INTRODUCTION — Patients with unstable or painful joints may have a limited understanding of activities that increase the risk of further joint damage or that promote inflammation. This topic will review the concept of joint protection and will suggest approaches to evaluation and interventions that may promote joint health.
Specific applications of joint protection to particular sites are presented separately. (See "Joint protection program for the upper limb" and "Joint protection program for the lower limb" and "Joint protection program for the neck".)
What is joint protection? — Joint protection is a process that includes the following two major components [1,2]:
●Individualized assessment of a patient's activities to ascertain the potential to contribute to worsening pain, inflammation, instability, and/or deformity of an already abnormal joint
●Creation of a program to increase a patient's functional ability that includes altered work methods, behavioral modifications, and good body mechanics and that is supplemented, if necessary, with splints, braces, or assistive equipment designed to minimize further joint damage
The process of joint protection also includes energy conservation, which is a paced, more efficient use of muscles and joints. These principles encourage people with musculoskeletal problems to utilize their bodies in a manner to minimize pain, swelling, and associated limitations of movement and function. Occupational therapists have training that allows them to assess patients and to provide individualized joint protection advice.
Although "joint protection" is the classic terminology, "joint care" more accurately describes the goal of these principles. "Protection," as used in this context, does not denote strict avoidance of use. Indeed, joint immobilization for a prolonged period can contribute negatively to joint problems by promoting articular stiffness and muscular weakness.
What is ergonomics? — Ergonomics is defined as the science related to humans and their work, embodying the anatomic, physiologic, and mechanical principles affecting the efficient use of human energy. Safe lifting techniques, proper posture, appropriate seating position, and assistive equipment are only a few of the many examples of ergonomics in the workplace.
Who benefits from joint protection? — Joint protection was originally designed for people with rheumatoid arthritis (RA) with the goals of reducing pain and inflammation and of protecting their fragile joint capsules and ligaments. These principles were subsequently expanded to include individuals with osteoarthritis (OA) [1] and overuse conditions.
Efficacy of joint protection and energy conservation — There is evidence that joint protection relieves pain, reduces local inflammation, and maintains functional ability. An overview of systematic reviews found high-quality evidence for beneficial effects of joint protection and patient education, with pain, function, and patient global assessment being the primary outcomes of interest [3]. The following are illustrative:
●Patients are able to identify activities that cause pain and experience an improvement when using joint protection techniques [1].
●Joint protection education programs, conducted with groups of patients, improve joint protection adherence and maintain long-term functional ability [4-6].
●Occupational therapy (OT) intervention was compared with usual care in a study that randomly assigned 127 patients with early RA [7]. After four years of follow-up, the joint protection group had a significantly greater improvement in the following domains: joint protection adherence, early morning stiffness, and arthritis impact measurement score-2 (AIMS2) activities of daily living (ADL) scores. The joint protection group also had significantly fewer hand deformities [7].
●There is conflicting evidence about the effectiveness of joint protection on hand function and pain. Patients with RA who participated in an education-behavioral joint protection program demonstrated a statistically significant reduction in pain and increased function [8]. At 12 months, those in the group education had a 5 percent decrease in hand pain while those in the control group had a 3.9 percent increase in pain. However, other studies have shown that joint protection as a self-management intervention has a similar effect as usual care on hand function and pain in patients with hand arthritis [9,10].
●Use of an elastic wrist orthosis resulted in decreased pain and significantly increased grip strength among women with RA during selected ADLs compared with a reference group [11].
●Patients with hand OA using assistive devices showed significant functional gains and increased participation in daily activities [12].
●Self-efficacy and RA patient knowledge showed significant improvements with web-based rehabilitation interventions, but the quality of this evidence was very low [13].
There is also evidence that muscle strengthening decreases pain and improves function. The beneficial effects of strength training in RA and OA are presented in more detail elsewhere [14,15]. (See "Management of knee osteoarthritis", section on 'Exercise' and "Nonpharmacologic therapies for patients with rheumatoid arthritis", section on 'Rest'.)
THE PRINCIPLES OF JOINT PROTECTION — The following principles are the foundation of patient education in joint protection. Each is discussed in more detail below.
