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Box 103-1 Overview of Protection Principles

Respect pain
1. stop activities before the point of discomfort
2. decrease activities that cause pain that lasts more than two hours
3. avoid activities that put strain on painful or stiff joints

Balance rest and activity


1. rest before exhaustion
2. take frequent, short breaks
3. avoid activities that can't be stopped
4. avoid staying in one position for a long time
5. alternate heavy and light activities
6. take more breaks when inflammation is active
7. allow extra time for activities avoid rushing
8. plan your day ahead of time
9. eliminate unnecessary activities

Exercise in a pain free range


1. initiate warm water pool exercise program
2. exercises should be spesific to each deformity

Reduce the effort


1. avoid excessive loads with carts, get help, and use appliances
2. keep items near where they are used
3. use prepared foods
4. avoid low chairs
5. maintain proper body weight
6. freeze leftovers for an easy meal later
7. try to eliminate trips up and down stairs by completing work on each floor
8. sit to work when possible

Avoid positions of deformity


1. avoid bent elbows, knees, hips and back while sleeping
2. practice good posture during the day
3. use workstation evaluation for proper posture
4. see text for spesific hand deformities

Use the larger joints


1. slide heavy objects on kitchen counters
2. use palms, rather than fingers, to lift or push
3. carry a backpack, instead of a handheld purse
4. keep packages close to the body use two hands
5. push swinging doors open with side of body instead of the hands

Use adaptive equipment: use jar openers, button hooks, etc that are specific to each
patient's needs. Distribute pressure. Use hands, leverage, carts, etc. Flexion forces that
contribute to palmar subluxation, lateral pinch, which can aggravate ulnar deviation of the
index digit and the pull of gravity with the hands in sustained postures.
In patients demonstrating a swan neck deformity, joint protection principles should
stress avoiding the intrinsic plus hand grasp during ADL, which may aggravate this
deformity. In patients demonstrating a boutonniere deformity, joint protection should include
avoiding activities that have prolonged and forceful PIP flexion, such as a tight, three jaw
chuck pinch when writing. Moving objects out of the hand (ex using a shoulder-strap tote
bag instead of a handled brief case) can be helpful, and plastic grocery bags held by the
handle should also be replaced with bags that can be carried closer to the body.
It is important to look at all aspects of the patient treating the arthritic hand. Patients
often place strong forces on the hands when lifting themselves from one position to another.
In some cases adaptive equipment can also reduce the effort on the lower extremities (e.g., a
lift chair, a shower chair, or elevated toilet seat) and may also help to reduce the stress placed
on the hands. In addition, the therapist should take into consideration the patient's
sociocultural context. The patient may or may not have insurance coverage or finances for
adaptive equipment or orthoses. Options should be carefully discussed with the patient and
weighed in terms of cost versus value in meeting specific needs. The therapist hould be aware
of low- or no-cost resources in the com munity that may assist patients in obtaining specific
adaptive equipment (e.g., grab bars, elevated toilet seats, etc.) if the equipments cost exceeds
the patient's available funds. Civic, community, or religious organizations may offer
resources. For further information on joint protection, the reader is encouraged to review the
work by Melvin and Ferrel, which provides a very comprehensive reference section.
Activity Joint Protection Technique
Closing a jar with the right hand Use the heel of the hand to close the jar or
use a jar opener with two hands
Smoothing a sheet with shoulder adduction Use shoulder abduction to smooth the sheet
Stirring with a spoon using forearm pronation Stir with the forearm in neutral, without
and lateral pinch pinching with the thumb
Resting the hand on the chin with ulnar Avoid resting the hand on the chin or place
forces to the digits the chin in the palm
Lifting a cup of coffee Use two hands and a lightweight cup
Cutting foods Hold the knife like a dagger or use a pizza
cutter or electric knife
Lateral pinch to turn the key in a car door or Use a built-up key turner
ignition
Carrying a purse strap with a lateral pinch Use a fanny pack, back pack, or shoulder bag
Removing a gas cap from a car Use a gas cap opener to increase leverage

Modalities
Thermal agents, such as heat and cold, are commonly used in the treatment of arthritic
conditions to decrease pain and increase flexibility, but further research is needed to
determine their effectiveness. During the acute inflammatory phase, when joint temperatures
are elevated, heat is contra indicated. Care must be taken when instructing the patient in a
home program of superficial heat therapy to avoid the possibility of burns due to improper
application. Cryotherapy, which lowers joint temperatures, reduces pain, and decreases
inflammation, is more applicable during the acute phase. Some patients report increased pain
with cold application, which should then be avoided. Cold should not be used for patients
with Raynauds phenomenon, which is often seen in cases of RA and SS. See Chapter 117 for
further information on these and other physical agents.

A Intrinsic plus finger position. Patients developing a swan-neck deformity should avoid
activities that place the digits in an intrinsic plus position. This can include activites such as
holding a book, cards, or a tray. Card holders, bookstands, and carts on wheels can reduce the
need for the intrinsic plus position. B Gentle stretching to prevent intrinsic contractures in
patients with early swan-neck deformity.

Exercise
General principles of upper extremity exercise include avoiding painful AROM and
PROM and the importance of working within the patient's comfort level. Exercise has been
found to be effective in decreasing arthritis-related pain, increasing blood flow, and
improving cartilage health. General AROM exercises for the hand include wrist flexion and
extension, gentle digit flexion and extension, and thumb opposition. Shoulder and elbow
AROM in the supine position is also beneficial for preventing stiffness. Patients often obtain
increased shoulder motion in the supine position, as a result of lessening the effects of gravity
during the exercise. ROM exercises should be kept pain-free to prevent overstretching of
joint structures, and the number of repetitions controlled to avoid over stressing vulnerable
tissues.
More specific guidelines for exercise depend on the involved and vulnerable
structures identified during the initial examination. For example, intrinsic tightness can lead
to a swan-neck deformity and can be addressed with appropriate intrinsic stretching and
lengthening exercises. With an unstable distal radioulnar joint and dorsally subluxed ulnar
head, repetitive wrist ROM exercises or, even worse, isotonic wrist curls with free weights
can lead to fraying and attritional rupture of the finger extensor tendons and must be avoided.
With finger flexor tenosynovitis, repetitive finger flexion exercises could exacerbate
symptoms.
Strengthening programs for the arthritic hand should be used with caution to avoid
aggravation of deformities. For example, with OA and RA even light putty-pinching exer
cises impart large forces to an unstable CMC joint and might aggravate a potential deformit.
Stability must not be sacrificed for a possible increase in strength. A stable, pain free thumb
provides a post, against which the digits can grip and pinch effectively Grip strengthening is a
common example of an exercise that can aggravate inflamed flexor tendons. A digit that is
triggering or locking is not improved with grip strengthening exercises, as strengthening
usually increases these symptoms. Therapy exercises should never create deforming forces or
cause pain in the arthritic patient.

Summary
Conservative management of arthritis requires an understanding of the disease
process, specific conditions, potential deformities, and the patient's individual needs. A
comprehensive holistic evaluation assists the therapist in appropriate goal setting and
treatment planning. Further research is needed to quantify the benefits that are clinically
observed in conservative management.