It’s not what you do it’s the way that you do it!

Joint protection is an alternative method of carrying out everyday tasks, which will reduce the strain on your joints and therefore reduce pain. Using these techniques will also help to minimise joint deformities. Joint protection is often taught as a group session at an Occupational Therapy department. It involves both formal teaching and practical applications. People often enjoy being in a group as they can then encourage each other and swap ideas. Indeed it is often the case that this is the first opportunity that people with rheumatoid arthritis have had to talk to others with it.

In order to achieve the optimum results from these sessions it is necessary to incorporate the new ideas on a daily basis. This will take quite a lot of thought initially but later on, if practised regularly, it will become automatic. If joint protection is incorporated into the daily routine then significant benefits should result. A study in The Lancet1 in 1991 demonstrated significant improvements in physical abilities for people with rheumatoid arthritis who attended the OT department for a programme of joint protection and other OT interventions.

There are three main principles involved in joint protection:

• 1Conserving your energy.
• 2Avoiding static positions.
• 3Discouraging deformities.

1 CONSERVING YOUR ENERGY

Having rheumatoid arthritis means that you are likely to have less energy than the average person when the rheumatoid arthritis is active. It also means that your joints are much more vulnerable to damage than other people’s joints are. You therefore need to be organised and only do things that are absolutely necessary or things that are important to you. This is particularly necessary if you have a flare-up and feel very tired. How much can be left undone depends on the situation you are in.

It is better to try to organise your life so that on an average day it is possible to fit in everything you want to do with time to spare. This means not taking on too much and being realistic in what you decide to achieve. In fact this should apply to everyone, not just people with rheumatoid arthritis. Try to spread the workload evenly over the week or month so that there is an even balance of more physical activities and more restful ones. For example it is not a good idea to clean all the windows on the same day, it is better to do one per day or one a week. Equally it is not a good choice to sit at a computer all day. Even if you are looking after young children it is possible to vary the activities carried out in any one day and, incidentally, this is much better for the children too.

You can do some physical activities but sit down and enjoy a game or read a book in between the demanding tasks.

Planning and prioritising

Think about the type of work you do because it may be possible to alter the planning of the day or build in rests. It might even be a good idea to change the type of work altogether if it is continually putting strain on the same joints or making you very tired. Start by analysing your working day and deciding what can be eliminated, if anything, and find a beneficial pattern of activity and rest for what remains. Ensure that you do some physical tasks because it is important to exercise to keep muscles strong. It is the balance of activity and rest that is essential. Prioritise and schedule the most important issues first. Sometimes we put too high expectations and standards on ourselves. Some tasks can be left undone without it really mattering too much; after all, health is the most important issue.

It is also important to think about the way you do tasks and the postures that you adopt for them because you could be placing more strain on your joints or taking more effort than you need to be.

• Is there an easier way to carry out this activity?
• Could it be done less often?
• Alternatively could someone else be doing it?

I practise energy conservation and the way I do this is by spreading my work hours over five days and working about five hours daily. I can do this because luckily I do

not have to work full-time. After work and at weekends I tend to do a mixture of physical activities like housework, cooking, walking the dog, swimming, shopping, light gardening and some restful ones like reading, singing, listening to music, telephoning, watching TV, socialising and using the computer. I never do more than two hours of anything and I take coffee breaks frequently! Occasionally I go out for a day and do more walking than usual and often I end up paying the price later in the day or the next day. It is still worth it on the odd occasion if you really want to do something special.

2 AVOIDING STATIC POSITIONS

A static position is one that involves using the same set of muscles continually rather than alternating the groups of muscles used. For instance, if you sit and hold up a newspaper this places the shoulder muscles in a static position. However, swinging your arms while you are walking is an action that involves continually changing the muscle groups. It places more strain on a joint to continually use it in the same way and it also uses more energy to maintain a static position.