●Respect pain
●Distribute the load over stronger joints and/or larger surface areas
●Avoid maintaining the same joint position for prolonged periods
●Reduce excess body weight
●Use good posture and body mechanics
●Use the minimum amount of force necessary to complete the job
●Simplify work by using efficiency principles: plan, organize, and balance work with rest
●Remain active to maintain and increase strength and range of motion
Respect pain — Activities that worsen joint pain warrant modification. Some patients avoid activity in order to prevent pain. Those who do this are more likely to experience increased joint stiffness and to become deconditioned. Other patients persevere in their activities despite pain.
Learning to respect pain involves attending to it and to aspects of activities that cause or worsen joint pain, followed by making an assessment and plan based upon previous experience, with the goal of continuing important activities with a minimum of pain. As an example, if pain results from too much activity, patients can try to take more rest breaks, perform tasks with adapted equipment, and/or otherwise modify how they carry out activities. If such modifications fail to prevent pain due to a particular task that could previously be performed with a minimum of discomfort, it may indicate a change in disease, and a clinician should be consulted.
For the patient who is deconditioned or inactive, exercise can initially reproduce or increase pain. Encourage patients to communicate with their therapist regarding the modification of their exercise program rather than stopping exercise completely. Often the pain is of muscular origin.
The two-hour pain rule — This rule is a useful guideline to evaluate excessive activity. If a patient has pain for two hours after the activity, it means they have done too much. While there are several time frames suggested in the literature, the Arthritis Foundation and the Arthritis Self-Management Course advocate use of the two-hour pain rule [1,16].
Factors affecting activity-related joint pain — Many factors can influence the onset and intensity of joint pain that is activity-related. The following are illustrative:
●Time – The length of time one spends on an activity can influence pain. As an example, five minutes of an activity may be manageable, but an hour of the same task may result in pain that lasts for a few days.
●Weight – Weight can influence pain in more than one way. Carrying a small bag of groceries with a few items may not cause any difficulties, but a full 10 lb (4.5 kg) bag of groceries can cause or worsen hand or knee pain depending upon the vulnerable joints. Pain can also occur from carrying too much body weight.
●Repetition – The number of repetitions of an activity that cause or worsen pain is notable. Stapling a few sheets of paper may not cause any pain, but stapling 25 or 50 handouts may cause significant pain that lingers for hours or days.
Lifting, climbing, kneeling, and squatting are work activities affected by time, weight, and repetition. A systematic review found that longer cumulative exposure to kneeling or squatting in the workplace is associated with a higher risk of knee OA [17].
Distribute the load — Distribute the load over stronger joints and/or larger surface areas. Large joints are stronger than small ones. This is a basic body mechanics principle [1]. Using larger joints will reduce strain that can overstretch ligaments and that can create instability. Even if one's joints are very stable, large loads on small joints can strain structures and can cause pain. Small hand joints are vulnerable to pain or inflammation when used too much or too often. When possible, patients should spread the load over several joints. Consider using an open hand rather than fingers to wash a table. One can wear a purse or satchel over their shoulder if they have a vulnerable elbow or hands. A backpack may be used if the shoulder is painful. These are good ways to spread the load over greater surface area.
Avoid prolonged immobility — Avoid maintaining the same joint position for prolonged periods. Joints that are kept in one position for long periods of time are inclined to get stiff (gel phenomenon). Immobilization of a joint for days or weeks can lead to muscle atrophy and joint contractures. Many patients complain of stiffness in their knees when they sit for long periods of time. Some people relieve stiffness by sitting on the aisle so they have the room to periodically stretch out bent knees during a play or movie. Often patients make these changes independently, and health professionals reinforce them. Clinicians can facilitate the process by asking patients, "When do you find yourself getting stiff in that joint?" Other questions include "Is there anything you already do that helps at least some of the time?" and "Is there anything else you can do that would help you manage your pain or stiffness?"
