavik (AGES-Reykjavik) photographic atlas was developed as a formal method for scoring hand photographs for OA [9]. It has been shown to be reliable and associated cross-sectionally with radiographic and clinical OA [10,11] and shows age-related prevalence trends that are comparable to those seen for clinical and radiographic OA [12]. However, it is not known whether this method is valid in comparison to the progression of radiographic OA and the increased presence of clinical features determined from a physical examination. ...
... Reliability of using the photographic scoring system has previously been established [11], thus reliability was undertaken at 7-years to ensure that this hadn't markedly changed. The inter-rater reliability of the scoring of photographic hand Fig. 1 An example of the photographic hand images obtained at baseline and 7 years for a participant OA at 7 years was assessed across all participants using intra-class correlation coefficients (ICC), using 2-way random effects models with absolute agreement, for the 10 hand joints and three joint groups. ...
... Two a priori hypotheses were set regarding these correlations at the joint and joint group level: 1) Change in photographic hand OA scores for each joint was expected to correlate more closely with the change in the number of clinical features than with the change in radiographic OA grade. 2) Correlations would be the same or slightly lower than was achieved at baseline for cross-sectional construct validity in each hand joint and joint group [11]. ...
Article
Full-text available
Background: To determine the longitudinal construct validity of assessing hand OA progression on digital photographs over 7 years compared with progression determined from radiographs, clinical features and change in symptoms. Methods: Participants were community-dwelling older adults (≥50 years) in North Staffordshire, UK. Standardized digital hand photographs were taken at baseline and 7 years, and hand joints graded for OA severity using an established photographic atlas. Radiographic hand OA was assessed using the Kellgren and Lawrence grading system. Hand examination determined the presence of nodes, bony enlargement and deformity. Symptoms were reported in self-complete questionnaires. Radiographic and clinical progression and change in symptoms were compared to photographic progression. Differences were examined using analysis of covariance and Chi-Square tests. Results: Of 253 individuals (61% women, mean age 63 years) the proportion with photographic progression at the joint and joint group-level was higher in individuals with radiographic or clinical progression compared to those without, although differences were not statistically significant. At the person-level, those with moderate photographic progression over 7 years had significantly higher summed radiographic and clinical scores (adjusted for baseline scores) compared to those with no or mild photographic progression. Similar findings were observed for change in symptoms, although differences were small and not statistically significant. Conclusion: Assessing hand OA on photographs shows modest longitudinal construct validity over 7 years compared with change in radiographic and clinical hand OA at the person-level. Using photographs to assess overall long-term change in a person with hand OA may be a reasonable alternative when hand examinations and radiographs are not feasible.
... The photographic method was in most aspects comparable to the other methods in relation to pain and disability. Subsequent studies have indicated that this method of photographic scoring system is reliable and also a good indicator of hand OA in a younger population and offers a feasible alternative to physical examination and radiography [12]. ...
... An aggregate score of 0-9 was thus obtained. A score of 4 or more was chosen to reflect severe hand OA in accordance with previous studies [8,12] Statistics were calculated using SPSS version 22. Chisquare and the Mantel Haenszel odds ratio estimate was used to calculate gender prevalence differences and the likelihood of having definite OA at a second site if participants had definite OA at one site. ...
... In addition, the simplified HOASCORE showed a high degree of correlation with aggregate scores of both radiology and clinical examination [8]. These findings have been corraborated in a younger symptomatic population from the UK [12]. The age related prevalences obtained by photograph scoring in the current study show age related patterns that are comparable to clinical and radiographic studies, such as the marked female preponderance in the postmenopausal age groups and in the thumb base. ...
