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TOPICAL REVIEW
Ahead of print publication  

Taking Good Care of Joints for Optimal Health in Rheumatology


 Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Cukurova University, Adana, Türkiye

Date of Submission23-Oct-2021
Date of Acceptance27-Jun-2022
Date of Web Publication13-Jul-2022

Correspondence Address:
Ilke Coskun Benlidayi,
Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Cukurova University, Adana
Türkiye
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injr.injr_242_21

  Abstract 


Patients with rheumatic diseases involving the joints experience pain, decreased range of motion in affected joints, and deterioration in functional activities. Individuals with arthritis require a comprehensive management strategy including pharmacological and nonpharmacological treatment options. Patient education and self-management protocols such as joint protection techniques are essential in the management of arthritis. The present topical review focused on joint protection, its implications on patients' daily living, and the potential effects among patients with arthritis. Implementing joint protection principles, such as avoiding repetitive movements, prolonged grips, and positions of deformity, is of great importance to provide a better outcome in patients with arthritis.

Keywords: Arthritis, joint diseases, joints, rehabilitation, rheumatic diseases



How to cite this URL:
Benlidayi IC. Taking Good Care of Joints for Optimal Health in Rheumatology. Indian J Rheumatol [Epub ahead of print] [cited 2022 Aug 20]. Available from: https://www.indianjrheumatol.com/preprintarticle.asp?id=350873




  Introduction Top


Joint involvement is a common feature of various rheumatic diseases. Management of arthritis requires a comprehensive approach involving both pharmacological and nonpharmacological strategies. Exercise, splinting, assistive devices, and joint protection are examples of nonpharmacological treatment options.[1]

Ensuring self-management is of critical importance in the management of rheumatic diseases with joint involvement and joint protection techniques are an integral part of self-management protocols. Joint protection techniques are used to improve pain, functionality, and quality of life in patients with rheumatic diseases involving joint structures.[2] The main mechanism underlying the beneficial effects of these techniques is the reduction of inflammation and stresses applied to joints during activities of daily living. They may also assist preserving the integrity of joint structures in long-term.[3]


  What Do Joint Protection Techniques Involve? Top


Joint protection techniques include the application of ergonomics, modification of working methods/movement patterns, and utilization of orthoses/assistive devices.[2] The term “joint protection” should not be misinterpreted as protecting the joint by means of refraining from using them.[4] This important point was discussed in the European League Against Rheumatism (EULAR) recommendations for the management of hand osteoarthritis. The task force highlighted the importance of education and training in ergonomic principles, pacing of activity, and the use of assistive devices in the management of hand osteoarthritis. EULAR task force concluded that this care should be offered to every patient with hand osteoarthritis.[4]


  How to Apply Joint Protection? Top


Education is an integral part of joint protection. The patient should be informed about the rheumatic condition, managing pain during daily activities, and how to change habits.[5] To decrease pain and improve functionality, hand exercises such as active range of motion and resistive exercises are usually combined with education in joint protection.[6]

The principles of joint protection include distributing the weight over several joints, avoiding strain on the thumb, avoiding repetitive thumb movements, refraining from prolonged grips in one position and trying to use a large grip, conservating energy, and reducing the effort while performing a task.[5] The principles of joint protection developed by Cordery[7] were then thematically categorized by Beasley[6] [Table 1]. As a summary, common joint protection principles for both osteoarthritis and rheumatoid arthritis are respecting pain (i.e. using carpometacarpal splints for osteoarthritis of this joint, using wrist splints for rheumatoid arthritis, stopping any activity before the feeling of discomfort/pain, and refraining from activities which put strain on affected joints), balancing rest and activity (i.e. taking breaks during activity, refraining from staying in one position for a prolonged time, avoiding rushing, resting before exhausting, and eliminating activities that are unnecessary), performing exercise in a pain-free range (i.e. pain-free active range of motion and strengthening exercises which are specifically directed to each potential deformity), avoiding positions of deformity (i.e. using appropriate work heights/stable joint positions and avoiding bending joints during sleep), reducing the effort/force (i.e. assistive devices/appliances, avoiding low chairs, and taking cautions for easy flow of work), and using larger/stronger joints (i.e. using palms while lifting or pushing an object and avoiding hand-held purses, using the side of the body while pushing doors).[6]
Table 1: Joint protection techniques[5],[6],[7]