Reduce excess body weight — With inactivity, it is easy to gain extra body weight. Excess weight puts a strain on the body, especially lower extremity joints such as hips, knees, and ankles. Excess body weight is a powerful risk factor for developing osteoarthritis (OA). Even modest amounts of weight loss may improve symptoms and function in patients with OA. The role of obesity in causation of OA and the role of weight loss in treatment of OA are discussed in more detail elsewhere. (See "Management of knee osteoarthritis", section on 'Weight loss' and "Epidemiology and risk factors for osteoarthritis", section on 'Obesity'.)
Extra weight can also result in strain on the lower back area. Some patients may compensate for abdominal obesity by developing an increased lumbar lordosis. Encourage patients to maintain a normal weight for their height and build. Weight loss often results in decreased pain and in increased energy. These patients may need to increase exercise, and the Arthritis Foundation pool program is one exercise option that can be recommended.
Use good posture and body mechanics — Another tenet of ergonomics and good biomechanics is that each joint should be used in its most anatomically stable and functional plane. Good body mechanics and posture can have a powerful impact by minimizing musculoskeletal strain and thereby preventing or reducing pain.
Spine — There is a lack of strong evidence to support a causal relationship between awkward postures and low back pain [18]. Thus, rather than recommending a specific posture, it may be preferable to encourage regular movement and avoid sustained postures, such as viewing a computer monitor in neck flexion, which may result in pain.
Peripheral joints — All body parts experience less strain in the neutral position. Patients are less vulnerable to wrist pain and strain when they avoid extremes of flexion and extension. A knee that is neither locked nor flexed is more stable.
People are often unaware of the impact of poor body mechanics and posture on their body. Teaching people with arthritis or overuse problems to be meticulous in their body mechanics and posture can have a significant impact on decreasing pain. While it takes more energy initially, once it becomes a habit, it takes less energy to maintain good posture.
Use the minimum necessary force — Squeezing and pinching activities put stress on the small joints of the hand. Patients can use less force by consciously holding equipment with less effort, by taking rest breaks, and by using special equipment. Patients with OA of the knees can descend stairs backwards, as this decreases joint forces in both the supporting and leading legs [19].
Assistive devices — For patients with painful hand and wrist problems, specially made or assistive devices allow forces to be spread over larger areas and permit joints to operate nearer the mid-range of their motion. Lightweight equipment with built-up handles of about one inch (2.5 centimeters) in diameter can decrease the amount of force on joints. Built-up handles can also help individuals with weak hands. A study of 53 women with rheumatoid arthritis (RA) showed that pain was significantly reduced when assistive devices were used for activities of daily living [20]. Another study demonstrated that nighttime hand-positioning splinting also improved grip and pinch strength, as well as upper limb function and functional status in RA [21]. Foam pipe insulation, widely available, can be cut to length and can be used as grip cushions on tools, handles, brooms, etc. Combining assistive equipment with joint protection education and exercise resulted in improved grip strength and global hand function in patients with hand OA [16].
Patients may search for these devices through online retailers. Examples of assistive devices can be found on the following websites:
Also, examples can be seen in The Arthritis Helpbook [22], available in bookstores and online.
Assistive devices for gait — Use of a cane in the contralateral hand decreases loading on the knee joint through reducing ground reaction forces and reducing the knee adduction moment. A randomized trial of patients with knee OA demonstrated significantly diminished pain and improved physical function after two months of daily cane use [23]. (See "Management of moderate to severe knee osteoarthritis", section on 'Walking aids'.)
Simplify work by using efficiency principles — Planning, organizing, and balancing work with rest are useful principles to employ to reduce stress on joints. Teaching joint protection and efficiency principles in a structured six-week occupational therapy program produced a trend toward improvement in pain, fatigue, and activity levels, as well as a better balance of rest and activity [24]. Moderate evidence supports balancing work with rest (activity pacing) as an occupational therapy intervention for hip and knee OA [25].
Planning — Patients who plan ahead can find the best time of day to perform a task, can allow enough time, can eliminate steps, and can simplify the task. By planning ahead, the patient may recognize that getting help to perform a difficult task can reduce stress and pain during a busy week. Patients tend to have less pain when they avoid rushing, simplify tasks, and spread out difficult tasks such as cleaning activities.
Organizing — Organizing tasks also makes them easier. Having supplies at easy to reach locations, between eye-level and hip-level, prevents excess strain on joints. Duplicating supplies in different locations avoids excess energy expenditure, and eliminating clutter helps patients avoid awkward positions and save time and energy in finding items.
