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Overview of joint protection

Overview of joint protection
Literature review current through: Jan 2024.
This topic last updated: Dec 01, 2023.

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. Patients are able to identify activities that cause pain and experience an improvement in pain when using joint protection techniques [1]. However, the strength of data may vary based on the underlying condition, area of pain, and type of joint protection intervention.

An overview of systematic reviews found high-quality evidence for beneficial effects of joint protection and patient education for patients with RA, with pain, function, and patient global assessment being the primary outcomes of interest [3]. There is conflicting evidence about the effectiveness of joint protection for hand arthritis in particular. Some studies have shown improvements and pain and function [4,5], while others failed to find a difference in outcomes for patients receiving a joint protection intervention compared with those receiving a self-management intervention [6,7].

There is some evidence to support various types of joint protection interventions, including group education programs [8-10] and web-based rehabilitation interventions [11].

More details on the use of many components involved in joint protection, such as education, exercise, and physical and occupational therapy referrals, for patients with RA and OA can be found elsewhere. (See "Nonpharmacologic therapies for patients with rheumatoid arthritis" and "Overview of the management of osteoarthritis".)

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 [12,13]. (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. 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 [1,14].

Activity pacing – Activity pacing involves goal setting, planning, and gradual increases around activity [15]. The goal of activity pacing is to avoid cycles of overactivity and underactivity, as can happen when activity leads to pain. As an example, providers may ask patients to follow three steps [16]:

Make a list of some of the things that you tend to overdo

Make a time limit for the activity and then stop and rest

Keep track of how you are doing (how many times did you stop yourself from overdoing it?)

Patients may need to track pain levels following activity and modify activity if they experience delayed increases in pain. Increased time in an activity is not helpful if it results in increased pain later. An activity pacing form for patients can be seen on the US Department of Veterans Affairs website [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].

Reduce excess body weight — Even modest amounts of weight loss (5.0 to 7.5 percent of body weight) may improve symptoms and function in patients with osteoarthritis (OA) [18]. 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 OA. Furthermore, joint pain can lead to inactivity and subsequent weight gain, which can further exacerbate pain. 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. We encourage patients to maintain a normal weight for their height and build. Weight loss often results in decreased pain and in increased energy [19]. Management of chronic low back pain, including exercise-based therapy, is discussed elsewhere. (See "Exercise-based therapy for low back pain", section on 'Subacute and chronic low back pain: Exercise is beneficial' and "Subacute and chronic low back pain: Nonpharmacologic and pharmacologic treatment".)

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. 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.

Spine – There is a lack of strong evidence to support a causal relationship between awkward postures and low back pain [20]. Thus, it may be preferable to encourage regular movement and avoid sustained postures (eg, sitting while viewing a computer monitor in neck flexion) rather than recommending a specific posture.

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.

Distribute the load — Patients with a painful joint may benefit from distributing the load over stronger joints and/or larger surface areas when possible. As examples, patients may wash a table with an open hand rather than fingers, wear a purse or satchel over their shoulder if they have pain in their elbow or hands, or use a backpack if the shoulder is painful. This is because large joints are stronger than small ones due to basic body mechanics [1]. Thus, using larger joints to bear a load will reduce strain that can overstretch ligaments and/or create instability. By contrast, small hand joints are more vulnerable to pain or inflammation when used too much or too often. Bearing large loads on small joints can strain and pain even if one's joints are very stable.

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, taking rest breaks, and 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 [21].

Assistive devices — Assistive devices include braces and splints, as well as modifications to devices (eg, foam padding to provide a grip cushion).

For the hand and wrist – 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. Foam pipe insulation is widely available and can be cut and used as grip cushions on tools, handles, brooms, etc.

Studies in patients with rheumatoid arthritis (RA) and OA support the use of assistive devices. A study of women with RA showed that pain was significantly reduced when assistive devices were used for activities of daily living [22]. 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 [23]. Combining assistive equipment with joint protection education and exercise resulted in improved grip strength and global hand function in patients with hand OA [14].

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 [24]. (See "Management of moderate to severe knee osteoarthritis", section on 'Walking aids'.)

