Joint Protection Principles

Original Editor - Venus Pagare

Top Contributors - Venus Pagare  

Background

  • Functional ability is reduced in 60% of people with rheumatoid arthritis (RA) within the first five years from diagnosis, with 16% developing more severe functional disability and 44% following a remittingurelapsing course.[1] 
  •  Within two years 50% experience difficulties in household tasks.[2] 
  • Women with RA can have on average only 40% of normal power and pinch grip within six months of diagnosis, even with early commencement of disease-modifying drugs (DMARDs).[3] This suggests therapy to help maintain hand function and independence should be provided early for those developing functional limitations.


Introduction to Joint Protection

  • Joint protection is a self-management approach that aims to maintain functional ability through altering working methods and movement patterns of affected joints, using assistive devices and pacing activities. This helps reduce pain, inflammation and stresses applied to joints during daily activity and may help preserve the integrity of joint structures longer term.[4] [5]
  • Rheumatology health professionals commonly teach joint protection. Focus is on changing hand habits, and increasingly people are referred earlier in the disease process for this education.
  • Providing self-management information (such as joint protection advice) does not, on its own, lead to significant improvements in adherence or health status.[6] Behavioural approaches (i.e., skills practice, goal-setting and home programmes) are significantly more effective in increasing use of joint protection than ‘standard’ education (i.e., information, demonstration and short supervised practice) anduor information booklets.
  • This approach is effective for people with both early (<5 years) [7] [8]and established RA (>/5 years).[9] [10]


Techniques

1. Planning

  • Think before starting ­ can the work be more efficient?
  • Can things be re­organise?
  • Can certain jobs be delegates, or done less frequently?
  • ‘do’ the work when you’re at your best


2. Pacing

  • Little and often
  • Take regular breaks ­ change position, stretch
  • Mix heavy and light jobs
  • Do harder/more tiring jobs when fresh


3. Respect for Pain

  • Pain that lasts more than 2 hours indicates joint damage.
  • Fear of pain results in inactivity and loss of motion and strength.
  • Disregard for pain results in joint damage and pain.
  • Stop activities before reaching the point of discomfort or pain.
  • Limit activities which cause pain to last more than one hour after you have stopped the activity.


4. Balance Activity and Rest

  • Rest before becoming tired.
  • Plan rest periods during longer or more difficult activities.
  • By resting 10 minutes during an activity, you will have more energy to continue.


5. Maintain muscle strength and joint range of motion

  • Achieve full range of each joint while performing daily activities.
  • Perform specific exercises and range-of-motion activities.
  • Loss of range of motion and strength = loss of function.


6. Avoid Activities Which Cannot Be Stopped

  • When you begin to feel joint pain, stop. This will eliminate excessive pain and fatigue later.
  • Prioritize activities. Consider the activity, length of time, and difficulty before beginning. Plan difficult activities for “peak” energy times.


7. Use Larger, Stronger Joints For Activities, When Possible, Distributing The Weight Over Non-involved Or Stronger Joints.

  • This means instead of using fingers, use wrist; instead of using wrist, use elbow; instead of using elbow, use shoulder.
  •  To lift a bag from a counter, bend knees, hug the bag with both arms. Bend elbows so that the bag is held tightly to chest and straighten knees. Keep hold on the bag by keeping elbows bent. If the load is too heavy, push shopping cart, or get help with groceries - use drive-up service.
  • Hip can be used to push open doors, and feet to close lower drawers
  • An envelope briefcase with a snap lock can be used rather than an attache case. By bending the elbows, the case can be carried under the arm so that the case rests on the forearm. Hold the case by resting arm against body. Switch the case from one side of the body to the other.
  • Use the larger joints (elbow or shoulder) to carry the weight of the purse.
    Wrong: The weight of the purse is all on the weak fingers.
    Right: The stronger elbow should carry the weight of the purse.


8. Avoid Staying In One Position For Extended Periods Of Time.

  • Plan rest periods.
  • Change position.
  • Stretch and relax your joints.


9. Maintain Joints In Good Alignment and use good body mechanics

  • If positioned correctly and muscles used are best suited to a physically demanding task, stress on joints can be minimized. Proper body mechanics allows use of body more efficiently.
  •  Carry heavy objects close to chest, supporting the weight on forearms. To pick up items from the floor, stoop by bending knees and hips.  Or sit in a chair and bend over.
  • Arranging work area wisely also can make a big difference:


While sitting: Make sure there is good back and foot support. Forearms and upper legs should be well supported, resting level with the floor.
While standing: The height of work surface should enable comfortable working without stooping
Posture: Whether walking, standing, sitting or even sleeping, good posture is important for people with arthritis. Poor posture can make arthritis worse. As for standing, stand straight, head high, shoulders back, stomach in, and hips and knees straight.
Walking: Walk erect, as in standing position. Arm swing freely at sides; let weight shift easily from side to the other. Don’t carry heavy packages in one hand. A lightweight shoulder bag is a good idea. If legs or knees are involved, a cane will make walking easier.
Resting/Sleeping: Patients with rheumatoid arthritis should avoid bent knees or arms. Lie straight at sides, knees and hips straight. Use a firm mattress or put plywood board between mattress and bedspring. If a pillow is needed under head, use a thin one. Keep sheets and blankets loose over feet, perhaps by using a blanket support.
Sitting: Keep good posture when sitting down. Use straight-back armchairs with firm seats. Sit with head up, shoulders back, stomach in, feet flat on floor. Use arms of chair to stand up slowly.