Resting — Patients should schedule rest breaks during the day. Breaks give patients an opportunity to rest their joints, thereby avoiding pain and inflammation. Alternating heavy and light tasks is another way to take pressure off joints. Many people alternate between sitting and standing activities to put less strain on joints. If work requires sitting all day, encourage patients to walk around and stretch periodically. If work requires prolonged standing in one location, placing a block of wood on the floor and stepping upon it with alternating feet may reduce strain.
For problems in the workplace, the patient should seek professional consultation with an onsite occupational health nurse or referral to an occupational therapist.
Using a computer workstation — An ergonomically coordinated workstation can minimize joint and body strain. Although, at first glance, working at a computer workstation looks like a low-strain activity, regular computer use can cause or contribute to back pain, neck pain, muscle fatigue, carpal tunnel syndrome, wrist fatigue, shoulder fatigue, headache, and eyestrain. Useful information can be learned by asking the patient how much time they spend on a computer and what other types of activity or exercise they do in an average week. All patients who work at a computer station who have any joint problems or signs of repetitive strain should be asked about their computer workstations at work and/or home, including how often and how long they use these workstations. Guidelines for sit-stand work surfaces and correct posture are listed on the OSHA website. Sit-stand workstations assist in reducing total sitting time. They offer the opportunity to change position as needed and may reduce musculoskeletal pain, although the data are mixed [26,27]. Some sit-stand workstations may reduce productivity [26]. More long-term studies are indicated to clarify the benefits of sit-stand workstations.
There are several key principles to follow to reduce risk of repetitive strain injury (RSI) and pain. These include good posture, proper placement of equipment, fitness maintenance, and regular rest breaks. Good posture and body alignment are key to any computer workstation. Below is a brief posture checklist for good posture at a computer station:
●Head and neck balanced and in-line with torso
●Trunk perpendicular to floor
●Shoulders relaxed
●Elbows close to body and supported
●Lower back supported
●Wrists and hands in-line with forearms (neutral alignment)
●Thighs parallel to the floor
●Hips, knees, and feet at 90 angles
●Feet flat on floor
The placement of the monitor, keyboard, and mouse is key to an effective workstation. Position the top of the monitor at or just below eye level. Make sure there is adequate room for the keyboard and mouse. If too far away or cramped, the operator will not be able to maintain posture as suggested above. Consider a wrist rest so that the body has a point of contact. If there are preexisting thumb or hand problems, consider an ergonomic mouse; one that has software that allows click-less use is available. If the patient talks on the phone frequently, a headset may be used. Many of these devices can be ordered through online retailers.
Continuous work on the computer puts a strain on the body. The speed of the computer has eliminated the short rest breaks that were provided by typewriters in the past (ie, return of the carriage, loading of new paper). These regular and short breaks provided opportunities for the body to rest and restore. Individuals need to take these rest breaks regularly themselves. Exercises improve circulation, increase mobility, and prevent pain and discomfort.
For example, every hour, the worker can perform warm-up exercises and stretches. Hand and thumb stretches for 10 seconds periodically can be helpful. Performing regular aerobic exercise improves blood flow and the body's muscle endurance. Strong muscles can also tolerate more stress. Those who are fit will be able to work at their workstations longer without developing symptoms.
A systematic review of workplace interventions to manage chronic musculoskeletal conditions found [28]:
●Specific strength exercises appeared to have better effects on pain and functional activity in comparison with other types of exercises, though all exercises showed within-group improvement.
●Improvement in functional status and decrease in pain was associated with the use of a workplace integrated care program provided by a physical or occupational therapist with ergonomics training.
●Self-management strategies consisting of leaflets, manuals, and e-learning appear to have little impact on outcomes.
Additional evidence in support of ergonomic interventions in the workspace comes from a small randomize trial in which workers in the intervention group who received tailored ergonomic workstation modifications experienced lower-intensity pain (on a self-reported scale) in areas including the neck, shoulder, upper back, wrist, and hand, as compared with the control group [29].
