© Springer International Publishing Switzerland 2015Ingrid Söderback (ed.)International Handbook of Occupational Therapy Interventions10.1007/978-3-319-08141-0_42
42. Joint Protection: Enabling Change in Musculoskeletal Conditions
University of Salford, L701 Allerton (OT), Frederick Road, Salford, M6 6PU Greater Manchester, UK
Joint protection includes applying ergonomic principles in daily life, altering working methods, using assistive devices, and modifying environments. It is taught to people with musculoskeletal conditions, such as rheumatoid arthritis (RA), osteoarthritis (OA), and soft tissue rheumatisms. Common principles are to: distribute load over several joints, reduce effort using assistive devices, pace activities, use orthoses, and exercise regularly. Cognitive-behavioral, self-efficacy, and motor-learning approaches are employed. Clinical trials demonstrate that using these approaches is significantly more effective than advice and demonstration alone in changing joint protection behavior, improving self-efficacy, function, and reducing pain in both early and established RA and hand OA. There is still conflicting evidence for its effectiveness in soft tissue rheumatisms.
KeywordsArthritis diseasesAssistive devicesEnergy conservationErgonomicsJoint protectionMusculoskeletal conditions
The problem is changing habits of a lifetime. Joint protection principles are easy to learn; the difficulty is changing habits sufficiently to make a difference.
Definition and Background
Joint protection is a core component of occupational therapy interventions for musculoskeletal conditions . Joint protection is an active coping (or self-management) strategy to improve clients’ perceived control of their condition, psychological and health status, daily activities, role performance, and social participation (Hammond 2004).
Joint protection intervention includes educating in (1) altering working methods, (2) use of proper joint and body mechanics through applying ergonomic principles, (3) use of assistive devices , and (4) modifying occupational performance and environments. It is often integrated with fatigue management, working splints and flexibility and strength hand exercises.
Joint protection was first developed in the 1960s, based on increased understanding of pathophysiologic changes in rheumatoid arthritis (RA) and on biomechanics. Principles were extended to other inflammatory arthropathies, osteoarthritis (OA), and soft tissue rheumatisms (Brattstrom 1987; Chamberlain et al. 1984; Cordery 1965; Melvin 1989; Sheon 1985). At that time, clients were encouraged to regularly practice joint protection in the expectation that they would apply this to their personal situation (Chamberlain et al. 1984; Cordery 1965). The focus was on improving body structures and function, and maintaining the ability to perform daily activities.
Research in the past 15 years has used structured self-management education and skills training to promote attitudinal, cognitive, and behavioral changes for improving protection of the joints. These cognitive-behavioral approaches further affect personal factors (e.g., increased self-efficacy, perceived control of the condition, problem-solving abilities, and reduced frustration). Additionally, they aim to enable clients to change habits and routines in their daily activities, work, and leisure.
Joint protection is an active self-management strategy aiming to maintain or improve (1) occupational performance in daily life, (2) role performance and participation in social life, (3) perceptions of control, and (4) psychological and health status (Hammond 2013).
The aims of joint protection are as follows:
For people with RA, reduce (a) load and effort during daily activity performance, thus reducing strain on joint structures weakened by the disease process; (b) pain; (c) irritation of the synovial membrane; (d) local inflammation; and (e) fatigue.
For people with OA, (a) reduce loading on articular cartilage and subchondral bone, (b) strengthen muscle support, and (c) improve shock-absorbing capabilities of joints (Cordery and Rocchi 1998).
For people with soft tissue disorders (e.g., de Quervain’s disease, carpal tunnel syndrome), reduce (a) pain, (b) inflammation, and (c) strain on soft tissues.
Candidates for the Intervention
Joint protection is provided to clients with the following:
Inflammatory polyarthropathies, such as RA and seronegative and psoriatic arthritis . These diseases affect three times more women than men, most commonly in the 40–60-year age range, but they may start at any age. RA affects on average 1 % of people globally (Kvien 2004).
OA affects the hand, hip, knee, or several joints of the body simultaneously (i.e., generalized OA). Nearly twice as many (1.8:1) women as men live with OA, and 10 % of people over the age of 60 years are symptomatically affected (Dennison and Cooper 2003).
Upper-limb soft tissue disorders: (1) de Quervain’s disease is more common in women than in men, with peak onset between 30 and 50 years of age. (2) Carpal tunnel syndrome occurs in 5.8 % of women and 0.6 % of men, with peak onset between 45 and 54 years of age (Fam 2003).
