Joint protection program for the upper limb

INTRODUCTION — Joint protection should be introduced to every patient with a chronic rheumatologic disorder in order to prevent recurrent sprains and strains which can add to inflammation and degeneration [1]. Conservative care includes preventive care, and joint protection is a fundamental way to provide preventive joint care.

Joint protection for the upper limb is reviewed here. An overview of joint protection and the application of the principles of joint protection to the neck and lower limb are presented separately. (See "Overview of joint protection" and "Joint protection program for the neck" and "Joint protection program for the lower limb".)

PRINCIPLES OF JOINT PROTECTION — These principles are derived from the simple, practical application of proper body mechanics, posture, and positioning of joints. Joint protection reduces local joint stress and preserves joint integrity. Joint protection is achieved through patient education, self-management, and problem-solving to promote behavior modification; energy conservation; exercise; and selective use of splints, adaptive devices, and modalities. Guiding patients to perform tasks in a manner that reduces stress on joints is generally preferred to prohibiting the task. (See "Overview of joint protection".)

Principles of joint protection include:

●Respect pain.

●Balance rest and activity.

●Participate in exercise or activity to maintain strength and range of motion.

●Use the minimum amount of force necessary to complete the job.

●Simplify work.

●Use good posture and body mechanics and avoid positions which induce deformity.

●Distribute the load over stronger joints and/or larger surface areas.

●Avoid maintaining the same joint position for prolonged periods.

IDENTIFYING AGGRAVATING FACTORS — Aggravating factors may be present when pain persists beyond the expected duration for a given problem, such as bursitis or tendinitis. Such factors include habits and activities that can initiate and/or perpetuate soft tissue or joint pain and disability. The patient's routine at work, at home, and in sports should be explored as the starting point for the identification of such factors so that the patient can appropriately modify their activities as a preventive strategy. Knowledge of specific risk factors for specific sports or activities can direct prevention recommendations. For swimming, risk factors with a moderate level of certainty for shoulder pain and injury include clinical joint laxity, instability, internal/external rotation, previous history of pain and injury, and higher competitive level [2]. The patient's occupation can predispose to musculoskeletal issues. As an example, in a meta-analysis of dentists in India, 68.3 percent reported musculoskeletal problems [3]. A systematic review of work-related musculoskeletal disorders found that females in medicine who perform surgery and procedures experience a higher incidence of upper extremity pain compared with males; contributing factors may include the design and size of procedural tools [4]. Findings from another systematic review and meta-analysis of working nurses suggest that psychosocial factors are associated with a higher prevalence of workplace-related upper limb musculoskeletal disorders [5].

The patient should be asked questions regarding several issues regardless of the area affected, while other questions depend upon the affected region.

General questions — Questions that should be addressed to most patients with persistent symptoms that may help identify aggravating factors include:

●Have you engaged in a new hobby, sport, or exercise?

●Have you increased the frequency/intensity of any current activities?

●Have you done any prolonged repetitive activity?

●Has your job changed?

●Have you done activities in an awkward position or for an extended length of time?

●Are you under increased stress?

Questions regarding specific regions — Some questions should be addressed to patients depending upon which region is affected, including:

●Shoulder region

•Have you pulled, reached for, or carried a heavier object than usual?

•Have you had recent leg problems forcing you to use your arms more?

•Do you perform overhead activity frequently, or sleep with arms raised above your head?

•Do you do pushups?

●Elbow region

•Have you driven a long way with elbow on armrest of car door?

•Have you been pushing up from bed with your elbow?

•Have you been doing computer or desk work?

●Hand and wrist

•Are you clenching your fist unnecessarily firmly?

GUIDELINES FOR UPPER LIMB PROTECTION — We advise patients to follow a series of both general guidelines for joint protection as well as region-specific guidelines that are applicable for the use of specific joints to protect the upper limb from injury.

General — The following strategies apply to a broad range of activities:

●Take regular rest breaks and avoid sustained positions; as an example, take a "mini-break" and make a change of positions every 20 to 40 minutes to interrupt repetitive activities, such as window washing, vacuuming, cooking, peeling, typing, knitting, writing, computer work, or working on an assembly line. There is low-quality evidence that rest breaks have an effect on upper limb discomfort [6].

