A Scoping Review of Joint Protection Programs for People with Hand Arthritis

REVIEW ARTICLE A Scoping Review of Joint Protection Programs for People with Hand Arthritis Pavlos Bobos, Goris Nazari, Emily A Lalone, Louis Ferreira, Ruby Grewal and Joy C MacDermid Western’s Bone and Joint Institute, Department of Health and Rehabilitation Sciences, Western University, 1151 Richmond Street, London, Ontario, Canada Faculty of Engineering, Department of Mechanical and Materials Engineering, Western University, 1151 Richmond Street, Ontario, Canada Western University, Roth | McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care London, 268 Grosvenor St, London, Ontario, Canada Physical Therapy and Surgery, Western University, St. Joseph’s Health Centre, 268 Grosvenor St, London, Canada


INTRODUCTION
Hand osteoarthritis (h-OA) is one the most common type of osteoarthritis (OA), and it is a leading cause of disability in the elderly population around the world [1].Asymptomatic h-OA is characterized by nodes and deformities in the finger joints.Symptomatic h-OA is usually associated with pain, stiffness and limited functional ability [2].Reports from "The Framingham study" in 2002 showed that the prevalence of symptoms in h-OA was higher than the symptoms in the knee [1].Management of h-OA typically includes pharmacological (medications) and/or nonpharmacological interventions such as joint protection programs, assistive devices, and hand exercises.Currently, there is no cure for h-OA and individuals with symptomatic h-OA need strategies and approaches on how to maintain their active daily living and functioning.
Joint protection programs were primarily developed for people with Rheumatoid Arthritis (RA) and had been reported to be beneficial [3].Joint protection includes self-management strategies to alleviate pain, reduce inflammation and reduce the risk of deformities [4].Also, joint protection has been developed as an approach to improve the performance of daily tasks by enhancing the control perceptions and improve the psychological status of the patient [5].Joint protection is considered a multimodal intervention that aims to alter working methods by using proper body mechanics and by using assistive devices.It is often integrated with stretching and hand exercises [54].Individuals with RA can play an essential role in the management of their disease progression, but this requires their involvement.The American College of Rheumatology in 2012 guidelines [6] suggested the use of joint protection for the management of h-OA however, no definite recommendations have been made so far.The European League Against Rheumatism (EULAR) evidence-based recommendations [3] reported that the joint protection programs is a well-established approach for the management of RA but whether this method can be generalized to h-OA remains unclear.A scoping review of joint protection programs will be a narrative synthesis that aims to map the basic principles of joint protection and identify the primary sources of the current scientific evidence.

PURPOSE OF THE STUDY
The purpose of this scoping review is to gather, synthesize and critically examine the scope of joint protection principles for the management of h-OA and guide future research on joint protection programs for the future management of h-OA.The following questions were generated: What are the main sources of scientific evidence of the current joint protection programs?1.
What are the main outcome measures that are used for joint protection? 2.
What are the current approaches of the joint protection programs?3.
What is available in "Grey Literature" for joint protection programs?4.

METHODS
This study followed the steps of reporting guidelines by Arksey and O' Malley's [7].The steps were as follows: identifying the research question [1], identifying relevant studies [2], study selection [1], charting the data [4] and synthesizing, summarizing and reporting the results [7].

Study Identification
The first author (PB) performed the literature search in 4 databases (PubMed, EMBASE, Google SCHOLAR and CINHAL) from January 1990 to February 2017.A combination of search terms was used such as hand osteoarthritis or/and rheumatoid arthritis, joint protection and/or hand exercises and/or self-management strategies.A Grey literature was also conducted through the Google web search engine.The grey literature was investigated through google manual searches in the first 10 pages of results.Also, relevant articles from the scientific databases and the grey literature were selected from the title and entered into a word database file.