Obtaining devices – Patients may search for these devices through online retailers using search terms such as "assistive devices," "adaptive equipment," and "adaptive devices." They can add specificity by adding the purpose of the devices (eg, eating, bathroom safety). Additional devices can be found by searching for "ease of use" products on the Arthritis Foundation website.

Simplify work by using efficiency principles — Planning, organizing, and balancing work with rest are useful principles to employ to reduce stress on joints. A 2016 systematic review found moderate evidence that education on joint protection and energy conservation increased joint protection behaviors [25]. Moderate evidence supports balancing work with rest (activity pacing) as an occupational therapy intervention for hip and knee OA [26]. For problems in the workplace, the patient should seek professional consultation with an onsite occupational health nurse or referral to an occupational therapist.

Planning – Patients who plan ahead can find the best time of day to perform a task, allow sufficient time, and eliminate steps or otherwise simplify the task. Patients tend to have less pain when they avoid rushing, simplify tasks, and spread out difficult tasks (eg, cleaning activities). In addition, patients may recognize during planning that getting help to perform a difficult task can reduce stress and pain during a busy week.

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.

Using a computer workstation — An ergonomically coordinated workstation can minimize joint and body strain. Although, working at a computer workstation looks like a low-strain activity at first glance, 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.

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. Guidelines for correct posture and sit-stand work surfaces are listed on the Occupational Safety and Health Administration (OHSA) 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 [27,28]. Some sit-stand workstations may reduce productivity [27]. More long-term studies are indicated to clarify the benefits of sit-stand workstations.

Individuals need to take rest breaks regularly. Brief 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 that specific strength exercises appeared to have better effects on pain and functional activity in comparison with other types of exercises, but all exercises showed within-group improvement [29]. Improvements in functional status and pain were associated with the use of a workplace integrated care program provided by a physical or occupational therapist with ergonomics training, whereas self-management strategies had little impact on outcomes. Additional evidence in support of ergonomic interventions in the workspace comes from a small randomized 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 [30].

Avoid prolonged immobility — Patients should 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?"

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, cardiovascular fitness, and prevention of coronary heart disease. Furthermore, exercise generally is expected to improve rather than worsen joint pain and function when individualized for a patient with musculoskeletal disorders.

Type of exercise — The type and amount of exercise depend upon the person for whom it is prescribed. Walking, swimming, aquatic exercise, tai chi, and biking are low-impact or non-impact forms of exercise that many people with arthritis can safely perform. 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.

Caution needs to be applied to 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, which is described in detail elsewhere. (See "Total hip arthroplasty", section on 'Follow-up and activity level' and "Total knee arthroplasty", section on 'Follow-up and activity level'.)

Some patients are not interested in a formal exercise program. 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 [31].

More detailed discussions of exercise for patients with OA and RA are presented elsewhere:

(See "Nonpharmacologic therapies for patients with rheumatoid arthritis", section on 'Physical activity'.)

(See "Overview of the management of osteoarthritis", section on 'Nonpharmacologic therapy'.)

(See "Management of hand osteoarthritis", section on 'Exercise'.)

(See "Management of hip osteoarthritis", section on 'Nonpharmacologic measures'.)

(See "Management of knee osteoarthritis", section on 'Initial nonpharmacologic measures'.)

The role of exercise in general health promotion is discussed in more detail separately:

(See "Exercise for adults: Terminology, patient assessment, and medical clearance".)

(See "Exercise prescription and guidance for adults".)

(See "The benefits and risks of aerobic exercise".)

(See "Strength training for health in adults: Terminology, principles, benefits, and risks".)

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 [25], 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 ask orthopedic surgeons and rheumatologists for referral, as these clinicians often have working relationships with therapists with relevant interest and expertise.

Is there a role for personal trainers? — Some personal trainers can provide useful exercise information for healthy individuals who want to exercise in a gymnasium or health club. However, their ability to advise patients with arthritis is likely to be inferior to that of a physical or occupational therapist due to significant differences in training and certification. The training of a personal trainer varies widely, from no training to certificate programs and brief clinical experience. 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 patient gets worse with a personal trainer, the physical therapist recommendations can provide a framework for a personalized exercise regimen.

What constitutes quality joint care education? — 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. 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 [4,8,9]. In addition, therapists can recommend what to look for when purchasing special equipment and stores or websites where patients can place orders.