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Above mentioned principles should be implemented into daily living activities. The patient can be instructed to keep the wrist in neutral position while plugging in/unplugging an electrical plug. Multiple fingers should be used while squeezing a spray bottle and turning a tap on/off. While applying pressure on a device (i. e. standard tap), the palm can be used instead of the fingers, if possible.[8] Labor-saving devices can be used to reduce the effort during daily routine tasks.[5] For example, assistive devices are useful to protect joints while unlocking a doorknob with a key, opening a bottle, doing up buttons, and writing.[8] Foam tubing is used to enlarge grips on daily routine objects such as hairbrushes and stirring spoons.[9]

Techniques for the prevention of joint structures can be introduced to patients by oral and/or written information. A one-to-one setting can be used for the demonstrations of joint protection methods by the occupational therapist. Psychoeducational methods are also beneficial while providing the techniques.[2] Self-efficacy scale of joint protection would be valuable in terms of obtaining information regarding the patients' perceived ability to perform joint protection, as well as assisting the physicians during the management plan.[10]


  What Are the Effects of Joint Protection Techniques? Top


Patients with arthritis experience several limitations in function and activities of daily living. Tanashi et al., in their cross-sectional, clinical observational study, showed that patients with hand arthritis move through a smaller arc of motion during some functional tasks when compared to healthy individuals.[8] The same study further demonstrated that instruction on joint protection techniques provided a significant impact on the amount of movement used to perform these tasks.[8] Joint protection combined with hand exercises can also provide positive outcomes in terms of grip strength and hand function.[11] Dziedzic et al., in their randomized factorial trial among patients with hand osteoarthritis, showed that patients who received joint protection intervention were more likely to be classified as responders to treatment at 6 months when compared to individuals who did not receive joint protection.[5] Evidence so far, in general, supports the use of joint protection techniques in patients with osteoarthritic finger joints.[12] Self-efficacy and self-management programs including joint protection measures are strongly recommended for patients with knee, hip, and/or hand osteoarthritis by the American College of Rheumatology.[13]

Current data regarding the use of joint protection techniques in patients with autoimmune inflammatory rheumatic diseases are related to rheumatoid arthritis in particular. In a two-arm randomized controlled trial, Shao et al. examined the effectiveness of a self-management program for joint protection and physical activity based on self-efficacy theory among patients with rheumatoid arthritis.[14] Eight-week self-management program aimed to provide information and nursing support on joint protection and physical activity was compared to standard care for rheumatology. At 6 months, the intervention group revealed greater improvement in terms of self-efficacy of pain, self-management behaviors, and physical functioning.[14] According to a systematic review by Siegel et al., strong evidence supports the use of individualized joint protection programs (as a psychoeducation intervention) for adults with rheumatoid arthritis.[15]


  Awareness Regarding Joint Protection Top


As a matter of fact, patients with rheumatic diseases are not much aware of the role of self-management in their treatment. A substantial proportion of patients also lack of knowledge about the principles of joint protection.[14] Kamruzzaman et al. evaluated the knowledge of patients with rheumatoid arthritis about their disease using the Bangla version of the Patient Knowledge Questionnaire.[16],[17] Patients demonstrated low scores in all domains with the lowest belonged to joint protection/energy conservation and medications.[16] Bobos et al. evaluated the barriers, facilitators, expectations, and patient preferences in terms of joint protection programs in patients with hand arthritis.[18] Cost, time, home–clinic distance, and work commitments appeared as potentially modifiable barriers to the participation of future joint protection programs. Strategies such as free and accessible forms of delivery of joint protection programs may be helpful in improving access to and participation in joint protection interventions.[18]


  Conclusions and Future Perspectives Top


Joint protection is an essential component of management in patients with rheumatic diseases involving the joint [Figure 1]. Implementing self-management protocols including individualized joint protection programs to treatment plans would be of much benefit for obtaining optimal health in rheumatology. Evidence regarding the benefits of joint protection techniques in rheumatic diseases mostly involves patients with hand osteoarthritis and rheumatoid arthritis. Future research among patients with autoimmune and inflammatory rheumatic diseases would be of benefit to increase our understanding on this particular topic.
Figure 1: Scientific cartoon depicting the importance of joint protection from a sense of humour perspective

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kroon FP, Carmona L, Schoones JW, Kloppenburg M. Efficacy and safety of non-pharmacological, pharmacological and surgical treatment for hand osteoarthritis: A systematic literature review informing the 2018 update of the EULAR recommendations for the management of hand osteoarthritis. RMD Open 2018;4:e000734.  Back to cited text no. 1
    