●Use proper posture/body mechanics and preventive strategies for physical activity. Examples include:

•Learn the proper technique/form and specific conditioning exercises for sports such as swimming, tennis, and golf to reduce injuries. Identification of specific signs of imbalance and impaired technique by clinicians and coaches can promote injury remediation, especially in competitive athletes [7].

•Use appropriate protective gear.

•Use proper grip size for racquet sports or golf. Golfers with arthritis should try using cushion grips and the baseball grip style (no interlocking fingers), should relax the grip until just before ball impact, and can consult a professional instructor for ways to address grip problems.

●Seek alternatives to interventions, such as electromyography (EMG) biofeedback, job stress management, and office workstation adjustment alone, as there is a moderate level of evidence they have no effect on work-related musculoskeletal disorders (MSDs) [8].

There is inconsistent evidence that workspace adjustments such as an alternative computer mouse or arm support will reduce neck or shoulder musculoskeletal disorders [6,8,9]. Further high-quality studies are needed to determine the effectiveness of these interventions.

Shoulder — The use of proper posture and body mechanics is important for the protection of the shoulder. The following strategies may be beneficial:

●Keep the elbow close to the body and change the angle of shoulder motion when possible.

●Sleep with the arms below the level of the chest.

●Avoid twisting and awkward positions such as reaching for objects in the back seat of a car from the front seat.

●Adjust crutches properly, if they are being used, to about 5 cm below the axillae, and carry weight on the ribs and hands, not under the arms. A forearm cane may be preferred.

●Use the contralateral arm and hand across the front of the body to reach a car seat belt.

●A swivel or wheeled chair may be useful when tasks done from a seated position are in various nearby locations.

●Keep the hands below the "3 o'clock" and "9 o'clock" positions on the steering wheel when driving. If possible, use a steering wheel that tilts.

Modification in work techniques has been shown to be beneficial in reducing shoulder disorders. In a study examining three different work techniques by 40 experienced painters, doing overhead work using a pushing technique using shorter strokes and lower speed resulted in fewer shoulder disorders than other approaches [10].

Attention to a number of factors associated with increased work-related risk for shoulder disorders can be helpful in identifying problematic activities that may need to be modified in patients with symptoms of shoulder disorders. Shoulder impingement syndrome was associated with highly repetitive work, forceful exertion in work, awkward postures, and high psychosocial job demand [11]. Flexion/abduction of greater than 60 degrees is associated with increased risk, and repeated or sustained shoulder flexion and abduction is associated with rapid onset of muscle fatigue [12]. The following factors were associated with increased risk of shoulder impingement syndrome [11]:

●Greater than 10 percent maximal voluntary contraction (MVC)

●Lifting >20 kg >10 times/day

●High level of hand force >one hour per day

●Highly repetitive shoulder, hand/wrist (greater than two hours per day)

●Hand-arm vibration

●Awkward postures such as working with hand above shoulder level or at 45 degrees of shoulder flexion over 15 percent of the day

●High job demands

There is some evidence that the same factors, including repetitive and overhead work, may apply to nonspecific shoulder disorders [11]. A systematic review found moderate evidence that shoulder elevation and shoulder load increased the incidence of specific shoulder disorders and low- to very low-quality evidence for association between hand force exertion, hand-arm vibration, psychosocial job demands, repetitive arm movements, social support, job control and security, and incidence of specific shoulder disorders [13]. Moderate evidence was found that arm-hand elevation and shoulder load double the risk of specific shoulder disorders [13]. Based on additional calculations, the "best estimate" of the doubling dose is 3636 hours of work with hands on or above the shoulder level [14].

Elbow and forearm — Protection of the elbow and forearm is focused upon reducing repetitive motion, load, and force on the elbow. Advice for patients to enhance protection of the elbow and forearm includes the following:

●Use minimum force.

●Avoid pressure and impact on the elbow.

•Do not push against a hard surface when sitting, driving, or changing positions.