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, improve psychological status, and self-manage their condition, compared with standard information-focused education [32]. 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 [33].

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.

When should a patient be referred to occupational and/or physical therapy? — Refer a patient who:

Has joint or overuse problems, has repeated exacerbations of pain following activity, and is unable to independently modify their behavior.

Has a joint injury and does not know how to care for their joints.

Has OA of the hand, for evaluation of ability to perform activities of daily living and for instruction in joint protection [34].

Has a newly diagnosed joint disease and who needs help learning to cope with their condition (eg, newly diagnosed RA) [3,35,36]. 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 [37].

Is deconditioned and 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 [38].

Is at higher risk for mobility loss, as there is evidence of higher commitment to improve lifestyle physical activity in this population [39].

More details on the use of physical and occupational therapy for patients with RA can be found elsewhere. (See "Nonpharmacologic therapies for patients with rheumatoid arthritis", section on 'Physical and occupational therapy'.)

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 [40]

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 [41]. The most consistent effect of splinting is reduction of pain [41]. Prefabricated wrist splints are better accepted than hard (plaster or molded thermoplastic) splints by patients [41].

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 [23]. The group assigned to splinting had less pain, improved grip and pinch strength, improved upper limb function, and improved functional status [23]. 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 [42].

Wrist splinting may also be beneficial for patients with carpal tunnel syndrome [43]. 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 has been shown to relieve pain and increase function for patients with CMC joint OA when used for at least three months [44]. 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 [40]. 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 [45]. Thermoplastic splints have been found to be equally effective [46]. In a systematic review, splints improved dexterity for patients with swan neck deformities, but there was no evidence supporting splints for RA boutonniere deformities [12]. 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 [47]. Discomfort and/or swelling are also sometimes reported by patients wearing night splints to manage carpal tunnel syndrome [48]. 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 [49].

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 [50,51]. (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 [50].

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

Joint protection – 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 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 who may benefit from joint protection – 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.)

Principles of joint protection – The principles that are the foundation of patient education in joint protection include:

Respect pain (see 'Respect 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)

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)

Using a computer workstation – An ergonomically coordinated workstation can minimize joint and body strain for patients spending significant time using a computer. (See 'Using a computer workstation' above.)

Role of occupational and physical therapists – 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.)

When to refer for joint protection – 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

Exercise modifications for select patients – 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.)

Use of braces and splints – 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.

