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November 2003

By Shelli Lucas Dellinger, OTR, CHT, MT

Recent statistics on arthritis are staggering. Arthritis affects one in six people in the United States, and by the year 2020, it is estimated that almost 20% of the population will suffer from some form of arthritis.^1,2 This is a 57% increase in prevalence of arthritis over the next 10 to 15 years.

Nationally, women make up 62% of the population affected by arthritis., while 285,000 children have some form of arthritis as well.^1,2 More than 50% of the population affected with arthritis is under the age of 65. The Arthritis Foundation and the AARP, formerly known as the American Association of Retired Persons, estimate that one out of every two adults over the age of 65 is affected by arthritis.^1-3

As a hand therapist, I can attest to the increasing number of patients I treat for arthritis at my clinic each day. All of these statistics mean that professionals specializing in the treatment of the upper extremity have an important role to play in treating and preventing this condition. Each patient needs an individualized treatment program that includes gentle exercises and graded activity programs.

Arthritis 101

Arthritis, meaning inflammation of the joint, typically affects areas around the joints but may affect other parts of the body such as the internal organs or the skin.^1,2,4 With many types of arthritis, the joints of the hand, wrist, and arm are often the first to exhibit symptoms.^3-5 The resulting dehabilitation can have an impact on everyday activities including self-care, work, and interpersonal relationships. Hands allow a person to reach out and explore the world they live in. If a person has pain or deformity in their hands or arms, they can have problems caring for themselves and their family, dramatically altering their lifestyle.

Inflammation, characterized by swelling, redness, and warmth, is the hallmark of the healing process in response to some type of tissue injury.^1-6 In wound healing, the inflammatory response occurs so the body can remove foreign material from the injured area. Then, the repair process begins in which fibroblasts migrate to the area. With most forms of arthritis, the body’s immune system turns on itself, attacking healthy tissues.^3-5,7

There are many different types of arthritis. Rheumatoid arthritis (RA) is the most common form of inflammatory arthritis, affecting about 1% of the population.^1-3 It is a devastating connective tissue disease. Primarily affecting the synovium of the joints, RA is progressive. Within 5 years of diagnosis, more than 50% of individuals with RA will be unable to work and will need to collect disability; the estimated annual cost of this disease is more than $1 billion.³ One researcher has estimated a loss of 18 years of life in patients who develop RA before the age of 50.³

Medical science thus far has not been able to significantly improve the long-term outcome of RA. The most common symptoms of RA are pain, stiffness (especially in the morning), and fatigue.^1-4 These symptoms are most commonly “managed” with nonsteroidal anti-inflammatory drugs or toxic medications that can cause severe side effects. Often, the patient has more complications from the medications than from the disease itself.

Alternative RA Treatment

Presently, medical science has no cure for rheumatoid arthritis. In turn, the goals of treatment aim at decreasing the inflammation and preventing joint deformity from occurring. Over the last 20 years, a more aggressive, albeit nonconventional, approach to treating RA has been developed. Thomas McPherson Brown, MD, a world-renowned rheumatologist, began treating RA and other rheumatic diseases in a very different manner. Brown believes that inflammatory rheumatic diseases are caused by chronic mycoplasma (bacterial) infections.^3,7 He has used low-dose antibiotic therapy to treat more than 10,000 patients with these diseases.

Another medical pioneer, Joseph Mercola, DO, has integrated a nutritional model into an arthritis treatment program.³ Mercola believes that dietary changes reduce the risk of exacerbation of symptoms once the antibiotic therapy is initiated. He believes that sugar is highly detrimental to the healing process.^3,7

Alternative arthritis treatments are also explored by rehabilitation specialists. In addition to using resistance with weights or rubber tubing for range of motion and strengthening, I have incorporated tai chi into all of my treatment programs.⁴ I find that instruction in joint protection and ergonomics is invaluable in aiding patients with arthritis.

What the Hand Therapist Can Do

Arthritis is not easy to live with. To have a productive and fulfilling life, it is important for people with arthritis to learn to manage all facets of their life in alternate ways. To successfully rehabilitate an arthritis patient, a certain amount of teamwork is involved.^4,5,8 Common arthritis treatment includes a physician recommending medications and a therapist offering exercises, joint protection techniques, and adaptive devices to modify the environment.^4,5,8

Additionally, the hand therapist can offer splints for the hands, wrists, and arms that will protect and support the joints.^4,5,8 Hand and wrist splinting by a qualified and trained hand therapist provides the joints with support and immobilization for the rest that the tissue needs. If a patient requires surgery, a hand therapist works closely with the hand surgeon both in the preoperative planning phase (including a preoperative evaluation and education about the surgery and postoperative therapy) as well as in the postoperative management.^4,5 The hand surgeon/hand therapist/patient team approach allows for the greatest chance for a successful treatment outcome.