Remain active — Patients are encouraged to remain active to maintain and increase strength and range of motion. Movement is vital to living. Exercise plays an important role in control of body weight, in cardiovascular fitness, and in the prevention of coronary heart disease, and, when individualized for a patient with musculoskeletal disorders, exercise generally is expected to improve rather than worsen joint pain and function. A systematic review found strong evidence to support physical activity, such as aquatic, aerobic, and resistive exercise, to improve function, pain, depression, and disease symptoms among people with RA [6].
A Cochrane review found that patients' report of adherence to exercise can be improved when health professionals provide better information and advice about the safety and value of exercise; exercises tailored to individual's preferences, abilities, and needs; information to challenge inappropriate health beliefs; and better support [30].
More detailed discussions of exercise for patients with OA and RA are presented elsewhere. (See "Management of knee osteoarthritis", section on 'Exercise' and "Nonpharmacologic therapies for patients with rheumatoid arthritis", section on 'Physical activity'.)
Type of exercise — The type and amount of exercise depend upon the person for whom it is prescribed. Walking, swimming, and biking are low-impact or non-impact forms of exercise that many people with arthritis can safely perform. Patients with arthritis may need some modifications, such as a longer warm-up and cool-down than the general population. An umbrella review found good evidence that standard exercise programs can reduce pain and improve physical function in patients with knee OA [31]. Engaging in moderate- to high-intensity exercise appears to be protective against increased disease activity, pain, and fatigue over time in older patients with RA [32]. If individuals need help with selecting appropriate exercises or with beginning an aerobic program, they may benefit from a referral to an occupational therapist, a physical therapist, or an exercise physiologist. Some hospital-based fitness programs have professionals on staff who have special training to help people with chronic illness and arthritis. There is limited evidence for OA exercises of the hand [14]. A Cochrane review did not find that adverse effects were associated with hand exercises for people with RA [33]. Those who received training in adherence strategies were more adherent in the medium term. It is uncertain whether exercise improves hand function or pain for people with RA in the short term.
Muscle weakness may contribute to the development of OA. The evidence related to this association is discussed in more detail elsewhere. (See "Epidemiology and risk factors for osteoarthritis", section on 'Muscle weakness/strength'.)
Caution needs to be applied for patients with lax or malaligned knees as greater quadriceps strength may increase progression of preexisting arthritis. Such patients should be referred to a physical therapist who specializes in treating people with arthritis knee problems. Treatment may include modified exercises and appropriate bracing. Caution is also indicated for physical activity after knee or hip arthroplasty. Clinical consensus statements prohibit high-impact sports such as running, football, baseball, basketball, and soccer but encourage participation in non-impact or low-impact sports such as swimming, cycling, walking, etc [34].
Some patients are not interested in a formal exercise program. Health benefits, largely cardiovascular, associated with formal exercise also occur with accumulated lifestyle physical activity. Examples of moderate-intensity lifestyle physical activity that patients with arthritis may perform include light housework, shopping, gardening, clearing walks and driveways, child care, care of older adults, leisure walking, and pool exercises [35]. The role of exercise in general health promotion is discussed in more detail separately.
FREQUENTLY ASKED QUESTIONS ABOUT JOINT PROTECTION
Who teaches joint protection or joint care? — Occupational and physical therapists teach patients how to care for their joints and how to use them wisely. Occupational therapists tend to have expertise in teaching patients specific ways to protect their hands and ways to use them in daily activities, while physical therapists tend to have expertise in teaching specific ways to protect knees and hips. Additionally, both instruct in proper body mechanics, posture, and transfers, with physical therapists more focused on ambulation and occupational therapists more focused on daily living activities. Other professionals, including exercise physiologists, may also have special training. Patients should be encouraged to check the training, as well as the certification or licensure, of individuals they consult and to consult orthopedic surgeons and rheumatologists for referral, as these clinicians often have working relationships with therapists with relevant interest and expertise. A systematic review found moderate evidence that educational interventions provided by occupational therapists for patients with rheumatoid arthritis (RA) that focus on joint protection and energy conservation improve joint protection behaviors. There was also strong evidence supporting pain management education and psychosocial interventions, emphasizing mindful thinking, to improve disease activity, physical function, and pain [36].