Anyone with rheumatoid arthritis needs to continually change positions to avoid repeated strain on particular joints. This means alternating between standing, sitting, walking and lying down. It also means that if you are working using your finger joints then your next action should preferably involve the use of different joints or the same joints used in a different way.

For instance if you are mixing a cake then this involves a beating motion with the hands and most of the strain is on the elbows, shoulders and wrists so the next task should use the hands in a different way. You could change to typing because this is using the fingers, wrists and shoulders in a different way, but it would be even better to walk the dog or sit down and read because this would be a complete change of activity involving different joints. Gentle movements of the joints seem to be best because they stop the joints stiffening, but do not strain them. I find that small amounts of light washing up are actually very beneficial. The warm water and gentle movements make the joints feel more comfortable.

Carrying out activities around the house is more beneficial than a long walk providing they are not too strenuous. This is because the movement loosens the stiffness but does not cause pain. If you need to sit down for a long time then get up and stretch your legs every 20 minutes or so. It is always a good idea to change positions every 20-30 minutes if you are able to.

3 DISCOURAGING DEFORMITIES

In rheumatoid arthritis the first joints to be effected are usually the fingers, wrists and toes. The overproduction of fluid results in the ligaments becoming loose and then these joints are able to move in an abnormal way. Inflammation sometimes also causes the tendons to weaken. Joint damage means that some movements are restricted. This restriction, combined with the loose ligaments, weak tendons and the swelling of the joints means that affected joints, are then used in abnormal ways to compensate. For instance, if the wrist movement is reduced then finger joints are more likely to take up abnormal positions to counteract this, such as the finger joints drifting and the fingers becoming angled towards the little finger. This is called ulnar drift (see Figure 2). Care is needed so that the fingers are not encouraged to take up these positions. Putting pressure on joints also makes deformity more likely. Joint protection procedures will not stop these things happening but they will slow down the process. Using the joints in as normal a way as possible also means that if joints do fuse because of cartilage damage, they will fuse in a normal working position and therefore it will still be possible to carry out many actions.

Avoid actions that encourage deformity

Opening jars, screwing lids, turning taps and holding plates can encourage deformities in the hands. You should hold a dinner plate either with two hands or by using the palm of the hand (see Figure 3). It is also better to use the palms of the hand when opening jars or bottles. If you have to perform a turning or twisting movement using the fingers always ensure that the fingers are being encouraged to move towards the thumb and not towards the little finger. This means that learning to use both hands is very useful. For example:

• You should turn on a tap with your right hand and turn it off with your left one.
• You could use a special jar opener to open the jar more easily (see Chapter 5).
• Use a wall tin opener for tins if they do not have a ring pull opener.
• Never pull open ring pull cans with one finger, use a knife to lever them open or use a special ring pull opener.
• Finger joints can also be placed into positions of deformity by pushing up on the knuckles or leaning the chin onto the hands. Both these positions should be avoided.
• Reading a book by holding it up in one hand can put strain on the finger joints. It is better to rest the book on the table or use a book-rest or draw up the knees and rest it on them.

Avoid tight grips

It places more pressure on the joints to pick up small items than larger ones.

• Handles on utensils should be larger to reduce the strain.
• It is therefore better to use mugs with thick handles rather than elegant china teacups with dainty handles (see Figure 4).

• Spreading your fingers around the mug is a much better position for the finger joints but always wait until the drink has cooled or use an insulated mug.
• Use kitchen tools and cutlery with chunkier handles rather than slim ones.
• If you are using a knife ensure that it is sharp, as this reduces the power needed to cut. There are special knives that can also be used, and these will be discussed in the equipment and adaptations section in Chapter 5.
• Use a thick pen or a pen grip, particularly if you intend to write for long periods of time.