  1. Cordery J, Rocchi M. Joint protection and fatigue management. In: Rheumatologic Rehabilitation, Melvin J, Jensen G (Eds), American Occupational Therapy Association, 1998. Vol 1, p.279.
  2. Hammond A. Rehabilitation in musculoskeletal diseases. Best Pract Res Clin Rheumatol 2008; 22:435.
  3. Christie A, Jamtvedt G, Dahm KT, et al. Effectiveness of nonpharmacological and nonsurgical interventions for patients with rheumatoid arthritis: an overview of systematic reviews. Phys Ther 2007; 87:1697.
  4. Hammond A, Freeman K. One-year outcomes of a randomized controlled trial of an educational-behavioural joint protection programme for people with rheumatoid arthritis. Rheumatology (Oxford) 2001; 40:1044.
  5. Nordenskiöld U. Daily activities in women with rheumatoid arthritis. Aspects of patient education, assistive devices and methods for disability and impairment assessment. Scand J Rehabil Med Suppl 1997; 37:1.
  6. Bobos P, Nazari G, Szekeres M, et al. The effectiveness of joint-protection programs on pain, hand function, and grip strength levels in patients with hand arthritis: A systematic review and meta-analysis. J Hand Ther 2019; 32:194.
  7. Bobos P, MacDermid JC, Nazari G, et al. Joint Protection Programmes for People with Osteoarthritis and Rheumatoid Arthritis of the Hand: An Overview of Systematic Reviews. Physiother Can 2021; 73:56.
  8. Hammond A, Young A, Kidao R. A randomised controlled trial of occupational therapy for people with early rheumatoid arthritis. Ann Rheum Dis 2004; 63:23.
  9. Scholten C, Brodowicz T, Graninger W, et al. Persistent functional and social benefit 5 years after a multidisciplinary arthritis training program. Arch Phys Med Rehabil 1999; 80:1282.
  10. Siegel P, Tencza M, Apodaca B, Poole JL. Effectiveness of Occupational Therapy Interventions for Adults With Rheumatoid Arthritis: A Systematic Review. Am J Occup Ther 2017; 71:7101180050p1.
  11. Srikesavan C, Bryer C, Ali U, Williamson E. Web-based rehabilitation interventions for people with rheumatoid arthritis: A systematic review. J Telemed Telecare 2019; 25:263.
  12. Roll SC, Hardison ME. Effectiveness of Occupational Therapy Interventions for Adults With Musculoskeletal Conditions of the Forearm, Wrist, and Hand: A Systematic Review. Am J Occup Ther 2017; 71:7101180010p1.
  13. Baradaran A, Baradaran A, Ebrahimzadeh MH, et al. Comparison of Custom-made Versus Prefabricated Thumb Splinting for Carpometacarpal Arthrosis: A Systematic Review and Meta-analysis. Arch Bone Jt Surg 2018; 6:478.
  14. Stamm TA, Machold KP, Smolen JS, et al. Joint protection and home hand exercises improve hand function in patients with hand osteoarthritis: a randomized controlled trial. Arthritis Rheum 2002; 47:44.
  15. Antcliff D, Keeley P, Campbell M, et al. Activity pacing: moving beyond taking breaks and slowing down. Qual Life Res 2018; 27:1933.
  16. US Department of Veterans Affairs. Activity pacing. https://www.mentalhealth.va.gov/coe/cesamh/docs/Activity_Pacing-patients.pdf (Accessed on November 30, 2023).
  17. Verbeek J, Mischke C, Robinson R, et al. Occupational exposure to knee loading and the risk of osteoarthritis of the knee: a systematic review and a dose-response meta-analysis. Saf Health Work 2017.
  18. Conley B, Bunzli S, Bullen J, et al. Core Recommendations for Osteoarthritis Care: A Systematic Review of Clinical Practice Guidelines. Arthritis Care Res (Hoboken) 2023; 75:1897.
  19. Chen LH, Weber K, Mehrabkhani S, et al. The effectiveness of weight loss programs for low back pain: a systematic review. BMC Musculoskelet Disord 2022; 23:488.
  20. Kwon BK, Roffey DM, Bishop PB, et al. Systematic review: occupational physical activity and low back pain. Occup Med (Lond) 2011; 61:541.
  21. Hasegawa M, Chin T, Oki S, et al. Effects of methods of descending stairs forwards versus backwards on knee joint force in patients with osteoarthritis of the knee: a clinical controlled study. Sports Med Arthrosc Rehabil Ther Technol 2010; 2:14.
  22. Nordenskiöld U. Evaluation of assistive devices after a course in joint protection. Int J Technol Assess Health Care 1994; 10:293.
  23. Silva AC, Jones A, Silva PG, Natour J. Effectiveness of a night-time hand positioning splint in rheumatoid arthritis: a randomized controlled trial. J Rehabil Med 2008; 40:749.
  24. Jones A, Silva PG, Silva AC, et al. Impact of cane use on pain, function, general health and energy expenditure during gait in patients with knee osteoarthritis: a randomised controlled trial. Ann Rheum Dis 2012; 71:172.
  25. Carandang K, Pyatak EA, Vigen CL. Systematic Review of Educational Interventions for Rheumatoid Arthritis. Am J Occup Ther 2016; 70:7006290020p1.