Is there a role for personal trainers? — The training of a personal trainer may range from nothing to a certificate after studying a syllabus and passing a written exam or to brief clinical experience. In the United States, the National Academy of Sports Medicine, the American College of Sports Medicine, the Aerobics and Fitness Association of America, and the American Council on Exercise provide clinics for hands-on training. However, simply being certified is no guarantee of competence. Some personal trainers can provide useful exercise information for healthy individuals who want to exercise in a gymnasium or health club, but their ability to advise patients with arthritis is likely to be inferior to that of a physical or occupational therapist.
Thus, if the patient has symptomatic or advanced osteoarthritis (OA) or an inflammatory arthritis, we suggest referral to a physical therapist for assessment and structuring of any activity as part of a health club program. Then, if a trainer is to be used, the physical therapist recommendations can be provided as a framework for a personalized exercise regimen.
What constitutes quality joint care education? — Some clinics provide handouts with lists of "Dos and Don'ts" to teach joint protection skills. While these lists contain useful information, they are NOT recommended as the sole focus of education because they do not teach people to apply the material to themselves. A good program explores the tasks patients need to do in their daily lives and identifies tasks patients find painful or feel unable to do. Together with the therapist, patients learn and practice alternate ways to perform tasks using the principles of joint protection.
Therapists can recommend stores, websites, etc for special equipment and can recommend what to look for when purchasing equipment. The key to success is engaging the patient in the process of identifying difficult and painful tasks, as well as finding and practicing solutions. Many clinics perform this training in small group settings. This is ideal as the patients can learn from others and can explore more tasks than they might by themselves [4,5,8,24].
A behavioral program that focuses on self-management education has been found to be more effective in the long term in enabling people with RA to reduce pain, to improve psychological status, and to self-manage their condition, compared with standard information-focused education [37]. Another study that demonstrated similar results found that improvements were not seen until six months after beginning the program. These findings suggest that patients with chronic disease may need a longer period of intervention and follow-up to observe results [38].
When should a patient be referred to occupational and/or physical therapy? — Refer a patient who:
●Has joint or overuse problems, who has repeated exacerbations of pain following activity, and who is unable to independently modify his/her behavior.
●Has OA of the hand, for evaluation of ability to perform activities of daily living (ADLs) and for instruction in joint protection [39].
●Has a joint injury and who does not know how to care for his/her joints.
●Has a newly diagnosed joint disease and who needs help learning to cope with his/her condition (eg, newly diagnosed RA) [3,40,41]. Patients can benefit from splinting during a flare-up to relieve pain and to increase grip strength, though patients are more likely to gain full benefit from occupational or physical therapy with some degree of disease control [42].
●Is deconditioned and who would benefit from strength or range of motion training and from referral to community resources to manage secondary effects of inactivity on his/her joint problems.
●Has a need to find resources for self-help and assistive equipment to manage independently at home.
●Is unable to successfully exercise at home or in the community.
●Has RA and is at high risk of work disability. A comprehensive occupational therapy program that includes training in motor function, instruction in joint protection and energy conservation, counseling, instruction about assistive devices, and provision of splints has demonstrated benefits [43].
●Is at higher risk for mobility loss, as there is evidence of higher commitment to improve lifestyle physical activity in this population [44].
What interventions maintain joint alignment and stability?
Braces — Symptomatic improvement in patients with knee arthritis may result from bracing. For those with varus deformity of the knee, an unloader brace may produce a significant decrease in pain and improvement in physical function. Patients with OA without severe deformity may experience a modest decrease in symptoms when using a neoprene sleeve. Bracing for patients with osteoarthritis is discussed in more detail elsewhere. (See "Management of moderate to severe knee osteoarthritis", section on 'Knee braces'.)
Splints — Splinting of the elbow, wrist, metacarpophalangeal (MCP), and interphalangeal (IP) joints may be beneficial for patients with arthritis or tendinopathy. Splints can reduce force on vulnerable areas during functional activities [11]. There is a wide variety of commercially available assistive devices available, and they are generally identified by the terms "adaptive devices" or "assistive devices."