Article
Full-text available
Background: Hand photography has been used in a number of studies to determine the presence and severity of hand osteoarthritis (HOA). The aim of this study was to present age and gender specific prevalences of HOA diagnosed by this method. Methods: Six thousand three hundred forty three photographs (from 3676 females and 2667 males aged 40-96) were scored for hand osteoarthritis by a 0-3 grade (0 = no evidence of OA, 1 = possible OA, 2 = definite OA and 3 = severe OA) for each of the three main sites, distal interphalangeal joints (DIP), proximal interphalangeal joints (PIP) and thumb base (CMC1). An aggregate score of 0-9 was thus obtained (HOASCORE) to reflect the severity of HOA in each case. Results: DIP joints were most commonly affected, followed by the thumb base and the PIP joints. Having definite DIP joint OA starts at a younger age compared with the other two sites, and there is a marked female preponderance in the age groups from 55 to 69, but after 70 the gender differences are less marked and the prevalence is fairly stable. PIP joint prevalence also indicates a female preponderance from 60 to 79. Thumb base OA has a more marked female preponderance and a rising prevalence thoughout life. The prevalence of individuals with no evidence of photographic OA (HOASCORE = 0) drops from 88% to 57% between the age categories 40-49 and 50-54 and decreased to 33% in the 70-74 age group with a slower decline after that age. DIP and PIP prevalence were strongly associated with each other with an OR of 16.6(12.8-21.5),p < 0.001 of having definite OA at the other site. This was less marked for the thumb base with an OR of 2.2(1.8-2.7, p < 0.001), and 2.7(2.0-3.5, p < 0.001) of having definite DIP or PIP HOA respectively. Conclusions: The prevalence of hand OA in DIP, PIP and thumb base joints obtained by the photographic HOASCORE method is higher in women and increases after the age of fifty. These results are in line with those obtained by clinical examination and radiography. The advantage of the method lies in easy applicability and low cost.
... This study was later extended to see if the atlas would be as useful for younger populations. The atlas and method created in the Iceland study was used with patients in Keele, UK and results of the study were published in 2013 [11]. In the study, the atlas developed was used to assess 558 participants who were community dwelling adults 50 years of age and older. ...
... In the study, the atlas developed was used to assess 558 participants who were community dwelling adults 50 years of age and older. The scoring system was shown to be reliable and a good indicator of hand OA [11]. ...
... Among the possible caveats of this study are the methods used for diagnosing hand osteoarthritis with photography and using TKR's after exclusion of other causes such as inflammatory arthritis or fractures as a marker of severe knee OA. The photographic method for diagnosing hand OA has been validated in other populations [28], and TKR's are considered as a sensitive marker of severe knee OA, mainly limited by unequal access to operation in different populations. In Iceland, the health care system is socialized and previous Icelandic studies have not found any association between the prevalence of TKR's and education or occupational classes, indicating equal access [14,29]. ...
Article
Full-text available
To investigate the association between osteoarthritis (OA) and microvascular pathology, we examined the relationship between retinal microvascular caliber and osteoarthritis of the hand and knee in an elderly population. The AGES-Reykjavik is a population-based, multidisciplinary longitudinal cohort study of aging. Retinal vessel caliber, hand osteoarthritis and total knee joint replacements due to OA were examined in 4757 individuals (mean age 76 ± 5 years; 57% female). Incident knee joint replacements during 5-year follow-up (n = 2961, mean age 75 ± 5 years; 58% female) were also assessed. Logistic regression analysis, adjusting for age, sex, and body mass index, showed an association between narrow arteriolar caliber and hand OA, as well as knee replacement. After adjustment for other covariates, including statin therapy, this association was significant for both hand OA in men and women [OR 1.10(1.03–1.17), p < 0.01] (per unit standard deviation decrease in CRAE) and TKR prevalence [OR 1.15 (1.01–1.32), p = 0.04], especially for men [OR 1.22 (1.00–1.51) p = 0.04] and also for incident TKRs in men [OR 1.50 (1.07–2.10), p = 0.04]. Narrow venular caliber was associated with hand OA in women [OR 1.10 (1.01–1.21), p = 0.03]. Retinal arterial narrowing in hand and knee OA is present in males as well as females. Venular narrowing in hand OA in women was an unexpected finding and is in contrast with the venular widening usually observed in cardiovascular diseases.
