PATHOPHYSIOLOGY OF HAND DEFORMITIES AND BIOMECHANICAL BASIS OF JOINT PROTECTION

Considering why deformities develop with RA helps in understanding how joint protection may contribute to preserving joint integrity. Deformities develop due to a combination of persistent synovitis disrupting joint structures and both normal and abnormal forces passing over joints (Adams et al 2005, Flatt 1995). In the longer-term, disruptions to bony architecture from erosions and osteophytes can further alter joint mechanics at any joint.

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:

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.

ENERGY CONSERVATION

This aims to reduce fatigue, pain and increase activity tolerance to achieve overall greater productivity and quality of life without exacerbating pain. Energy conservation principles are included in Box 10.1 and Chapter 16 (Box 16.4). Usually taught alongside joint protection, practical strategies include:

SLEEP HYGIENE

A sleep diary can be helpful (see Useful Websites). Solutions depend on the problems and can include: using more supportive mattresses and pillows; establishing a regular bedtime and evening routine, e.g. relaxation, soothing music, warm bath or shower, gentle exercise; avoiding stimulants 2–3 hours before bedtime (tea, coffee, caffeinated soft drinks, alcohol, smoking); reducing stimuli in the bedroom, e.g. avoiding television and computer use, turning clock faces away, black-out curtains, muted colour schemes.

COGNITIVE INTERVENTIONS

Evaluate potential common psychosocial causes of fatigue: loss of valued activities, poor self-efficacy, anxiety and problematic social support (Katz &Yelin 1995, Lorish et al 1991, Riemsma et al 1998, Wolfe et al 1996). Cognitive approaches used by OTs include: stress management (including managing automatic negative thinking, relaxation); mindfulness therapy; goal-setting to increase valued activity engagement (e.g. paid/unpaid work, leisure, social activities); assertiveness and communication training; liaising with family and carers. Stress and pain management can help improve self-efficacy, coping and perceptions of control (Rhee et al 2002) and referral for individually tailored cognitive-behavioural therapy is beneficial for those with more severe problems (Evers et al 2002).

PHYSICAL INTERVENTIONS

Regular physical activity and exercise reduce aches, pain and fatigue and improve sleep quality. Evaluate current level of physical activity and discuss benefits of and overcoming barriers to exercise (see Ch. 7). Recommend simple walking programmes (see Useful Websites) and referral to physiotherapy as necessary.

MEDICAL INTERVENTIONS

Good pain control can significantly reduce fatigue (Pollard et al 2006). Encourage taking analgaesia and prescribed medication effectively (see Ch. 15). Whilst providing specific medication advice is outside the professional competency of most therapists, explain the benefits of medication, mode of action and that timing or dosage may be improved. Recommend discussing medication with the rheumatology nurse (via the Rheumatology department’s telephone advice line) or at their next Consultant, GP or rheumatology nurse appointment.

WHAT JOINT PROTECTION AND FATIGUE MANAGEMENT ARE NOT

Joint protection is often misperceived as meaning stopping activities, keeping joints immobile and excess rest. It can be seen as ‘giving in’. Many find it confusing that the OT tells people to ‘protect joints’ (incorrectly perceived as limiting movement and activity) whilst the physiotherapist tells them to exercise as much as possible (incorrectly perceived as meaning all types of exercise causing pain and strain). These seem opposing messages. Rheumatology OTs and physiotherapists must give similar explanations to ensure patients are not confused. Emphasise ‘looking after joints’ means adapting activities and movements and reducing strain or force on joints. Exercise means being more physically active as well as stretching, strengthening and low-impact aerobic exercises. Exercise also applies joint protection principles, e.g. avoiding twisting (torque) forces or excess shock (e.g. high impact aerobics, wearing thin soled shoes whilst walking) and helps support joints so they are better able to tolerate forces that cannot be reduced. Fatigue management increases energy to be more physically active and do more enjoyable things in life. The combined benefits of all three help a more meaningful life to be lived (see Fig. 10.8).

Figure 10.8 Joint protection, exercise and fatigue.

USUAL JOINT PROTECTION EDUCATION

Barry et al (1994) evaluated in a randomized controlled trial (RCT) 1 hour of individual education, similar to the ‘usual’ content above, and identified improvement in joint protection knowledge. Two trials have evaluated usual joint protection education for 2.5 hours (as part of an 8 hour standard arthritis education programme). These also improved knowledge but not behaviour (Hammond & Freeman 2001, Hammond & Lincoln 1999a). Interviews identified only 25% of participants considered they had made changes (Hammond & Lincoln 1999a).

However, analysis of hand use patterns before and after education showed many cited changes were performed beforehand. Education raised awareness of changes already subconsciously made. For others, barriers to change were:

Interventions need to address these barriers to be effective.