•Use elbow pads for protection if there is a risk of repeated trauma or persistent pressure over this area.

•Use the abdominal muscles to help roll over when getting out of bed.

There is conflicting evidence regarding the benefits of splinting for epicondylitis [15]. While studies have found splints can be beneficial, there are also adverse effects in splinting for epicondylitis including higher rates of limited duty, more medical visits, higher cost, and longer treatment durations [15,16]. However, a systematic review identified evidence that a simple elbow band worn under the lateral epicondyle was as effective as the more elaborately designed Thamert splints [15]. Therapeutic taping has also been found to be beneficial [17].

Exercise improves pain, range of motion, and strength for patients with lateral epicondylitis, but there is no consensus regarding the best type of exercise [15]. One study found that a combination of strengthening and stretching resulted in a statistically significant increase in grip strength and that progressive strengthening and stretching reduced pain. Significant differences have not been shown between eccentric strengthening, stretching, and a concentric strengthening program. Another systematic review found that manual therapy and eccentric strength training as physical therapy treatments may have the greatest benefits [17].

The majority of literature on elbow protection is focused on medial and lateral epicondylitis. (See "Elbow tendinopathy (tennis and golf elbow)".)

A systematic review exploring work-related factors associated with specific disorders of the elbow identified the following risk factors for epicondylitis [18]:

●Lateral epicondylitis

•Handling tools >1 kg

•Handling loads >20 kg at least 10 times per day

•Repetitive movements >two hours per day

•Low job control and low social support

●Medial epicondylitis

•Handling tools >5 kg two times per minute for two or more hours per day

•Handling loads >20 kg at least 10 times per day

•High hand grip forces >one hour per day

•Repetitive movements >two hours per day

•Working with vibrating tools >two hours per day

However, findings from a subsequent systematic review suggest that the evidence for a causal relationship between lateral elbow tendinopathy and exposure to biomechanical risk factors is still limited, and for medial elbow tendinopathy, the evidence of this relationship is insufficient [19].

Hand and wrist — Strategies for protection of the hand and wrist include the following guidelines, which are supported in part by experimental data, expert opinion, and clinical experience (see 'Hand and wrist interventions' below):

●Use the stronger larger joints.

•Use the palms and forearms to carry heavy objects.

•Grasp objects with the hand and all fingers.

•Use both hands as much as possible when lifting heavy objects.

●Use good posture/body mechanics and avoid positions that promote deformity.

•Rest the hands flat and open rather than with a tight fist.

•Be aware of hand clenching, and wear stretch gloves while driving or to bed when nocturnal hand clenching is recognized.

•Keep the hand and wrist extended for work activities.

•Adapt tools with handles designed so that the wrist is maintained in a neutral position.

•Use a wrist rest while working on a keyboard.

•Avoid uncomfortable hand positions.

●Use minimum force.

•Use a relaxed grip on tools.

•Enlarge the handles of work tools, utensils, and steering wheel. Handle diameter of about 1.5 to 2 inches (about 4 to 5 cm) is optimal for most people with arthritis.

•Add texture to handle surfaces to provide a surface that is easier to hold with less grip strength.

•Squeezing actions should be avoided, especially for patients with systemic inflammatory arthritis, as they tend to further injure soft tissue and may increase ulnar deviation.

•Use adaptive devices such a jar opener, car door opener, and key holder when these may be beneficial.

•Power tools (eg, screwdriver, drill) are often preferable and easier to use than manual tools.

•Push, slide, or roll objects instead of lifting them.

•Fit the handles of vibrating tools with shock absorbers or rubber, or wear gloves with gel inserts. Avoid strong vibrations (greater than 12 meters per second squared) and vibrations lasting longer than one hour. Work activities that require maximum full-force grip and vibrating tools increase the risk of carpal tunnel syndrome [20]. The injury risk increases when the work tasks are accompanied by repetitive movements.

●Simplify activities.

•Plan and organize tasks and workspaces to save time and energy (eg, eliminate steps, remove clutter, take rest breaks, storage between eye and hip level).

•Patients with inflammatory arthritis generally benefit from evaluation by and instructions from a physical and/or occupational therapist.