... Using 3D DOT, researchers could distinguish between distal interphalangeal joints (DIPJ) affected by osteoarthritis (OA) and healthy joints 232 . After further methodological refinements, this technique could distinguish between patients with hand OA and patients with psoriatic arthritis or healthy individuals 233 . Incorporating PAI with DOT improves the image resolution enabling better differentiation of bone from soft tissue 234 . ...
Article
Osteoarthritis (OA) is a highly prevalent condition, and the hand is the most commonly affected site. Patients with hand OA frequently report symptoms of pain, functional limitations and frustration in undertaking everyday activities. The condition presents clinically with changes to the bone, ligaments, cartilage and synovial tissue, which can be observed using radiography, ultrasonography or MRI. Hand OA is a heterogeneous disorder and is considered to be multifactorial in aetiology. This Review provides an overview of the epidemiology, presentation and burden of hand OA, including an update on hand OA imaging (including the development of novel techniques), disease mechanisms and management. In particular, areas for which new evidence has substantially changed the way we understand, consider and treat hand OA are highlighted. For example, genetic studies, clinical trials and careful prospective imaging studies from the past 5 years are beginning to provide insights into the pathogenesis of hand OA that might uncover new therapeutic targets in the disease.
Article
Objective The RADIANT study aimed to investigate the efficacy and safety of a complementary medicine supplement combination in people with hand osteoarthritis (HOA). Method This was an internet-based, double-blind, randomised, placebo-controlled trial. Participants aged over 40 years with symptomatic HOA with radiographic confirmation (Kellgren Lawrence grade ≥ 2) throughout Australia were recruited and randomly assigned (1:1) to receive either a supplement combination composed of Boswellia serrata extract 250 mg/day, pine bark extract 100 mg/day, methylsulfonylmethane 1500 mg/day and curcumin 168 mg/day or placebo for 12 weeks. The primary outcome was change in hand pain assessed using a visual analogue scale (VAS 0-100) from baseline to week 12. A range of secondary outcomes and additional measures were recorded. Adverse events were monitored weekly. Results One hundred and six participants were included with mean age 65.6 years and 81% were women. 45% of the participants were graded as KLG 4, 40% KLG 3 and 39 (37%) had erosive OA. There was no significant difference in pain VAS reduction between groups. The adjusted between group difference in means (95%CI) was 5.34 (-2.39 to 13.07). Five participants (10%) in the supplement combination group discontinued study treatment due to AE versus four participants (7%) in the placebo group. Conclusion There were no significant differences in symptomatic relief between the two groups over 12 weeks. These findings do not support the use of the supplement combination for treating hand pain in people with HOA. Registration Prospectively registered (Australian New Zealand Clinical Trials Registry ACTRN12619000835145, 31/05/2019).
Book
The impetus for writing this textbook arose from our teaching experiences in epidemiology at Harvard Medical School and Boston University School of Public Health as well as at other schools of medicine and public health, both in the United States and abroad. Our students have consistently suggested that their learning would be enhanced by the availability of an accompanying textbook, to serve both as an aid during the course and, subsequently, as a reference resource. We have also delivered lectures and conducted seminars with groups ranging from predominantly health professionals, such as the American Heart Association and the American Cancer Society, to media representatives, to meetings of biochemists, pharmacologists, nutritionists and other investigators whose primary interest is in basic science or clinical research. The universal concerns expressed by all these diverse groups have been how to evaluate what they read in the medical literature, and how to determine its value to their particular areas. We believe these concerns to be both important and timely. The importance of gaining such insights is borne out by the fact that much of continuing medical and public health education is derived from current literature. The timeliness is reflected in the large quantity of information from the medical literature which is now widely and daily disseminated to the general public by the media. © 1987 by Charles H. Hennekens and Julie E. Buring. All rights reserved.
