OBJECTIVE: Joint protection aims to reduce pain and local inflammation, preserve the integrity of joint structures and improve function. There is evidence that it can improve pain and function in the short term, but the long-term effects are uncertain. This study evaluated the effects of joint protection in early rheumatoid arthritis (RA). METHODS: A randomized, controlled, assessor-blinded trial of duration 1 yr was conducted. Two interventions (both 8 h) were compared: standard arthritis education, including 2.5 h of joint protection education based on typical UK practice; and a joint protection arthritis education programme, using educational-behavioural teaching methods. Assessments were made at entry and 6 and 12 months. RESULTS: Sixty-five people with RA attended the joint protection programme and 62 the standard programme. The groups were matched for age (51 and 49 yr), disease duration (21 and 17.5 months) and use of non-steroidal anti-inflammatory drugs and disease-modifying anti-rheumatic drugs. In comparison with the standard group, the joint protection group significantly improved with respect to adherence to the joint protection programme (P=0.001), hand pain (P=0.02), general pain (P=0.05), early morning stiffness (P=0.01), self-reported number of disease flare-ups (P=0.004), visits to the doctor for arthritis (P<0.01), and the AIMS2 (Arthritis Impact Measurement Scales) activities of daily living scale (P=0.04). A trend to improved swollen joint counts was identified (P=0.07). Within-group analyses also showed improvements in arthritis self-efficacy and perceived control. Hand deformity scores continued to increase in both groups. CONCLUSION: We found significant improvements in adherence, pain, disease status and functional ability amongst those attending the joint protection programme. Benefits became more apparent with time, suggesting that joint protection can help slow the progression of the effects of RA over and above the effects of drug therapy.
This study investigates the use of custom-made and prefabricated splints for swan neck deformities in rheumatoid arthritis. The splints were compared on the variables cosmesis, comfort, functional use and wearing time per 24 hours. Effects on stability, grip strength and mobility were also recorded. 18 patients, divided into two groups of nine patients each, were involved. During a three-month period one group used custom-made splints while the other group used prefabricated splints. Then the first group changed to prefabricated splints for another three-month period and the second group changed to custom-made splints. The outcome of this study indicates that using a splint increases finger stability significantly (p< 0.014) and passive extension of the distal interphalangeal (DIP) joint (mean ± SD 3.33° ± 6.41; p= 0.042). The flexed position of the DIP joint was found to decrease significantly (mean ± SD 4.72° ± 6.96; p=0.010). These results were not dependent on the type of splint. The prefabricated splint was worn during longer periods of time and scored higher for cosmesis (p<0 .0001). Used as a first splint the prefabricated splint scored higher for comfort (p <0 .011). The overall conclusion from this study is that the prefabricated splints are tolerated better and more acceptable in terms of wear then the custom-made splints.
OBJECTIVE: To evaluate the effects of an education programme in improving adherence with joint protection by people with rheumatoid arthritis (RA). DESIGN: A repeated measures design. Subjects were assessed at six weeks and one week before and six and twelve weeks after education. SETTING: Rheumatology unit in a large district general hospital. SUBJECTS: Twenty-one people diagnosed with RA (mean age 48.95 years (SD 12.54) and disease duration of 6.43 years (SD 7.7) ). INTERVENTION: An 8-hour arthritis education programme delivered over four sessions, including two hours of joint protection education designed to be typical of current UK practice. MAIN OUTCOME MEASURES: The Joint Protection Behaviour Assessment (JPBA), an observational assessment of hand joint protection methods used during kitchen activities, to measure adherence with education. Other assessments included a joint protection knowledge questionnaire, hand joint counts, hand pain visual analogue scale, the Health Assessment Questionnaire (HAQ) and HAQ Pain scale to identify any short-term changes in hand pain, pain on activity and functional status. At the beginning and end of the study subjects were interviewed to obtain their self-report of joint protection behaviours and reasons for following or not following the advice given. RESULTS: Median JPBA scores did not improve pre- to posteducation (18.4% to 23.7%; p = 0.65) and neither did hand joint count, hand pain, HAQ and HAQ Pain scores. However, joint protection knowledge improved significantly (p = 0.01) and the majority of people believed joint protection to be a beneficial strategy. Reasons for not changing behaviour included problems recalling information; joint protection being considered inappropriate as 'hands were not that bad yet'; lack of skill; and difficulties changing habits. CONCLUSION: The joint protection education programme improved knowledge but not use of taught methods. Educational strategies being used by therapists need to be focused on enhancing adherence.