10. Maintain Proper Weight.

  • Additional weight can stress weight-bearing joints (hip, knees, feet, back).


11. Wear splints and/or braces for Protection

  • Lifting and twisting = joint strain
  • Look at how you use joints. Can you work differently?
  • Can gadgets help?
  • Protect and provide rest to very weakor unstable joints.
  • During activity, provide external stability to an unstable joint.



12. Avoid positions of deformity


13. 'Slide all objects that slide and put whatever is practical on wheels.'

Examples: slide pots and pans across stove and counter to sink. Use a kitchen cart to carry foods and dishes and a laundry cart for laundry.


14. Add leverage to appliances and fixtures to reduce the force to operate them

  • Example: lengthen the lever of the can opener, put an extension on the water faucet, etc.


15. Hold all handles straight across the palm – never diagonally.

  • Examples: hold your knife and fork for cutting in an overhand grasp and hold a mixing spoon the same way.


                                                                         


                                                                     SPECIAL CONSIDERATIONS FOR THE HANDS
1. AVOID TIGHT GRASP

  • Use a relaxed grip.
  •  Enlarge handles.
  • Place palm of hand on jar lid, and using weight of body, turn arm at shoulder to open jar. A sponge or wet towel under the jar prevents sliding
  • Hold the knife or mixing spoon like a dagger, with the handle parallel to knuckles. Cutting is then changed from sawing to pulling
  • Don't carry heavy handbags, pails, and bags by the handle.
  • Hold everything no tighter than necessary.
  • Release tight grasp frequently if you have to use it.
  • Use built-up handles on writing utensils, pot handles, tools, etc.
  • Use adaptive equipment such as jar openers.


2. AVOID PRESSURE ON BACK OF KNUCKLES (MP JOINTS)

  • Avoid all pressures against the backs of fingers: this type of pressure contributes to dislocation of the large joints between the palm and the fingers (metacarpal-phalangeal joints).
  • This occurs while pushing up from a chair using a closed fist or resting chin on the backs of fingers.
  • Use palms while holding fingers straight.


3. USE BOTH HANDS WHEN POSSIBLE
4. AVOID REPETITIVE HAND ACTIVITIES

  • Take breaks
  • Change activity, i.e. using screwdriver, crocheting.


5. AVOID PRESSURE TO TIP OR PAD OF THUMB

  • The thumb is necessary for 40 percent of hand activities
  • Example: opening car doors, ringing doorbells
  • To protect thumb joints, open milk containers with heels of the hands rather than thumbs.


6. AVOID PRESSURE AGAINST THE RADIAL SIDE OF EACH FINGER THUMB SIDE) 

  • Don't rest chin on the side of fingers.
  • Add levers to keys, handles, and knobs.
  • Hold handles straight across the palm.


7.AVOID PROLONGED PERIODS OF HOLDING HANDS IN T5HE SAME POSITION 

  • Sit if the task takes more than 10 minutes.
  • Stand up after sitting for 20-30 minutes.
  • Reposition yourself often.


References

  1. Young A, Dixey J, Cox Net al. How does functional ability in early rheumatoid arthritis (RA)affect patients and their lives? Results of 5 years of follow-up in 732 patients from the Early Rheumatoid Arthritis Study (ERAS)Rheumatology 2000;39: 603-11.
  2. Eberhardt KB, Rydgren LC, Petersson H, WollheimfckLRFA. Early rheumatoid arthritis- onset, course andfckLRoutcomes after two years.Rheumatol Int 1990;10:135-42.
  3. Hammond A, Kidao R, Young A. Hand impairment and function in early rheumatoid arthritis.Arthritis Rheum 2000;43(9 suppl):S285.
  4. Cordery J, Rocchi M. Joint protection and fatigue management. In: Melvin J, Jensen G eds. Rheumatologic rehabilitation, Volume 1:Assessment and management. Bethesda, MD: American Occupational Therapy Association, 1998: 279-322.
  5. Melvin J.Rheumatic disease: occupational therapy and rehabilitation, second edition. Philadelphia: FA Davis, 1989: 351-71
  6. Riemsma RP, Kirwan JR, Taal E, Rasker JJ. PatientfckLReducation for adults with rheumatoid arthritis(Cochrane review). In:The Cochrane Library, Issue 2. Oxford: Update Software, 2003.
  7. Hammond A, Freeman K. One year outcomes of afckLRrandomised controlled trial of an educational- behavioural joint protection programme for peoplefckLRwith rheumatoid arthritis.Rheumatology2001;40:1044-51.
  8. Brus HLM, van der Laar MAFJ, Taal E, Rasker JH. Effects of patient education on compliance with basic treatment regimens and health in recent onset active rheumatoid arthritis.Ann Rheum Dis 1998; 57: 146-51.
  9. Hammond A, Lincoln N, Sutcliffe L. A crossoverfckLRtrial evaluating an educational behavioural joint protection education programme for people with rheumatoid arthritis.Patient Educ CounsellingfckLR1999;37:19-32.
  10. Hammond A, Jeffreson P, Jones N, Gallagher J, Jones T. Clinical applicability of an educational-behavioural joint protection programme for people with rheumatoid arthritis. Br J Occup Ther 2002;65: 405-12