2.
Niedermann K, Forster A, Ciurea A, Hammond A, Uebelhart D, de Bie R. Development and psychometric properties of a joint protection self-efficacy scale. Scand J Occup Ther 2011;18:143-52.  Back to cited text no. 2
    
3.
Hammond A, Freeman K. The long-term outcomes from a randomized controlled trial of an educational-behavioural joint protection programme for people with rheumatoid arthritis. Clin Rehabil 2004;18:520-8.  Back to cited text no. 3
    
4.
Kloppenburg M, Kroon FP, Blanco FJ, Doherty M, Dziedzic KS, Greibrokk E, et al. 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Ann Rheum Dis 2019;78:16-24.  Back to cited text no. 4
    
5.
Dziedzic K, Nicholls E, Hill S, Hammond A, Handy J, Thomas E, et al. Self-management approaches for osteoarthritis in the hand: A 2×2 factorial randomised trial. Ann Rheum Dis 2015;74:108-18.  Back to cited text no. 5
    
6.
Beasley J. Osteoarthritis and rheumatoid arthritis: Conservative therapeutic management. J Hand Ther 2012;25:163-71.  Back to cited text no. 6
    
7.
Cordery JC. Joint protection; a responsibility of the occupational therapist. Am J Occup Ther 1965;19:285-94.  Back to cited text no. 7
    
8.
Tanashi A, Szekeres M, MacDermid J, Lalone EA. Comparison of finger kinematics between patients with hand osteoarthritis and healthy participants with and without joint protection programs. J Hand Ther 2020:S0894-1130 (20) 30189-7. [doi: 10.1016/j.jht. 2020.10.010].  Back to cited text no. 8
    
9.
McVeigh KH, Kannas SN, Ivy CC, Garner HW, Barnes CS, Heckman MG, et al. Dynamic stabilization home exercise program for treatment of thumb carpometacarpal osteoarthritis: A prospective randomized control trial. J Hand Ther 2021:S0894-1130 (21) 00083-1. [doi: 10.1016/j.jht. 2021.06.002].  Back to cited text no. 9
    
10.
Zhao WH, Zhang LX, Liu CX, Niedermann K, Yang HZ, Luo W. Validation of the Chinese version of joint protection self-efficacy scale in patients with rheumatoid arthritis. Clin Rheumatol 2019;38:2119-27.  Back to cited text no. 10
    
11.
Stamm TA, Machold KP, Smolen JS, Fischer S, Redlich K, Graninger W, et al. Joint protection and home hand exercises improve hand function in patients with hand osteoarthritis: A randomized controlled trial. Arthritis Rheum 2002;47:44-9.  Back to cited text no. 11
    
12.
Beasley J, Ward L, Knipper-Fisher K, Hughes K, Lunsford D, Leiras C. Conservative therapeutic interventions for osteoarthritic finger joints: A systematic review. J Hand Ther 2019;32:153-64.e2.  Back to cited text no. 12
    
13.
Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Rheumatol 2020;72:220-33.  Back to cited text no. 13
    
14.
Shao JH, Yu KH, Chen SH. Effectiveness of a self-management program for joint protection and physical activity in patients with rheumatoid arthritis: A randomized controlled trial. Int J Nurs Stud 2021;116:103752.  Back to cited text no. 14
    
15.
Siegel P, Tencza M, Apodaca B, Poole JL. Effectiveness of occupational therapy interventions for adults with rheumatoid arthritis: A systematic review. Am J Occup Ther 2017;71: 7101180050p1-7101180050p11.  Back to cited text no. 15
    
16.
Kamruzzaman AK, Chowdhury MR, Islam MN, Sultan I, Ahmed S, Shahin A, et al. The knowledge level of rheumatoid arthritis patients about their disease in a developing country. A study in 168 Bangladeshi RA patients. Clin Rheumatol. 2020;39:1315-23.  Back to cited text no. 16
    
17.
Hill J, Bird HA, Hopkins R, Lawton C, Wright V. The development and use of Patient Knowledge Questionnaire in rheumatoid arthritis. Br J Rheumatol 1991;30:45-9.  Back to cited text no. 17
    
18.
Bobos P, MacDermid J, Ziebart C, Boutsikari E, Lalone E, Ferreira L, et al. Barriers, facilitators, preferences and expectations of joint protection programmes for patients with hand arthritis: A cross-sectional survey. BMJ Open 2021;11:e041935.  Back to cited text no. 18
    


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Introduction
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