OBJECTIVE: To compare the short-term utility and clinical effectiveness of the commercial-made Futuro wrist orthosis with a newly developed, custom-made ThermoLyn wrist orthosis. METHODS: Using a randomized cross-over trial, 10 patients with rheumatoid arthritis used each of the two orthoses for two weeks. Outcome measures were patients' judgments with respect to different statements about utility and clinical assessments including pain and swelling of the wrist and finger joints, range of motion of the wrist, and grip strength. At the end of the study the patients were asked which of the two orthoses they preferred and why. RESULTS: Patients tended to favor the Futuro wrist orthosis with respect to pain relief and to handling the orthosis. The visual analog scale score of the appearance of the ThermoLyn wrist orthosis was a little higher than that of the Futuro wrist orthosis, but the difference was not statistically significant. Clinical parameters such as pain in the wrist, swelling of the wrist and finger joints, and movements of the wrist showed that the Futuro orthosis tended to be more effective than the ThermoLyn orthosis. None of the differences reached statistical significance. At the end of the study, 5 patients preferred the Futuro and 5 patients the ThermoLyn wrist orthosis. Arguments in favor of the ThermoLyn orthosis were better hygiene, stability, and no need to remove the orthosis during dirty and wet conditions. Arguments in favor of the Futuro orthosis were greater suppleness and freedom of movement. CONCLUSIONS: The ready-made fabric Futuro wrist orthosis appears to be as good as the more expensive individually made synthetic ThermoLyn wrist orthosis with respect to short-term utility and clinical effectiveness. The conditions under which the orthosis will be worn will help to decide which orthosis is the best for the patient. In the event that the patient wants to use the orthosis in wet and dirty conditions, the ThermoLyn wrist orthosis is a good alternative to the Futuro wrist orthosis.
Joint protection (JP) is a self-management technique widely taught to people with rheumatoid arthritis (RA). JP education aims to enable people with RA to reduce pain, inflammation, joint stress and reduce risks of deformity through using assistive devices and alternative movement patterns of affected joints to perform everyday activities. Previous studies evaluating JP education methods common in the UK have identified JP adherence is poor. A group education programme was developed using the Health Belief Model and Self-efficacy Theory. Strategies used to maximise JP adherence included goal-setting, contracting, modelling, homework programmes, motor learning theory, recall enhancing methods and mental practice. A crossover trial (n = 35) was conducted. Adherence with JP was measured using an objective observational test (the Joint Protection Behaviour Assessment). Significant improvements in use of JP were recorded at 12 and 24 weeks post-education (P < 0.01). No significant changes in measures of pain, functional disability, grip strength, self-efficacy or helplessness occurred post-education, although this may have been due to the small sample size recruited. In conclusion, JP adherence can be facilitated through the use of educational-behavioural strategies, suggesting this approach should be more widely adopted in clinical practice.
OBJECTIVE: To determine the effect of a wrist orthosis on work performance, hand dexterity, and pain during task performance, 40 individuals with rheumatoid arthritis were studied using a 2 period, crossover design. METHODS: Each patient was fitted with a Futuro wrist orthosis. Dexterity was measured with and without the orthosis using the Jebsen Hand Function Test. Work performance was assessed using 2 tasks (one simulating the use of shears, the other the use of a screwdriver) on a work simulator. All tasks were performed both with and without the orthosis, with the order of orthosis versus no orthosis randomly assigned. Pain before and after performing tasks was assessed using a 10 cm horizontal visual analog scale. RESULTS: While on the screwdriver task work performance was less with the orthosis (p = 0.0002); on the shears task there was no significant difference in work performance with and without the orthosis. The average pain after performing both tasks was significantly less with the orthosis on. A 2 factor analysis of variance model with repeated measures suggested that taking into account the reduced work performance during splint wear, pain was still significantly reduced with splint wear. The average time to complete all 7 tasks on the Jebsen Hand Function Test was longer when the subjects wore the splint compared to when they did not (62.0 vs 57.6 s, respectively; p = 0.0086). CONCLUSION: The results suggest that the effect of splint wear on work performance is highly task specific, and thus the ergonomic demands of the individual's daily life must be considered if a splint is to provide maximal effectiveness.
To determine whether a postoperative rehabilitation protocol incorporating continuous passive motion would increase the total range of motion obtained 6 months following silicone interposition arthroplasty of the metacarpophalangeal joints in patients with rheumatoid arthritis, a prospective trial randomizing patients to receive either continuous passive motion or the standard dynamic splint protocol (modified Madden protocol) was undertaken. Fifteen hands (60 joints) were treated with the modified Madden protocol and 10 hands (40 joints) had continuous passive motion. The mean 6-month postoperative range of motion was 7 degrees in the modified Madden cohort compared with 39 degrees in the continuous passive motion cohort, representing an improvement of 22 degrees in the modified Madden cohort compared with an improvement of only 5 degrees in the continuous passive motion cohort. Residual ulnar deviation 8 degrees vs 12 degrees and grip strength (2.3 kgf v 3.7 kgf) were both lower in the continuous passive motion cohort. Incorporation of the continuous passive motion machine in the postoperative rehabilitation protocol does not offer sufficient advantages to justify the added costs.