An integral part of hand therapy arthritis treatment involves educating the patient about their condition and teaching valuable prevention techniques.^1,2,4-6 It is important to manage the pain and prevent joint deformity. The person with arthritis must learn to manage the time spent on activities and what type of activities are performed to prevent further injury to their joints. They must listen to their body for signs of pain and fatigue. Symptom-management skills use problem-solving methods to identify difficulties with daily activities. The therapist can offer suggestions and modifications to the patient’s environment in order to minimize the stress on their body and their mind. They can also educate the patient about the importance of protecting the joints and pacing their daily schedule to reduce stress and fatigue on the joints. One of the most important aspects of learning to use and apply joint protection is self-responsibility and a specialized treatment program that has been designed to manage daily tasks and activities in addition to preventing further arthritis damage.

Hand therapists often incorporate body ergonomics, the application of scientific information about humans to the design of objects and systems, in their patient treatment programs.^4,8 The principle of ergonomic joint protection is to take scientific information about the body and to apply it to the activities that the body performs. Joint protection should begin early in life to prevent premature failure of the joints. We work with arthritis sufferers regularly, and it is important for them to remember the small tasks and easy techniques that they can incorporate into their lives in order to alleviate arthritis pain and inflammation:

Respect pain. Avoiding or modifying activities that cause pain is important. Educate patients about the difference between discomfort and pain. This will prevent overuse and overstress of inflamed joints. The affected area of the body must be rested, which may call for a splint.
Balance activity with rest. Taking frequent breaks or changing activity will prevent inflammation of the joints. Alternating sitting or standing for long periods of time will refresh the joints. Resting before fatigue sets in will prevent joints from swelling.
Reduce the effort. Examining, analyzing, and simplifying a patient’s job tasks will make workplace activities easier on the body. An arthritis sufferer should learn to analyze each daily activity for joint safety. Organizing the work area and keeping tools and equipment at a convenient level will prevent repetitive movements. For example, many people with arthritis use a lazy Susan to keep desktops clear and tools in easy reach.
Use the stronger, larger joints. Teaching patients about body mechanics and how not to put pressure on weak joints is also important. Using both hands to carry objects weighing more than seven to 10 pounds is a common behavior adjustment. For example, patients should not carry five grocery bags on one arm—it is a sure way to develop tendonitis. Another common way to adjust joint pressure during daily activities is to push open a door using body weight rather than the fingertips.
Maintain joint alignment. Using each joint to its best mechanical advantage is important. There is more power grip with wrist extension than flexion. Patients can use an array of specifically designed adaptive equipment designed for ergonomic tasks. When sitting, arthritis sufferers can use a chair that provides good thoracic and sacral spine support.
Change positions frequently. Muscles held in one position for any length of time tire easily. Remind patients of the importance of changing positions and/or stretching every 15 to 20 minutes. When writing or typing for periods of more than 30 minutes, they should stop, stand, stretch, and sometimes even walk around. A simple suggestion that many therapists recommend is to set an egg timer for 30- or 60-minute periods. When it rings, it reminds a person to stop what they are doing and move on to a new task.
Avoid positions and devices that may cause deformity. Avoiding a tight grasp or tight pinch will add years to the use of the hands. Patients can use tools with built-up handles or pens and pencils with grips or foam rubber. Scissors that have a spring open are now designed with joint health in mind. These types of tools help a patient avoid pressure against the back of the fingers, which prevents overstretching of the finger ligaments. Arthritis sufferers should also avoid sideways pressure on the fingers. For example, when they are using a key in a door lock, the pressure on the fingers exponentially increases.

Conclusion

Educating arthritis patients about good body mechanics is an integral part of a treatment program. Using the body wisely to place less stress on the joints will lengthen the life of the hands and wrists. Overall, patient education about the disease process is key to helping patients understand aspects of joint health and encouraging compliance in their rehabilitation program in order to ensure the most effective treatment and to restore their prearthritis quality of life.

Shelli Lucas Dellinger, OTR, CHT, MT, is a charter member and awareness division director of the American Society of Hand Therapists (ASHT). She owns a private practice, Lucas Health Solutions, in San Diego, and operates www.ergokids.com, a children’s ergonomic Web site. For more information on the ASHT, see its Web site at www.asht.org. Disclaimer: the views dictated in this article reflect those of the author and do not reflect the views of the ASHT.

References

Fox DA. Rheumatoid Arthritis Pamphlet. Arthritis Foundation, 2001.
Gardner G, Matsen FA. Rheumatoid arthritis. Available at: www.orthop.washington.edu. Accessed September 22, 2003.
Mercola JM. Physician’s protocol for using antibiotics in rheumatic disease. Available at: www.mercola.com. Accessed September 22, 2003.
Dellinger SL. Arthritis: evaluation and treatment. Presented at Contemporary Theories in the Therapeutic Management of the Upper Extremity, Catapult Meetings Inc, New Orleans, 1994.
Philips CA. Management of the patient with rheumatoid arthritis. The role of the hand therapist. Hand Clin.1989;5(2):291-309.
Hatch M. Joint Protection Principles Presentation, University of California San Diego Hand Rehabilitation Center, San Diego, 1996.
Brown TM, Clark HW, Bailey JS, et al. Relationship between mycoplasma antibodies and rheumatoid factors. Arthr Rheum. 1970;13:309-310.
Occupational Therapy When You Are Living with Arthritis. American Occupational Therapy Association, Bethesda, Md, 2002.

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