●Respect pain

•Wear an appropriate splint during activities that increase symptoms and/or at night if joints are painful (picture 1). Do not wear splints all day unless specifically advised to do so.

•Consult an occupational therapist about work-induced problems, splinting, and modifying or adapting tools and equipment.

EFFICACY OF JOINT PROTECTION AND EXERCISE

Upper limb exercise — Upper limb exercising by patients with joint and periarticular disease should be guided by a physical or occupational therapist. The evidence of benefit from such exercises for joint protection is mixed, possibly due to variations in study design and specific exercise prescriptions that make comparisons of different approaches difficult to interpret. However, some analyses suggest that exercise programs lead to reductions in pain and improvement in function [21].

The following examples illustrate the range of evidence:

●A moderate-quality randomized trial including people with rheumatoid arthritis (RA) found a home exercise program of strengthening exercises led to better function at six-month follow-up than a home exercise program focused on stretching or no home exercise program [22].

●A systematic review that examined different types of exercise found strong evidence for home exercise programs, dynamic exercise (defined as exercise in which recurrent and substantial body movements predominate), aerobic exercise, aquatic exercise, and resistive exercise. Benefits include improved strength, mobility, function, pain, depression, muscle strength, aerobic capacity, and fatigue. Weak evidence was found for use of yoga among people with RA and, while tai chi showed little clinical changes in disease activity (eg, swollen joints, function), participants enjoyed it and had higher participation [23].

●Some systematic reviews of randomized trials examining the benefits of exercise programs for osteoarthritis (OA) or RA of the hand have found limited evidence that such programs reduce pain [24,25].

●A randomized trial of 490 patients with RA found that an individualized hand and upper limb exercise program of strengthening and stretching exercises resulted in improved hand function at 4 and 12 months over usual care, but with no significant difference in pain. Usual care consisted of joint protection, functional splinting if indicated, and general exercise advice. The intervention involved six sessions with an occupational or physical therapist, daily home exercises, and strategies to maximize adherence [26].

●A systematic review of cohort studies and randomized trials of exercise for hand OA found moderate evidence supporting hand exercises for increased grip strength, range of motion (ROM), hand function, and reduction in pain [27]. According to the Ottawa Panel of experts, there are many programs involving exercises with positive outcomes. Yet, there is a need for research to isolate specific effects of exercise components [28].

●Systematic reviews of aerobic exercise for patients with RA, including both upper and lower limb studies, have found evidence that upper limb exercises improved muscle strength, functional ability, pain relief, and improved aerobic capacity. Importantly, none of the studies found evidence of increased joint destruction associated with exercise programs [29,30].

●A systematic review of conservative interventions for treating work-related complaints of the upper extremity found very low-quality evidence for exercise [31]. Pain, recovery, disability, and sick leave were similar in the group receiving exercise compared with those receiving counseling, massage, or no treatment. General exercises were more effective than specific ones in the short term. Patients with inflammatory conditions were excluded from the analysis, and the prevalence of osteoarthritis was not described.

●A systematic review of workplace-based interventions for musculoskeletal disorders (MSDs) found strong evidence that resistance training can prevent and manage upper-extremity MSD symptoms and moderate evidence for the benefits of stretching programs [8]. A systematic review of interventions among workers with physically demanding employment recommends strength training at the workplace to reduce MSD and insufficient evidence to recommend workplace ergonomics [32].

Hand and wrist interventions

Tool design for minimum force — Engineering analyses informing tool design provide information that has been used to help create tools that reduce digit force on the normal hand [33]. Additional studies are required for optimal application of these findings to patients with arthritis. As an example of such studies, total finger force decreases as tool diameter increases. However, in one analysis of optimal handle size for grip force tasks, mid-size handles of 30 mm (1.18 inches), 35 mm, and 40mm (1.57 inches) were described as more comfortable than handles of a large diameter 50mm (1.97 inches), and the most comfortable handle diameter was found to be 19.7 percent of the user's hand length [34]. In another study, the use of a validated biomechanical model suggested that the ideal handle diameter for the exertion of minimal force by the general population was 33 mm (1.3 inches) [35]. Other studies have indicated that a cylindrical handle that is parallel rather than perpendicular to the push/pull direction decreases needed force [33]; and that handle design that reduces wrist ulnar deviation requires the least amount of grip force [36].