Study Selection
The title and the abstract from all the articles and the grey literature were independently screened by 2 investigators (PB) and (GN) and discrepancies were resolved by discussion with a 3 rd investigator (JM).We included all articles and handbooks (grey literature) that contained information about joint protection programs for people with hand osteoarthritis and/or rheumatoid arthritis.Studies, where the primary language was not in English, were excluded from the review process.Also, studies and grey literature that focused exclusively on assistive devices or orthotic devices or hand exercises were excluded from our review.Articles with the same data presentation were prioritized as the ones that have the most details, and the others were eliminated.A flow diagram of the search results and selection process is shown in Fig. (1).

Data Charting
Data were extracted from the first author (PB) from the included studies.Data information included Author(s) name or source, year of publication, type of research, study population, age, outcome measures, joint protection approaches, and by whom it was provided, and if authors made any recommendations.

Analyzing, Synthesizing and Reporting the Results
Description of the study design, the population that was examined and by whom the joint protection was delivered.The reported summarized findings are presented in a summary (Table 1).To answer our research questions, we categorized each type of study by level of evidence.Current joint protection approaches/principles and outcome measures are listed and reported in separate Tables 2 and 3. Grey literature was reported in a different category (Tables 4 and 6).The Number of sessions dependent on clinical need up to a maximum of three sessions or 1.5 hours in total.Rheumatoid Arthritis, a booklet providing general information about the disease and its management; Looking After Your Joints When You Have Arthritis, describing various self-management techniques and JP advice; and Keep Moving -How a few Simple Exercises can Make You Feel Better About Yourself and Your Arthritis, a booklet providing general exercise information along with suggestions as to specific exercises that could be performed for all parts of the body Joint protection consists of information about hand anatomy, osteoarthritis, and theoretical and practical information about pain and how to cope with it [6].To introduce alternate working methods to reduce difficulties of daily activities the women tried grip assistive devices and elastic thumb splints during the day both at the clinic and at home.joint protection instruction: the need for balance between movement and resting a joint; dividing stress between as many joints as possible; using larger and stronger joints; using each joint in its most stable plane to reduce pressure on the joint; avoiding staying in one position, and avoiding vibrations for the finger joints.
Hammond 2001 principles of joint protection and energy conservation; demonstration of some hand-joint protection methods; and a homework task to identify problem activities and to find solutions using the principles taught.

RESULTS
Our search found 8,788 citations.After duplication 231 articles were deemed relevant from the title and abstract.Review of abstracts identified 111 articles and were assessed for a full-text review.In total, 40 articles were eligible for inclusion in the scoping review (Fig. 1).The most common reason that studies were excluded was that either they did not test joint protection on hand or they talked about patient education in general and not for joint protection.Approximately 72% of the included articles reported Rheumatoid Arthritis (RA) as a patient population and only 20% reported patients with hand Osteoarthritis (h-OA).A small portion of studies (8%) included both populations for joint protection programs.The average age of the included population was ranging from 48.95 to 67.2 years old.In terms of sex, more than 75% of the included sample size were females across the studies.

AVOID TIGHT GRASP
• Use a relaxed grip.
• Enlarge handles.• Place the palm on the jar lid, and using the weight of the body, turn arm at the shoulder to open the jar.A sponge or wet towel under the jar prevents sliding • Hold the knife or mixing spoon like a dagger, with the handle parallel to knuckles.
Cutting is then changed from sawing to pulling • Don't carry heavy handbags, pails, and bags by the handle.
• Hold everything no tighter than necessary.• Release tight grasp frequently if you must use it.
• Use built-up handles on writing utensils, pot handles, tools, etc.
• Use adaptive equipment such as jar openers

AVOID PRESSURE ON BACK OF KNUCKLES (MP JOINTS)
• Avoid all pressures against the backs of fingers: this type of pressure contributes to dislocation of the large joints between the palm and the fingers (metacarpal-phalangeal joints).• This occurs while pushing up from a chair using a closed fist or resting chin on the backs of fingers.• Use palms while holding fingers straight.