The numbers of people potentially benefiting from joint protection can be estimated from percentages of those with activity limitations. Among people living with RA, about 60 % have activity limitations, particularly related to hand function (Young et al. 2000). There is a high prevalence of people with hand impairments, pain, and muscle weakness in RA over 2 years duration (Horsten et al. 2010). A community survey by Jordan et al. (2000) found that 43 % of people over 65 years of age with arthritis (mainly OA) experienced difficulty with household activities. The number of people living with soft tissue disorders who could benefit from joint protection interventions is unknown. These figures suggest many people with musculoskeletal conditions could benefit from joint protection advice.
Joint protection is most often provided in rheumatology and occupational therapy departments, to both in- and outpatients, as well as in community settings.
The Role of the Occupational Therapist
In providing joint protection, occupational therapists (OTs) have both facilitatory and teaching roles. The OT has knowledge of (1) pathophysiology of musculoskeletal conditions, (2) ergonomic and biomechanical principles for protecting joints, and (3) cognitive-behavioral methods. This knowledge constitutes the theoretical base for joint protection interventions, which are clinically applied using educational and facilitatory strategies.
The commonest principles taught to clients are the following:
Joint protection: Respect pain; distribute load over several joints; use the strongest, largest joint to perform an activity; avoid working in positions of potential deformity; reduce effort by using assistive devices and avoiding lifting and carrying; and avoid prolonged periods of working in the same position.
Energy conservation: Pace by balancing rest and work and alternate heavy and light activities; use work simplification; use correct working positions and postures.
Orthoses: Use working orthoses appropriately to reduce pain and improve grip function.
Exercise: Exercise regularly to maintain range of motion and muscle strength.Beasley (2012) provides an extensive list of principles.
The educational and facilitatory strategies used include motivational, cognitive-behavioral, self-efficacy , and motor learning approaches. These enable clients to overcome barriers to changing behavior and to maximize performance of joint protection so that therapeutic aims are achieved.
These strategies include the following:
Discuss health beliefs and attitudes to the disease. Additionally, clients may have developed misconceptions of joint protection, that means using joints as little as possible, only during certain activities, or only when pain is present (Niedermann et al. 2010).
Identify clients’ expectations, worries, or concerns, and their valued activities and life goals.
Teach cognitive-behavioral strategies, such as self-monitoring, goal setting, and how to develop action plans for practicing techniques at home. A regular review of such home programs with clients is essential.
Teach using effective educational techniques to enhance recall of joint protection principles and methods, such as simplification, use of advance organizers, and explicit categorization.
Teach joint protection techniques using effective skills training methods (e.g., practicing simple and then more complex activities using joint protection, feedback, and mental rehearsal).
Joint protection can be taught using individual or group education, supported by self-help booklets.
How the Intervention Eases Impairments, Activity Limitations, and Participation Restrictions
Joint protection reduces pain and the likelihood of deformities, and maintains activity and participation (Hammond and Freeman 2001, 2004)
A survey of the UK practice found that joint protection education typically lasts for 1.5 h over two treatment sessions and does not use behavioral approaches. The usual content is (1) education about RA, (2) how joints are affected, (3) joint protection principles, (4) demonstrations with short (e.g., 15–30 min) practice of hand joint protection methods commonly used in cooking and housework activities (e.g., making a cup of tea), and (5) discussion of solutions to specific problems, supported by a self-help booklet (Hammond 1997). This is still the typical practice.
Clinical Trials Investigating Joint Protection Education
A randomized controlled trial (n = 55; 6-month follow-up) of 1 h of individual education, similar to the typical content described above, but not compared to an intervention, improved clients’ knowledge of joint protection methods (Barry et al. 1994). Similarly, a pretest, posttest clinical trial of a group program (n = 21; 3-month follow-up) providing this typical intervention for 2.5 h as part of an 8-h arthritis education program also found improved knowledge of joint protection, but no significant changes in joint protection behavior occurred. Barriers to changing behavior were identified through interview as (1) being unable to recall methods sufficiently during daily activity performance; (2) considering these as not applicable, as “my hands are not that bad yet” or using techniques on bad days only; (3) difficulty getting used to the different actions; and (4) difficulty changing the habits of a lifetime (Hammond and Lincoln 1999).