Hand splinting — The potential benefits of hand splinting have been evaluated both in patients with OA and inflammatory arthritis, particularly RA.

●Osteoarthritis – Carpometacarpal (CMC) joint splinting for OA (picture 1) has been shown in systematic reviews, meta-analyses, and well-designed clinical trials to decrease pain and in some trials to improve function, although evidence of functional benefit has been inconsistent [24,27,37-41]. Additional studies are required to determine the best design, wearing schedule, and materials, particularly for particular activities [37,40].

•In a randomized trial involving 112 patients, night-only splinting of the CMC joint for at least 12 months resulted in significant improvements in pain, hand function, and perceived disability, although at only one month, there was no significant improvement in pain and hand function. Patients tolerated wearing the splints well, with 93 percent of patients having worn their splints five to seven nights per week at one month, and 86 percent at 12 months [24,38].

•A randomized trial involving 40 patients over a six month period found that a functional splint for the dominant thumb CMC worn during activities of daily living significantly reduced pain in the short and long term, but no improvements in function or strength were seen [39].

•A randomized crossover trial to evaluate CMC splint design compared functional outcome and patient preference between a custom and a prefabricated splint. Patients were told to wear the splints when symptomatic and if desired at night. Both splints had equivalent effects on hand function and on grip and pinch strength. While the custom splint had a greater effect on reducing pain, more patients preferred the softer, prefabricated splint [41].

More limited study has suggested that splinting of the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints may be of benefit for pain reduction, although positioning was not functional [33,37].

●Rheumatoid arthritis — There is uncertainty regarding the effectiveness of resting and working splints for patients with RA, with some evidence of reduced pain and improved grip strength, but findings also suggesting that splinting leads to reduced dexterity and hand movement [21,25,33].

Three-point splints are used to manage flexible swan neck deformities. Silver Ring Splints and prefabricated splints have been shown to comparably improve dexterity and were equally preferred by patients [25,33]. The splints are not recommended for nighttime use or in presence of PIP swelling. There is limited evidence for the effectiveness of three-point splints to reduce flexion contractures in flexible boutonniere deformities [25].

Joint protection education — Education in joint protection strategies contributes to improvements in hand and wrist function and pain relief, particularly when employed as part of a multidimensional program incorporating other strategies, such as appropriate splinting and exercise. However, a meta-analysis found low-quality evidence suggesting that the effects of joint protection programs compared with usual care in patients with RA and hand OA are too small to be clinically important [42]. This is in conflict with other systematic reviews.

Osteoarthritis — The use of joint protection strategies for hand OA, including the provision of adaptive devices, is supported by a 2010 systematic review of studies examining conservative approaches to treatment and by a number of other studies [24,27,43-48]. As examples:

●Several systematic reviews have found that the combination of joint protection education and hand exercises performed at home was more effective than education alone in improving hand function and increasing grip strength in patients with OA of the hand [24,27].

●A trial for treatment of basal thumb joint OA comparing a joint protection group education program with the group education plus splinting and exercise found that patients who also received the splinting and exercise demonstrated greater improvements in pain, stiffness, grip strength, and independence in activities of daily living (ADL) at 12-month follow-up [43].

●Joint protection advice also appears to be valuable for patients considering hand surgery for OA of the CMC joint of the thumb. As an example, in a prospective study, 33 patients scheduled for first CMC surgery were given joint protection advice and were randomly assigned to receive one of two types of splints. After seven months of observation, the majority of patients had improved enough that surgery was no longer needed. In follow-up at seven years, only two of the remaining 19 patients wanted surgery [44]. In our experience, even some patients who have been too disabled to continue working are able to return to work in the same job following evaluation and treatment by an occupational therapist.

Rheumatoid arthritis — Randomized trials support the view that energy conservation and joint protection can reduce pain and inflammation for those with RA [45,46].