USE BOTH HANDS WHEN POSSIBLE
• Not specified how

AVOID REPETITIVE HAND ACTIVITIES
• Take breaks • Change activity, i.e., using screwdriver, crocheting

AVOID PRESSURE TO TIP OR PAD OF THUMB
• The thumb is necessary for 40 percent of hand activities • Example: opening car doors, ringing doorbells • To protect thumb joints, open milk containers with heels of the hands rather than thumbs.

AVOID PRESSURE AGAINST THE RADIAL SIDE OF EACH FINGER THUMB SIDE
• Don't rest chin on the side of fingers.• Add levers to keys, handles, and knobs.
• Hold handles straight across the palm.

AVOID PROLONGED PERIODS OF HOLDING HANDS IN THE SAME POSITION
• Sit if the task takes more than 10 minutes.
• Stand up after sitting for 20-30 minutes.
• Reposition yourself often.• Use a grip that keeps the wrists straight and the fingers in line with the wrist as much as • possible.

Avoid activities that do not allow for a change of position
• Be mindful of how long you have been doing specific activities, joint and muscles do not like to be held in the same position.They become stiff and work less effectively which leads to pain, damage and further deformity.When writing, doing hand work, release your grip every 10 to 15 minutes.On long car trips, get out of the car, stretch and move around at least every one to two hours.

Respect pain
• If you have arthritis, you may always have some pain.If pain continues for hours after the activity has stopped, this indicates that the event was too much and should have been changed or stopped sooner.

Avoid tight grips or gripping for long periods
• Gripping tightly increases pain and can cause further joint damage.Gripping small objects require greater force

Avoid deforming positions
• When opening new or tight jars consider using a gripping aid and direct the force through the palm of your hand rather than just through the fingers.There are several types of jar opening devices.Ask others to undo the lids, while you close them.• Use a flat hand when possible for cleaning, wiping, dusting.
• Try using cups with larger, straighter handles than cups with curved handles.• In general, finger motions should be in the direction of the thumb whenever possible.

Use one large joint or many joints
• Carry objects with your palm open to distribute weight equally over your forearms.
• Slide objects along a counter or workbench rather than lifting and carrying them.
• Carry light bags on your shoulders rather than with your hands.• When standing up from a chair or bed, rock forward and use your leg muscles rather than pushing up from your knuckles or wrists.• Use your hip or lower leg to close drawers.

OUTCOME MEASURES
The outcome measures that were used in the included studies are summarized in Table 2. Pain was the most evaluated outcome measure and it was evaluated with Visual Analog Scale (VAS) or by pain subscale of Health Assessment Questionnaire (HAQ) or by Numeric Pain Rating Scale (NRS) and by Michigan Hand Questionnaire.Selfreport measures for psychological domains were evaluated with the Arthritis Self-Efficacy Scale (ASES), Hospital Anxiety and Depression Scale (HADS), Arthritis Helplessness Index (AHI) and Sense of Coherence (SoC).Diseasespecific activity outcome measures were evaluated with the Disease Activity Score 28 (DAS28), Rheumatoid Arthritis Disease Activity Index (RADAI), Arthritis Impact Measurement Scale (AIMS2).Quality of life was assessed with EUROHIS-QOL 8 and health status with SF-12 and EQ-5D-3L.Functional ability was evaluated with HAQ, Dreiser Functional Index (DFI), Australian Canadian Osteoarthritis Index (AUSCAN), and Functional Index for Hand Osteoarthritis (FIHOA).The adherence of joint protection programs was measured with the Joint Protection Behaviour Assessment (JPBA), and joint deformity was assessed with Hand Joint Alignment and Motion Scale.Efficacy was measured with general self-efficacy scale and with global change.Disability was assessed with HAQ and with Disabilities of the Arm, Shoulder, and Hand (DASH).Performance-based tests were performed to assess grip and pinch strength as well as hand dexterity.Clinician based-outcomes included wrist range of motion and finger range of motion.