  26. Dorsey J, Bradshaw M. Effectiveness of Occupational Therapy Interventions for Lower-Extremity Musculoskeletal Disorders: A Systematic Review. Am J Occup Ther 2017; 71:7101180030p1.
  27. Chambers AJ, Robertson MM, Baker NA. The effect of sit-stand desks on office worker behavioral and health outcomes: A scoping review. Appl Ergon 2019; 78:37.
  28. De Carvalho D, Greene R, Swab M, Godwin M. Does objectively measured prolonged standing for desk work result in lower ratings of perceived low back pain than sitting? A systematic review and meta-analysis. Work 2020; 67:431.
  29. Skamagki G, King A, Duncan M, Wåhlin C. A systematic review on workplace interventions to manage chronic musculoskeletal conditions. Physiother Res Int 2018; 23:e1738.
  30. Lee S, DE Barros FC, DE Castro CSM, DE Oliveira Sato T. Effect of an ergonomic intervention involving workstation adjustments on musculoskeletal pain in office workers-a randomized controlled clinical trial. Ind Health 2021; 59:78.
  31. Semanik P, Wilbur J, Sinacore J, Chang RW. Physical activity behavior in older women with rheumatoid arthritis. Arthritis Rheum 2004; 51:246.
  32. Hammond A, Bryan J, Hardy A. Effects of a modular behavioural arthritis education programme: a pragmatic parallel-group randomized controlled trial. Rheumatology (Oxford) 2008; 47:1712.
  33. Shao JH, Yu KH, Chen SH. Effectiveness of a self-management program for joint protection and physical activity in patients with rheumatoid arthritis: A randomized controlled trial. Int J Nurs Stud 2021; 116:103752.
  34. Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken) 2012; 64:465.
  35. Mathieux R, Marotte H, Battistini L, et al. Early occupational therapy programme increases hand grip strength at 3 months: results from a randomised, blind, controlled study in early rheumatoid arthritis. Ann Rheum Dis 2009; 68:400.
  36. Masiero S, Boniolo A, Wassermann L, et al. Effects of an educational-behavioral joint protection program on people with moderate to severe rheumatoid arthritis: a randomized controlled trial. Clin Rheumatol 2007; 26:2043.
  37. Ekelman BA, Hooker L, Davis A, et al. Occupational therapy interventions for adults with rheumatoid arthritis: an appraisal of the evidence. Occup Ther Health Care 2014; 28:347.
  38. Macedo AM, Oakley SP, Panayi GS, Kirkham BW. Functional and work outcomes improve in patients with rheumatoid arthritis who receive targeted, comprehensive occupational therapy. Arthritis Rheum 2009; 61:1522.
  39. Feinglass J, Song J, Semanik P, et al. Association of functional status with changes in physical activity: insights from a behavioral intervention for participants with arthritis. Arch Phys Med Rehabil 2012; 93:172.
  40. Falconer J. Hand splinting in rheumatoid arthritis. A perspective on current knowledge and directions for research. Arthritis Care Res 1991; 4:81.
  41. Haskett S, Backman C, Porter B, et al. A crossover trial of custom-made and commercially available wrist splints in adults with inflammatory arthritis. Arthritis Rheum 2004; 51:792.
  42. Adams J, Burridge J, Mullee M, et al. The clinical effectiveness of static resting splints in early rheumatoid arthritis: a randomized controlled trial. Rheumatology (Oxford) 2008; 47:1548.
  43. Karjalainen TV, Lusa V, Page MJ, et al. Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev 2023; 2:CD010003.
  44. Kloppenburg M, Kroon FP, Blanco FJ, et al. 2018 update of the EULAR recommendations for the management of hand osteoarthritis. Ann Rheum Dis 2019; 78:16.
  45. Zijlstra TR, Heijnsdijk-Rouwenhorst L, Rasker JJ. Silver ring splints improve dexterity in patients with rheumatoid arthritis. Arthritis Rheum 2004; 51:947.
  46. van der Giesen FJ, van Lankveld WJ, Kremers-Selten C, et al. Effectiveness of two finger splints for swan neck deformity in patients with rheumatoid arthritis: a randomized, crossover trial. Arthritis Rheum 2009; 61:1025.
  47. Egan M, Brosseau L, Farmer M, et al. Splints/orthoses in the treatment of rheumatoid arthritis. Cochrane Database Syst Rev 2003; :CD004018.
  48. Page MJ, Massy-Westropp N, O'Connor D, Pitt V. Splinting for carpal tunnel syndrome. Cochrane Database Syst Rev 2012; :CD010003.
  49. Brouwer RW, Jakma TS, Verhagen AP, et al. Braces and orthoses for treating osteoarthritis of the knee. Cochrane Database Syst Rev 2005; :CD004020.
  50. Stern EB, Callinan N, Hank M, et al. Neoprene splinting: dermatological issues. Am J Occup Ther 1998; 52:573.
  51. Sakata S, Cahill J, Nixon R. Allergic contact dermatitis to thiourea in a neoprene knee brace. Australas J Dermatol 2006; 47:67.
Topic 7754 Version 25.0

References

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