Joint protection education is more effective when taught using a self-management approach with active patient involvement. In a randomized trial involving 54 patients with RA, individualized joint protection education (including joint protection skills plus a self-management approach using individualized goals setting and resources) led to greater improvement in arthritis self-efficacy and less hand pain at three months compared with traditional joint protection education (including written information, demonstration supervised practice, and visual aids) [47]. At the 12-month follow-up, the individualized joint protection group had significantly higher self-efficacy and greater grip strength [48].

Ergonomic interventions — Workstation adjustment combined with ergonomic training may reduce upper extremity musculoskeletal symptoms and improve function, but workstation adjustments alone do not appear to provide substantial benefit [9]. Experts generally favor multifactorial approaches [49]. As an example, a small study

of actively working keyboard operators with at least a three-month history of nonspecific work-related upper limb disorders showed improvements in pain and work-related typing abilities nearly comparable to a pain-free control group after a combined rehabilitation program [50]. This program included stretching and strengthening of the affected muscles taught by an occupational therapist, self-exercises, rest breaks, and employee-provided ergonomic workstation improvement. The use of very specific inclusion criteria and of exercise focused on affected muscles appeared to be important elements of the program.

RESOURCES

●For patients:

medlineplus.gov/arthritis.html

Offers educational materials compiled by the National Library of Medicine from trusted sites including videos and easy-to-read materials on arthritis and disease management, exercise, and other general information

www.arthritis.org

Presents information on a wide variety of topics including tips on healthy living and pain management for people with arthritis

www.rsi.deas.harvard.edu

A website for repetitive strain injuries; maintained by Harvard students, very helpful (with illustrations)

●For clinicians:

Armstrong AD, Hubbard MC, (Eds). Essentials of Musculoskeletal Care, 5th, American Academy of Orthopaedic Surgeons, Rosemont 2015

Anderson BC. Office Orthopedics for Primary Care: Diagnosis and Treatment, 3rd, WB Saunders, Philadelphia 2006

NIOSH: National Institute for Occupational Safety and Health

Musculoskeletal Program Portfolio

Website: www.cdc.gov/niosh/topics/ergonomics/

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 5^th to 6^th 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 10^th to 12^th 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.)

●Beyond the Basics topics (see "Patient education: Arthritis and exercise (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Patients with a chronic musculoskeletal disorder (MSD) should be educated in approaches to joint protection to help prevent injuries that can add to inflammation and degeneration. The principles of joint protection derive from the practical application of proper body mechanics, posture, and positioning of joints to reduce local joint stress and, thus, to preserve joint integrity. These principles include (see 'Introduction' above and 'Principles of joint protection' above):

•Respect pain.

•Balance rest and activity.

•Participate in exercise or activity to maintain strength and range of motion.

•Use the minimum amount of force necessary to complete the job.

•Simplify work.

•Use good posture and body mechanics and avoid positions which induce deformity.

•Distribute the load over stronger joints and/or larger surface areas.

•Avoid maintaining the same joint position for prolonged periods.

●In patients in whom pain persists beyond the expected duration for a given problem, such as bursitis or tendinitis, the clinician should elicit information regarding habits and activities that can initiate and/or perpetuate soft tissue rheumatic pain and disability. Such aggravating factors, typically at work, at home, or in sports, may include new activities, increased intensity of use of the affected area, and psychological or social factors affecting use. (See 'Identifying aggravating factors' above.)

●Guidelines for joint protection differ depending upon the involved joint; common features include avoidance of repetitive use, optimization of mechanics of use, modification of tools and activities to minimize strain, and instruction in individualized therapy directed at strengthening and in strategies for adapting to specific tasks. (See 'Guidelines for upper limb protection' above and 'Shoulder' above and 'Elbow and forearm' above and 'Hand and wrist' above.)

●Patients with systemic inflammatory disorders involving the upper extremity should be evaluated by an occupational or physical therapist for instruction in exercise, use of modalities, and strategies for energy conservation and joint protection, which can reduce pain and inflammation. (See 'Efficacy of joint protection and exercise' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Robert Sheon, MD, who contributed to an earlier version of this topic review.