JOINT PROTECTION APPROACHES
In half of the studies, it was not clear who was primarily involved in delivering the joint protection program.Only two studies reported that the joint protection was provided by medical staff (nurse or physician) and by a research assistant.Joint protection and energy conservation were administered mostly with two methods such as an educationalbehavioral approach or as an approach that was focused on personal goals and available resources.The average time of a standardized joint protection education lasted from 1.5 to 3.25 hours approximately over two sessions.The usual content of the joint protection education was to educate the participants about the disease and how the joints are affected by h-OA or RA.The education sessions included information about the joint protection principles with short time demonstrations (15 to 30 minutes) of hand joint protection approaches usually for household activities.At the end of the joint protection education, there was a discussion about patients' needs and problems that were mostly supported by a leaflet.The joint protection tasks are summarized in detail in Table 3. Assistive devices were not reported in the vast majority of the studies.

GREY LITERATURE
Our grey literature search identified several online sources that are [1]: non-profit organizations (e.g.National Agricultural Safety Database (NASD), East Sussex Healthcare NHS, OASIS-Vancouver Coastal Health.Hand Osteoarthritis) [68] [2] educational e-learning communities (e.g.Physiopedia) [69] that have available online material for joint protection for people with hand arthritis and [3] Thesis from post-graduate and doctoral studies.General joint protection principles for hand consideration included: avoid tight grasp, avoid pressure on back of knuckles, use both hands when possible, avoid repetitive hand activities, avoid stress to tip or pad of thumb, avoid to pressure against the radial side of each finger thumb side, avoid prolonged period of holding hands in the same position, use more prominent joints to complete a task, plan ahead, use orthotic devices to protect your joints and respect pain., and further details are summarized in Tables 4-7.
Table 7. Energy conservation and joint protection from National Agricultural Safety Database (NASD) Grey Literature online material on joint protection.
• Respect PAIN as a signal to STOP the activity.
• Make a SCHEDULE of daily activities.Write down when PAIN and FATIGUE occur and schedule in REST BREAKS as needed.
• Avoid POSITIONS OF DEFORMITY and FORCES in their direction.Finger motions should be in the direction of the thumb whenever possible.When getting up from a chair or holding a magazine, use the palms of the hands rather than the knuckles.
• Use the LARGEST and STRONGEST joints available for a job.Save weaker joints for the specific tasks that only they can handle.For example, carry bags on the shoulder instead of at the elbow, wrist, or fingers.
• Avoid staying in ONE POSITION for a LONG PERIOD OF TIME.Don't give your joints the chance to become stiff.When writing or doing handwork, release your grip every 10 to 15 minutes.On long car trips, get out of the car, stretch and move around at least every hour.While watching television get up and walk around every 30 minutes.
• Use a CART to carry heavy items.If no cart is available, it is better to take several trips to get a job done than to overload and make one trip.
• SLIDE or PUSH items whenever possible.
• Avoid making a TIGHT FIST or PINCHING objects tightly.Instead, use a grasp that places your KNUCKLES PARALLEL to the handle of the tool or utensil being used.
• DO NOT start an activity that cannot be STOPPED IMMEDIATELY if pain or fatigue should occur.