●Lateral epicondyle of the elbow – A wrist brace with a metal stay may be effective for some patients with lateral epicondylitis (tennis elbow). This type of splint may reduce pain by reducing forces on wrist extensor tendons. Use of splinting and compression straps for patients with lateral epicondylitis is discussed in more detail elsewhere. (See "Elbow tendinopathy (tennis and golf elbow)", section on 'Bracing'.)
●Wrist – Prefabricated soft wrist splints have been reported to increase pinch and grip strength, decrease pain, decrease inflammation, and improve the patient's ability to carry out everyday tasks [45]. The most consistent effect of splinting is reduction of pain [45]. Prefabricated wrist splints are better accepted than hard (plaster or molded thermoplastic) splints by patients [45].
Nighttime use may be preferable to continuous use for patients with RA. One study randomly assigned 50 patients with RA to the use of a nighttime hand positioning or to usual treatment [21]. The group assigned to splinting had less pain, improved grip and pinch strength, improved upper limb function, and improved functional status [21]. However, in another randomized controlled trial with 120 patients, there was no significant difference between the two groups on measures of grip strength, deformity, hand function, and pain [46].
Wrist splinting may also be beneficial for patients with carpal tunnel syndrome. Use of splints for carpal tunnel syndrome is discussed in detail elsewhere. (See "Carpal tunnel syndrome: Treatment and prognosis", section on 'Wrist splinting'.)
●Carpometacarpal (CMC) joint – Arthritis in the first carpometacarpal (CMC) joint of the thumb can be painful and can interfere with daily activities. Splinting the CMC joint can relieve pain for patients with CMC joint OA. Splints for the first CMC joint may be molded to the patient's thumb and wrist from thermoplastic by an occupational therapist. Alternatively, a prefabricated CMC splint may also be used. A more detailed discussion on the role of splinting for CMC joint OA can be found elsewhere. (See "Management of hand osteoarthritis", section on 'Splints and other assistive devices'.)
●Interphalangeal (IP) joint – Ring splints designed to provide stability and to improve alignment of the IP joints are pieces of jewelry fabricated from silver or gold. Their design prevents hyperextension of the IP joint. They can improve grasp and prehensile strength, as well as the appearance of the joint [47]. In a pilot study with 17 patients with RA, ring splints significantly improved dexterity, and patients reported improved hand function. For satisfactory results, careful patient assessment by an occupational therapist and well-fitting splints are required. Patients with early-stage RA disease are the best candidates for extensive hand splinting [48]. In a systematic review, splints improved dexterity for patients with swan neck deformities, but there was no evidence supporting splints for RA boutonniere deformities [14]. Splints for OA in the distal interphalangeal (DIP) joint may also be helpful, although these are less frequently prescribed. (See "Management of hand osteoarthritis", section on 'Splints and other assistive devices'.)
Potential adverse effects of a splint or brace — Adverse reactions are uncommon for those wearing splints and/or braces, although some patients with RA report decreased grip strength and dexterity with use of working wrist splints [49]. Discomfort and/or swelling are also sometimes reported by patients wearing night splints to manage carpal tunnel syndrome [50]. A 2005 systematic review found some evidence to suggest that long-term adherence to knee bracing for osteoarthritis is relatively low, but the reasons were not determined [51].
Neoprene sensitivity is another potential risk but is rare. Splints and braces made with neoprene pose two dermatological risks: allergic contact dermatitis (ACD) and miliaria rubra (prickly heat). The most common symptom of ACD is severe itching at the contact site. Swelling in the contact area and distally is also common. Prickly heat is caused when sweat ducts are blocked by dirt, dust, or creams. Characteristic symptoms are small red, elevated, inflammatory papules that produce a tingling, burning, or pricking sensation. Thiourea compounds and mercaptobenzothiazole (MBT) used in the manufacturing of neoprene are thought to be the causes of these reactions, which can occasionally be of sufficient severity to require hospitalization. These dermatological conditions may be underdiagnosed in patients using splints [52,53]. (See "Clinical features and diagnosis of allergic contact dermatitis" and "Approach to the patient with pustular skin lesions", section on 'Miliaria'.)
