Joint Protection Principles

Original Editor - Venus Pagare

Top Contributors - Venus Pagare and Abbey Wright  

Introduction

Knee braces can be used to offload the joint in acutely painful arthritis
Joint protection is a self-management approach that aims to maintain functional ability through changing/adapting working methods and movement patterns of affected joints. This can be with the use of devices such as splints or pacing activities.

Changing this habits can help reduce pain, inflammation and stress that is applied to joints during daily activity and may help preserve the integrity of joint structures longer term.[1] [2]

Health professionals commonly teach joint protection for patients with rheumatoid and osteoarthritis. Focus is on changing habits, and increasingly people are referred for intervention and advice earlier in the disease process[1].

Providing self-management information (such as joint protection advice) does not, on its own, lead to significant improvements in health status.[3][4] Behavioural approaches are significantly more effective in increasing use of joint protection than ‘standard’ education with information booklets[5].

This approach is effective for people with both early and established RA. [6] [5][7] [8]

Background

Wrist splint can be used to immobilise an acutely painful arthritic wrist for short periods of time
In 60% of rheumatoid arthritis (RA) patients functional ability is reduced within the first five years from diagnosis, with 16% developing more severe functional disability and 44% following a relapse/ flare up of pain.[9]

Within two years 50% of sufferers experience difficulties in household tasks.

Women can be deteriorate more rapidly than men.[9]

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).[10] This suggests therapy to help maintain hand function and independence should be provided early for those developing functional limitations.

Techniques

1. Planning

  • Think before starting ­can the work be more efficient?
  • Can things be re-organised?
  • Can certain jobs be delegated, or done less frequently?
  • Do work when you’re at your best

2. Pacing

  • Break down tasks to be little and often
  • Take regular breaks to change position
  • Mix heavy and light jobs
  • Start with the more difficult tasks first

3. Respect for Pain

  • Fear of pain results in inactivity and loss of motion and strength.
  • Disregard for pain can lead to poor movement patterns and can increase the 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 leads to a loss of function.

6. Use larger, stronger joints for activities

  • Instead of using fingers, use wrist; instead of using wrist, use elbow; instead of using elbow, use shoulder.
  • For example: 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.

7. Avoid staying in one position for extended periods of time.

  • Plan/set a reminder for when to change position.
  • Moving/ getting up from your desk when at work regularly will help prevent stiffness
  • Keep mobile

8. Maintain good movement patterns

  • If the body moves well it can minimise stress on joints
  • Proper body mechanics allows use of body more efficiently.
  • Try to avoid breath holding and jerky movements.

9. Loosing weight[11]

  • Additional weight leads to increased stress on weight-bearing joints

10. Wear splints/braces to offload joints

  • Use of a splint or brace can be used temporarily to help offload acutely painful joints.
  • Splints can also be used to immobilise smaller joints in order for them to rest
  • It is important to spend time out of a brace in order to maintain full ROM

11. Change the way you move objects

  • For example: 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.

Hand arthritis

[12]

Arthritis of the hands can be very frustrating and lead to a lack of function rapidly due to the intricate nature of the fine motor skills that hands do.


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 weight bearing on the knuckles (Metacarpal-phalangeal joints)

  • Avoid putting weight against the backs of fingers
  • 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 activities

  • Take breaks
  • Change activity regularly, i.e. when doing DIY using screwdriver for a while, change the activity to painting or something different.

5. Avoid pressure to tip or pad of thumb

  • The thumb is needed for 40% 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 

  • 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 hands in the same position 

  • Re-position yourself often.
  • Move your hands frequently to ensure they do not get stiff

Resources

References

  1. 1.0 1.1 Hammond A, Lincoln N. The effect of a joint protection education programme for people with rheumatoid arthritis. Clinical rehabilitation. 1999 Oct;13(5):392-400.
  2. Melvin J.Rheumatic disease: occupational therapy and rehabilitation, second edition. Philadelphia: FA Davis, 1989: 351-71
  3. Dziedzic KS, Hill S, Nicholls E, Hammond A, Myers H, Whitehurst T, Bailey J, Clements C, Whitehurst DG, Jowett S, Handy J. Self management, joint protection and exercises in hand osteoarthritis: a randomised controlled trial with cost effectiveness analyses. BMC musculoskeletal disorders. 2011 Dec;12(1):156.
  4. Riemsma RP, Kirwan JR, Taal E, Hans JJ. Patient education for adults with rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2003(2).
  5. 5.0 5.1 Brus HL, Van De Laar MA, Taal E, Rasker JJ, Wiegman O. Effects of patient education on compliance with basic treatment regimens and health in recent onset active rheumatoid arthritis. Annals of the rheumatic diseases. 1998 Mar 1;57(3):146-51.
  6. Hammond A, Freeman K. One‐year outcomes of a randomized controlled trial of an educational–behavioural joint protection programme for people with rheumatoid arthritis. Rheumatology. 2001 Sep 1;40(9):1044-51.
  7. Hammond A, Lincoln N, Sutcliffe L. A crossover trial evaluating an educational–behavioural joint protection programme for people with rheumatoid arthritis. Patient Education and Counseling. 1999 May 1;37(1):19-32.
  8. Dziedzic KS, Hill S, Nicholls E, Hammond A, Myers H, Whitehurst T, Bailey J, Clements C, Whitehurst DG, Jowett S, Handy J. Self management, joint protection and exercises in hand osteoarthritis: a randomised controlled trial with cost effectiveness analyses. BMC musculoskeletal disorders. 2011 Dec;12(1):156.
  9. 9.0 9.1 Young A, Dixey J, Cox N, Davies P, Devlin J, Emery P, Gallivan S, Gough A, James D, Prouse P, Williams P. How does functional disability in early rheumatoid arthritis (RA) affect patients and their lives? Results of 5 years of follow‐up in 732 patients from the Early RA Study (ERAS). Rheumatology. 2000 Jun 1;39(6):603-11.
  10. Hammond A, Young A, Kidao R. A randomised controlled trial of occupational therapy for people with early rheumatoid arthritis. Annals of the rheumatic diseases. 2004 Jan 1;63(1):23-30.
  11. Bliddal H, Leeds AR, Christensen R. Osteoarthritis, obesity and weight loss: evidence, hypotheses and horizons–a scoping review. Obesity reviews. 2014 Jul;15(7):578-86.
  12. OT Regina. Joint Protection for ADLs (2014). Available from: https://www.youtube.com/watch?v=f029z3tB7hw [last accessed 14.04.2014]