BEHAVIOURAL JOINT PROTECTION EDUCATION

In contrast, structured group programmes, of 8–16 hours duration, emphasising active learning, problem solving, behavioural approaches, frequent practice and home programmes have been proven effective.

An RCT with people with early RA (n = 127) compared an 8 hour cognitive-behavioural approach joint protection programme with a standard arthritis education programme (including 2.5 hours of usual joint protection, not using behavioural approaches). At 1 year the behavioural group, compared to the standard group, significantly improved the use of joint protection, improved functional ability and reduced hand pain, general pain and early morning stiffness (Hammond & Freeman 2001). Benefits continued at 4 years and the behavioral group had fewer hand deformities (Hammond & Freeman 2004). Timing of education needs careful consideration as there is evidence it can be provided both too early and too late (Hammond 2004). Other studies in patients with established RA have also shown benefits:

COMBINED JOINT PROTECTION, FATIGUE MANAGEMENT AND EXERCISE

RCTs in people with established RA have resulted in significant improvements in pain, functional and physical ability, self-efficacy and psychological status (Hammond et al 2008, Masiero et al 2007). An RCT in people with hand OA identified significant improvements at three months in grip strength and self-perceived hand function, in comparison to a control group receiving education about OA (Stamm et al 2002).

TEACHING JOINT PROTECTION AND FATIGUE MANAGEMENT

Promoting change – practise, goal setting and home programmes

During practical training, apply the educational and skills training approaches described in Chapter 6. Everyday movement patterns are automatic movements using open-loop motor control, i.e. pre-programmed, often from childhood. Change requires shifting to closed-loop motor control whilst learning new movement patterns. Start with part-blocked practice, i.e. single tasks repetitively performed. This can be an early home programme activity. Each week practice with progressively more complex activities, e.g. a hot drink, then snack meal then a full meal. If performance errors are noted delay feedback initially (e.g. 3 seconds) to enable the person to identify and problem solve their own errors. Teach mental rehearsal to improve skills and practice opportunities. Further details on motor learning can be found in Ezekiel et al 2000, Lehto et al 2000, Marley et al 2000 and Wishart et al 2000.

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Goal setting helps people commit to weekly home practice. Each session ask them to state and, preferably, write down an action plan (see Box 10.4). Goals should be determined by the person: and specify what, how often and how much (see Ch. 6). Encourage identifying rewards contingent on achieving their plan. Pushing people to practise too much is unlikely to be successful. Use a 10 point scale (see Box 10.4): how confident are they to complete each task on a scale of 0-10? Then the whole plan? If the answer is less than 7, ask them to revise their goal/plan to be more achievable.

BOX 10.4 Example of an action plan

Dates from:___Monday________________ to:_____Sunday__________

The Plan:

1. Practise the range of movement hand exercises three times each for 3 days.

2. Use the joint protection methods making a hot drink five times.

3. Imagine using the hot drink joint protection methods three times.

4. Listen to relaxing music tape before bedtime on three evenings.

I am sure I can complete this plan (circle):

When I complete the plan, my reward will be:

Put feet up with a cappuccino!

How well did I do with my plan?

At the start of the each session, always review goal progress. The home programme is an important, integral part of treatment. Failure should not be criticised. Rather, identify barriers and jointly problem-solve overcoming these (see also Ch. 6., Box 6.3). Finally, schedule a follow-up appointment 6–8 weeks after education finishes to review progress and promote continuing independently setting goals for longer term change.

KNOWLEDGE

The Joint Protection Knowledge Assessment (Hammond & Lincoln 1999b): 20 multiple choice items assessing ability to identify best methods. Some arthritis knowledge questionnaires also include joint protection and fatigue management items (see Ch.6).

SELF-EFFICACY

The Joint Protection Self-Efficacy Scale (Niedermann et al 2009b, in review): 10 items assessing confidence in caring for hand and finger joints, and applying joint protection methods. The RA Self-Efficacy Scale (Hewlett et al 2001) includes questions about confidence in using joint protection and fatigue management strategies.

ADHERENCE

IMPACT ON FUNCTIONAL AND HEALTH STATUS

Relevant scales can be found in Chapters 4, 6 and 16 (Box 16.3). More specific questionnaires are:

The Evaluation of Daily Activities Questionnaire (Nordenskiold et al 1996, 1998) evaluating functional ability with and without assistive devices/altered working methods. This is used to evaluate joint protection and in clinical practice in Scandinavia. A UK version is in development.

Fatigue: the Multidimensional Assessment of Fatigue: 16 questions concerning the quantity, degree, distress, impact, and timing of fatigue (Tack 1991). The Vitality subscale of the SF-36 comprises four items (full of life, energy, worn out, tired) with six responses from ‘all of the time’ to ‘none of the time’ (Ware & Sherbourne 1992).