Use a larger joint or several joints rather than small joints

• If you are carrying objects like saucepans and plates then use two hands. Using one hand will place that hand in a position of deformity.
• You can buy dishes, casseroles and saucepans with two handles on.
• It is useful to use a tray to carry items but make sure that it has suitable handles at each side.
• It is never a good idea to carry heavy loads and certainly not on one or two fingers. Alternatively they can be carried close to the body in a bag.
• Shopping bags should be carried over the arm or over the shoulder and they should not be too heavy (see Figure 5).

• It is always better to spread loads over more joints or use larger joints.
• Use a car or home delivery wherever possible, or otherwise a trolley, rather than carrying weights long distances.

Choose suitable equipment

• Using lightweight equipment will reduce the strain on joints. There are lighter options for most equipment, whether it is for kitchen use, for DIY or for housework. If you are buying new equipment or being given a present choose with the weight in mind rather than just going for looks.
• Choose fittings that can easily be operated, like levers rather than knobs, for example choose lever taps in place of crystal or traditional four-prong taps.

A PERSONAL SCENARIO

Occupational Therapists will give this information to their clients if they are referred for therapy. I was not referred until I already had many deformities and therefore I did not know about joint protection until I had had rheumatoid arthritis for ten years. I therefore did all the wrong things for a very long time.

As I mentioned, at the time the arthritis started I was working in a park. I was digging, driving a tractor, lifting heavy wheelbarrows and a very heavy teapot. I did not want to appear pathetic and soldiered on even though I was in a lot of pain and my joints were very stiff. It is likely that I would have suffered a lot less pain if I had practised joint protection.

Dr Alison Hammond2 is an Occupational Therapist who has evaluated joint protection. In 2001 the results of her evaluation of 65 rheumatoid arthritis patients were published. She found significant improvements in pain, disease status and functional ability amongst patients on the joint protection programme.

Liz MacLeod3 is a physiotherapist who has published guidelines on the pain concern website. She talks about learning to negotiate. She says that some pain sufferers have changed their lifestyle and reduced their flare-ups whilst others have made little or no changes and endure pain and distress.

I have learnt to negotiate in order that I can be pain free, although this does not mean that I have been prepared to give up everything that I enjoy. There have been many times when I have chosen to ignore joint protection because I had to achieve a personal goal, however I only ignore it for an extremely good reason. At 39 I had never achieved my ambition of going skiing and for a week I put my principles on hold and punished my joints and also risked a few broken bones. I did some exercise before I went and luckily my bones survived intact. It was well worth the risk to achieve an ambition. I really enjoyed the opportunity to ski.

Generally though, since being aware of joint protection, I am a lot more careful. I mostly follow the guidelines and have also found my own ways to make my life easier and to protect my joints. In the kitchen my cooker is near to the sink and I can slide saucepans along. I can then tip them from the edge of the sink into a colander without the

need to lift them. I took a lot of care when I bought the cooker, ensuring that I could use the controls. The knobs are an optimum size and easy to turn and the oven is self cleaning inside. These priorities came before being fashionable or having the colour or model that I preferred. Within the price range it usually means that I effectively have very little choice!

All the taps in the house are now very easy to use and if any equipment is due to be replaced I always choose very light items. Most of my pots and pans have two handles or are very light and I am still able to cook the meals. I can also take the vacuum cleaner upstairs, as well as doing the ironing and most light domestic activities.

On the whole, once you have learnt the principles of joint protection you will find ways of incorporating them into your own lifestyle. I have my own way of peeling potatoes. I put them onto the surface, holding them still with one hand and then I use a sharp knife to peel downwards. I do not hold the potatoes in my hand because it is uncomfortable and encourages deformity. I have drawers that can slide open easily and I use appropriate heights to prepare food. I also have a small jug kettle, or otherwise use both hands when I lift a larger kettle. I use a plastic jug to fill the kettle.

Sometimes specialised equipment is necessary to assist with reducing deformities and the reduction of strain on the joints. I have a few items that I regularly use. In the next chapter I will outline the most commonly used equipment that can be beneficial for people with rheumatoid arthritis.