A new program based on improved user participation for the selection of assistive devices was implemented and its effectiveness and efficiency assessed. The intervention was compared with traditional routines. The study population comprised persons with rheumatoid arthritis who lived in two communities in Sweden. The selection process yielded increased user participation, user satisfaction, an increased number of prescriptions, and consequently also higher costs. The outcome measures showed more vague improvements. No improvement in functional ability was found regarding pain and difficulty with daily activities in the two study groups, but an increased use of assistive devices was found among women below 64 years in the intervention group (p = 0.001). Women below 64 years in the intervention group rated an improved health-related quality of life regarding both the total score (p = 0.017) and the underlying dimensions of physical function (p = 0.012). Even though the intervention yielded positive results on process-variables as increased user participation and an increased number of prescribed assistive devices, only women below 64 years showed an increased use of assistive devices in daily activities and an improved health related quality of life.
OBJECTIVE: To investigate the effect of 3 commercial wrist orthoses on finger dexterity and hand function of patients with rheumatoid arthritis (RA). METHODS: Forty-two patients with definite RA participated in the cross-over study comparing 3 styles of commercial wrist orthoses. Finger dexterity and hand function of the dominant hand were assessed while splinted and unsplinted, at the initial session and after 1 week of intermittent orthosis use. Finger dexterity was assessed using two subtests from the Purdue Pegboard Test (Purdue) and hand function was assessed using the Jebsen-Taylor Hand Function Test (Jebsen-Taylor). RESULTS: Both finger dexterity and hand function were reduced by splinting; men and women were affected similarly. There was no difference in finger dexterity or hand function afforded by the 3 orthoses. Results on both the Purdue and Jebsen-Taylor tests showed a significant learning effect across time. CONCLUSIONS: The 3 commercial wrist orthoses studied reduce dexterity similarly and significantly. When commercial wrist orthoses are to be used during tasks that require maximum dexterity, this reduction should be weighed against the known benefits of splinting.
OBJECTIVE: To describe patients' functional uses of 3 commercial wrist orthoses, to describe patients' preference patterns for the orthoses, and to clarify orthotic attributes that are viewed positively and negatively. METHODS: Using a cross-over design, 42 patients with definite rheumatoid arthritis used each of 3 commercial orthoses for one week. There was a one-week wash-out between each week of use. At the end of the study, private semi-structured interviews were conducted with each participant. Data from close-ended questions were tabulated. Open-ended data were analyzed using qualitative methods. RESULTS: Patients reported that the 3 commercial wrist orthoses reduced wrist pain similarly, but that comfort and a sense of security during functional tasks were only found if the orthoses were comfortable and well-fitting. Most subjects preferred the padded, short forearm orthosis, though a small number found it uncomfortably warm, and many complained that it was difficult to use when wearing long-sleeved garments. Common complaints about the two elastic orthoses included chafing at the thumb webspace and chafing at the proximal closures. Longer forearm length was often perceived as providing unnecessarily high levels of wrist support. CONCLUSIONS: No single orthosis suited all subjects. Satisfaction with an orthosis appears to be based not only on its therapeutic effect, but also the comfort and ease of its use. To maximize patient satisfaction and improve the likelihood of appropriate fit and comfort, several styles of commercial orthoses should be available. The current trend toward restricted clinic stocks appears contrary to both therapeutic goals and patient satisfaction.
Joint protection aims to reduce pain and local inflammation, preserve the integrity of joint structures and improve function. There is evidence that it can improve pain and function in the short term, but the long-term effects are uncertain. This study evaluated the effects of joint protection in early rheumatoid arthritis (RA).
METHODS:
A randomized, controlled, assessor-blinded trial of duration 1 yr was conducted. Two interventions (both 8 h) were compared: standard arthritis education, including 2.5 h of joint protection education based on typical UK practice; and a joint protection arthritis education programme, using educational-behavioural teaching methods. Assessments were made at entry and 6 and 12 months.
RESULTS:
Sixty-five people with RA attended the joint protection programme and 62 the standard programme. The groups were matched for age (51 and 49 yr), disease duration (21 and 17.5 months) and use of non-steroidal anti-inflammatory drugs and disease-modifying anti-rheumatic drugs. In comparison with the standard group, the joint protection group significantly improved with respect to adherence to the joint protection programme (P=0.001), hand pain (P=0.02), general pain (P=0.05), early morning stiffness (P=0.01), self-reported number of disease flare-ups (P=0.004), visits to the doctor for arthritis (P<0.01), and the AIMS2 (Arthritis Impact Measurement Scales) activities of daily living scale (P=0.04). A trend to improved swollen joint counts was identified (P=0.07). Within-group analyses also showed improvements in arthritis self-efficacy and perceived control. Hand deformity scores continued to increase in both groups.
CONCLUSION:
We found significant improvements in adherence, pain, disease status and functional ability amongst those attending the joint protection programme. Benefits became more apparent with time, suggesting that joint protection can help slow the progression of the effects of RA over and above the effects of drug therapy.