Article
Objectives: Nodal osteoarthritis of the hand (hand OA) is a subset of OA with a strong heritable component. Multiple genetic analyses of this condition have been performed and are underway. Highest yield from any genetic study depends upon a clear clinical phenotype for case definition. Radiographs may provide the most detail about the nature of the lesion. Physical examination is an imperfect means of evaluating each patient, particularly when hundreds or thousands of patients are required for study. Our study evaluated the accuracy, relative to a radiograph, of a digital photograph of the hands for the presence of CA in a particular joint, as well as for the diagnosis of nodal hand OA. Methods: Consecutive patients were evaluated as part of the I-NODAL study (Investigation of Nodal Osteoarthritis to Detect an Association with Loci encoding Interleukin-1 [IL-1]). Evaluation included a physical examination by a trained rheumatologist, a postero-anterior radiograph of the hands, and a digital photograph of each hand. Radiographs were read by one trained observer using the Kellgren-Lawrence scale. Photographs were taken by one individual and were analyzed by an experienced rheumatologist. Kappa statistics were determined for each modality and accuracy was assessed using radiographic readings as a gold standard. Results: Intra-reader reliability for radiograph interpretation was good for the overall diagnosis of hand OA (kappa0.76 [0.45,1.07]), but varied widely for the presence or absence of K-L grades 2-4 in individual joints (median kappa0.70, range 0.49-0.87 for ACR index joints). Distal interphalangeal joint (DIP) nodes on physical examination were sensitive (median 96.27, 93.94-100), but not specific for radiographic hand OA in the corresponding joint (median 33.0, 17.24-42.86). Physical examination evidence of CA in the 1st carpo-metacarpal (CIVIC) and proximal interphalangeal (PIP) joints provided only moderate sensitivity and specificity. However, the negative predictive value of the examination of individual joints was good (median negative predictive value was 82.58 for IP joints with a range 68.29-100.00), particularly in the DIP joints. Specificity of a node visualized on hand photograph was variable (median for all IP joints and 1st CMC 83.77, range 53.37-96.97), with greatest specificity for radiographic CA in the corresponding joint found in the 1st CIVIC and the PIP joints. Clinical hand OA was sensitive, but not specific for the radiographic diagnosis of hand OA; while, photographic CA was moderately specific, but insensitive. Conclusion: The visualization of a node on a digital photograph of the hand provides fair to moderate specificity for radiographic hand CA in the corresponding joint, with generally poor sensitivity. A photograph has limited value as a screening tool for the diagnosis of radiographic hand OA.
Article
The success of the Apgar score demonstrates the astounding power of an appropriate clinical instrument. This down-to-earth book provides practical advice, underpinned by theoretical principles, on developing and evaluating measurement instruments in all fields of medicine. It equips you to choose the most appropriate instrument for specific purposes. The book covers measurement theories, methods and criteria for evaluating and selecting instruments. It provides methods to assess measurement properties, such as reliability, validity and responsiveness, and interpret the results. Worked examples and end-of-chapter assignments use real data and well-known instruments to build your skills at implementation and interpretation through hands-on analysis of real-life cases. All data and solutions are available online. This is a perfect course book for students and a perfect companion for professionals/researchers in the medical and health sciences who care about the quality and meaning of the measurements they perform. © H. C. W. de Vet, C. B. Terwee, L. B. Mokkink and D. L. Knol 2011.
Book
Clinicians and those in health sciences are frequently called upon to measure subjective states such as attitudes, feelings, quality of life, educational achievement and aptitude, and learning style in their patients. This fifth edition of Health Measurement Scales enables these groups to both develop scales to measure non-tangible health outcomes, and better evaluate and differentiate between existing tools. Health Measurement Scales is the ultimate guide to developing and validating measurement scales that are to be used in the health sciences. The book covers how the individual items are developed; various biases that can affect responses (e.g. social desirability, yea-saying, framing); various response options; how to select the best items in the set; how to combine them into a scale; and finally how to determine the reliability and validity of the scale. It concludes with a discussion of ethical issues that may be encountered, and guidelines for reporting the results of the scale development process. Appendices include a comprehensive guide to finding existing scales, and a brief introduction to exploratory and confirmatory factor analysis, making this book a must-read for any practitioner dealing with this kind of data.