Joint protection and fatigue management address the priority concerns of people with arthritis: pain, fatigue and hand and finger function (Heiburg & Kvien 2002, Hewlett et al 2005). Joint protection underlies all rehabilitation of people whose joints are at risk from arthritis (Cordery & Rocchi 1998), yet fatigue management is often inadequately addressed (Hewlett et al 2005). To be effective, both require people with arthritis changing habits and routines. Teaching facts can be done quickly but enabling long-term behavioural change requires greater input. This chapter discusses what joint protection and fatigue management strategies are, practical applications, evidence for effectiveness, how to help people change and outcome measures.

Joint protection developed from understanding pathophysiology of joint diseases, joint biomechanics, forces applied during activity and how these contribute to the development of deformity (Brattstrom 1987, Chamberlain et al 1984, Cordery 1965, Cordery & Rocchi 1998, Melvin 1989). The aims of joint protection in inflammatory arthritis are to:

For people with osteoarthritis (OA) the aims are to:

Joint protection is an active coping strategy to improve daily tasks and role performance helping reduce frustration arising from difficulties with these, enhance perceptions of control and improve psychological status (Hammond et al 1999). Much of joint protection literature focuses on hand problems in rheumatoid arthritis (RA), so this is explored in detail in this chapter but strategies are similarly applicable in other conditions and for other joints.

JOINT PROTECTION AND THE HANDS

Anatomical disruptions, combined with normal daily hand use patterns, can promote deformity. Power grip requires MCP ulnar deviation, especially in the 4^th and 5^th fingers. During lifting, external pressures in a volar or longitudinal direction increase strain on weakened wrist ligaments. Strong pinch grips increase intrinsic muscle pull promoting imbalance at the IP joints. Hand joint protection in RA thus focuses on changing movement patterns to limit: strong grips, twisting movements and sustained grips at the MCPs (reducing MCP ulnar forces); lifting heavy objects and sustained wrist radial positioning (reducing wrist volar and radial forces); and tight, prolonged key, tripod and pinch grips (reducing volar and ulnar forces on the MCP and IP joints).

In the early stages, many with RA are all too aware of hand function problems: dropping items, weaker grip, reduced dexterity and frustration from activities taking longer and being more painful. However, early signs of RA can be subtle (see Fig. 10.1). Whilst swelling may be noticeable, many do not notice a more prominent ulnar styloid, slight wrist radial deviation and 5^th MCP ulnar deviation, early correctable finger deformities, nor gradual loss of movement. In early RA average losses are 20° wrist extension, 30° wrist flexion, 15° MCP flexion and only 40% of normal power and pinch grip strength (Hammond et al 2000). A third can develop hand deformities by two years (Eberhardt et al 1990). This suggests joint protection and hand exercises should be provided early and effectively to limit decline (Fig. 16.4 Ch 16).

Figure 10.1 The hand in early rheumatoid arthritis showing swelling of the metacarpophalangeal joints and proximal interphalangeal joints.

With permission from: Goldenburg DL 2003 Clinical features of rheumatoid arthritis. In: Hochberg MC et al (eds.) Rheumatology 3rd edn, Elsevier, London. Fig. 68.6 p 770.

JOINT PROTECTION PRINCIPLES

Principles taught are shown in Box 10.1 and in Chapter 16 (Box 16.4). Focus on priority messages in plain English. For example, for the hands:

• Spread the load of what you lift (e.g. use two hands)

• Use stronger, larger joints

• Reduce effort to do tasks (e.g. use a gadget)

• Change how you move: keep wrists up, fingers straighter and looser grip when working.

BOX 10.1 Joint protection and energy conservation principles

Joint protection

Respect pain: use this as a signal to change activities

Distribute load over several joints

Reduce the force and effort required to perform activities by altering working methods, using assistive devices and reducing the weight of objects

Use each joint in its most stable anatomic or functional plane

Avoid positions of deformity and forces in their direction

Use the strongest, largest joint available for the job

Avoid staying in one position for too long

Avoid gripping too tightly

Avoid adopting poor body positioning, posture and using poor moving and handling techniques

Maintain muscle strength and range of movement.

Energy conservation

Pace activities by balancing rest and activity, alternating heavy and light tasks and performing activities more slowly

Use work simplification methods, e.g. planning ahead, prioritising, using labour saving gadgets and delegating to others when necessary

Avoid activities that cannot be stopped immediately if it proves beyond the person’s ability

Modify the environment to suit ergonomic/joint protection practices.

(College of Occupational Therapists 2003).

Joint protection principles are reviewed in Palmer and Simons (1991).

JOINT PROTECTION STRATEGIES

Joint protection is the application of ergonomics to everyday activities, work and leisure. Many people find ways of reducing pain and fatigue in daily activities through trial and error, but this takes time. Joint protection and energy conservation education should apply a systematic approach to changing habits, finding new solutions and speeding up change. Strategies include:

Respecting pain

Using aches and pains as a prompt to changing activities.

Altering working methods

E.g. altering movement patterns during tasks; more efficient positioning, e.g. sitting on a perch stool to iron; and reducing forces from lifting, pushing/pulling, stretching/reaching, carrying (Figs 10.2–10.5).

Figure 10.2 Carrying a kettle with two hands – distributing load, reducing metacarpophalangeal joint deviation.

Figure 10.3 Opening a jar – alternate method avoiding ulnar deviation.

Figure 10.4 Carrying a pan with two hands.

Figure 10.5 Holding a mug with two hands distributing load, avoiding metacarpophalangeal joint deviation.

Restructuring activities

E.g. reordering task sequences within these, eliminating unnecessary steps to increase efficiency.

Using assistive technology

Reducing effort required performing activities, e.g. jar openers, dycem matting, key turners, easy-grip scissors, walking aids (see Ch. 9, Fig. 9.3).

Altering the environment

E.g. bringing objects within the person’s reach envelope; reorganizing work areas to streamline activity processes; raising or lowering working heights.

Selecting appropriate product designs (universal designs)

E.g. equipment with non-slip handles (e.g. irons, screwdrivers, Good Grip kitchen equipment); electric alternatives (e.g. can openers, see Fig. 10.6); lightweight models (e.g. hand held vacuum cleaners for stairs); labour saving equipment (e.g. tumble drier, plug pulls, see Fig. 10.7); lever taps. Further details on assistive technology and environmental adaptation can be found in Chapter 9.

Figure 10.6 Electric can opener, avoiding ulnar deviation at the metacarpophalangeal joints.

Figure 10.7 Electric plug pull, reducing forces on the wrist and metacarpophalangeal joints.

Fatigue increases pain, cognitive disturbance (e.g. reduced concentration) and psychological effects (e.g. increased stress, low mood). There are many possible causes (see Box 10.2) and multiple solutions are needed. Helping people identify potential causes helps them prioritise changes. Practical strategies include:

BOX 10.2 Examples of factors contributing to fatigue

Physical

Pain

The disease (e.g. inflammation, especially in a flare up).

Physical demands due to biomechanical disruption of joints (e.g. lower limb OA, RA)

Anaemia (due to the disease, medication or other heath/diet reasons)

Poor sleep (e.g. due to pain, stress, the menopause)

Deconditioning: insufficient physical activity causing muscle weakness

Overdoing activities (boom-bust cycle)

Other health problems (e.g. heart or lung disease)

Poor nutrition: loss of appetite due to the disease; medication; difficulty cooking and shopping.

Psychosocial

Depression, anxiety, helplessness, stress

Poor self-efficacy

Work pressures (e.g. difficulty fulfilling job demands)

Problematic social support e.g. family and friends giving upsetting/unhelpful advice, lack of understanding.

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