Strategies for reducing the dermatologic risks of splints and braces include:
●Screening patients for history of allergies to neoprene or other materials containing thiourea compounds and using alternate materials for those at risk
●Educating patients regarding the increased risk from hot and humid environments. Patients should be warned against wearing splints over open wounds, during hot humid weather or work conditions, and for tasks that are likely to increase sweating. Stockinette is not recommended in hot humid environments because it does not act as a sufficient barrier to prevent allergic skin reactions.
●Discontinuing use at the first sign of allergy. Symptoms can worsen with increased exposure. Patients should be warned to discontinue use of a neoprene splint at the first sign of symptoms [52].
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Physical activity for people with arthritis (The Basics)")
●Beyond the Basics topics (See "Patient education: Arthritis and exercise (Beyond the Basics)".)
SUMMARY AND RECOMMENDATIONS
●Patients with unstable or painful joints may have a limited understanding of activities that increase risk of further joint damage or that promote inflammation.
●The two major aspects of joint protection are individualized assessment of the patient's activities and creation of a program to improve function. The potential of the patient's activities to contribute to worsening pain, inflammation, instability, and/or deformity of an already abnormal joint should be assessed. The interventions may include altered work methods based upon ergonomics, behavioral modifications, and instruction in good body mechanics. Splints, braces, or assistive equipment designed to minimize further joint damage may also be helpful. (See 'What is joint protection?' above and 'What is ergonomics?' above.)
●Patients with chronic forms of inflammatory arthritis, with osteoarthritis (OA), or with overuse syndromes may benefit from joint protection, which can relieve pain, reduce local inflammation, and maintain functional ability. (See 'Who benefits from joint protection?' above and 'Efficacy of joint protection and energy conservation' above.)
●The principles that are the foundation of patient education in joint protection include:
•Respect pain (see 'Respect pain' above and 'The two-hour pain rule' above and 'Factors affecting activity-related joint pain' above)
•Distribute the load over stronger joints and/or larger surface areas (see 'Distribute the load' above)
•Avoid maintaining the same joint position for prolonged periods (see 'Avoid prolonged immobility' above)
•Reduce excess body weight (see 'Reduce excess body weight' above)
•Use good posture and body mechanics (see 'Use good posture and body mechanics' above and 'Spine' above and 'Peripheral joints' above)
•Use the minimum amount of force necessary to complete the job (see 'Use the minimum necessary force' above)
•Simplify work by using efficiency principles (plan, organize, and balance work with rest) (see 'Simplify work by using efficiency principles' above)
•Remain active to maintain or increase strength and range of motion (see 'Remain active' above)
●An ergonomically coordinated workstation can minimize joint and body strain for patients spending significant time using a computer.
●Clinicians with expertise in joint protection include occupational therapists and physical therapists. Assessment should include identification of the tasks performed by patients in their daily lives that are painful or difficult to carry out. Occupational therapists focus more on activities of daily living and use of the hands, while physical therapists focus more on ambulation and lower extremity function. Both focus on body mechanics and transfers. (See 'Who teaches joint protection or joint care?' above and 'What constitutes quality joint care education?' above and 'Is there a role for personal trainers?' above.)
●Indications for referral for joint protection assessment and instruction in patients with joint disease include (see 'When should a patient be referred to occupational and/or physical therapy?' above):
•Repeated exacerbations of pain following activity
•Joint injury
•A newly diagnosed joint disease
•Deconditioning and other secondary effects of inactivity
•A need to find resources for self-help and assistive equipment to maintain independent functioning
•An inability to successfully exercise at home or in the community
●Patients with lax or malaligned knees should be referred to a physical therapist with particular expertise in treating knee problems related to arthritis. Patients who have had knee or hip arthroplasty should be counseled not to participate in high-impact sports and should be encouraged to take part instead in non-impact sports and activities. (See 'Type of exercise' above.)
●Symptomatic improvement in patients with knee arthritis may result from bracing. Splinting of the elbow, wrist, metacarpophalangeal (MCP), and interphalangeal (IP) joints may be beneficial for patients with inflammatory arthritis. (See 'What interventions maintain joint alignment and stability?' above and 'Braces' above and 'Splints' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Robert Sheon, MD, who contributed to an earlier version of this topic review.