DISCUSSION
This study aimed to summarize the extent of the evidence for joint protection principles for the management of RA / h-OA and identified randomized controlled trials, systematic reviews and overviews of reviews as the primary sources of scientific evidence for the current joint protection programs.Pain, function, psychological domains, adherence, quality of life and health-status were the main outcomes that were administered.More specifically, pain levels were mainly examined by Visual Analog Scale, Health Assessment Questionnaire, Numeric Rating Scale and self-reported psychological domains Arthritis Self-Efficacy Scale, Health Anxiety and Depression Scale, Arthritis Helplessness Index and Self of Coherence.Function was mostly examined by Australian Canadian Osteoarthritis index (AUSCAN), Michigan Hand Questionnaire (MHQ) and Health Assessment Questionnaire (HAQ).While the occupational therapist was primarily responsible for the delivery of joint protection, in half of the included studies, it was unclear who was mainly involved in delivering the joint protection program.Also, the current joint protection programs primarily focused on tasks associated with home care and kitchen, and the review of the grey literature yielded principles such as avoiding tight grips, awareness of pain, limiting prolonged periods of holding and use of larger joints.This scoping study did not evaluate the effectiveness of Joint protection programs but identified 18 RCTs that can be synthesized to investigate their effectiveness.The two most recent systematic reviews (26,27) provided recommendations from 8 RCTs in total leading to the exclusion of 10 additional trials.Therefore, an update of the most recent evidence is highly recommended.
Joint protection as a multimodal intervention includes the following components [1] altering working methods [2], use of proper joint and body mechanics through applying ergonomic principles [3], use of assistive devices, and [4] modifying functional performance and environments [54].It is often integrated with fatigue management, working splints and flexibility and strengthening exercises [54].We were unable to extract all the components mentioned above of joint protection because either there was a lack of reporting or either the joint protection intervention was not fully implemented.Joint protection programs may include specific principles and techniques such as avoiding tight grips or use of larger joints or utilize particular exercises or energy conservation methods.Therefore, it is crucial to ensure comprehensive reporting of all the components of such programs when used in clinical studies.In this review, we were unable to extract specific information on what exactly included in joint protection programs from most of the clinical studies because the information was not available.
Future research needs to focus on clear and concise reporting of different principles included in joint protection programs utilized in clinical studies and ensure adequate representation of men and women.It is crucial to assess the effectiveness of such joint protection programs in large-scaled well-designed randomized controlled trials by incorporating all the components of joint protection and not only parts of joint protection.
The strengths of this review are that we summarized all the reported joint protection principles in peer-reviewed and grey literature.We highlighted the main outcome measures that were used in most of the studies to help future clinical studies to select the most commonly used self-report outcome measures and performance-based tests.We identified a lack of clarity and lack of detailed description on the components of joint protection that were tested.Finally, we indicated that many RCTs (n=10) have been published that have not been considered in a recent evidence synthesis.
Despite the authors' efforts to follow rigorous guidelines from Arksey and O'Malley (7), this scoping study is subjected to several limitations.A thorough literature search was performed; however, we may have missed research articles that were under development during the study period.Also, a search of the grey literature was conducted through google search web engine, but we have decided to stop after the first ten pages of google web.Therefore, online material that addresses joint protection strategies may have been missed during the search process.

CONCLUSION
This review synthesized and critically examined the scope of joint protection programs for management of h-OA and found that RCTs, systematic reviews and overviews of reviews constituted two-thirds of the current body of literature.Furthermore, it identified a lack of clarity regarding the specific elements of joint protection programs used in studies.

KEY MESSAGES
An occupational therapist mainly delivers joint protection.Pain levels (VAS, HAQ, NRS), self-reported psychological domains (ASES, HADS, AHI, SoC) and function levels (AUSCAN, HAQ, MHQ) were identified as the main outcomes that were administered.Lack of detailed reporting for the components of joint protection programs.
Hammond 2008   joint protection (including 45min demonstration and practice), managing fatigue, aims of splinting, managing stress and relaxation (45 min practice) Masiero 2007 Principles of JP and energy conservation, including a demonstration of various hand-JP techniques, plus a homework task to identify problem activities and find solutions based on the imparted principles, work difficulties, etc. O'Brien 2006 basic principles of joint protection, energy conservation, 'top tips' relating to personal and household activities, Hammond 2004 Both education programmes consisted of four 2-hour weekly meetings.Stamm 2002

Table 3 . Joint protection Principles/Approaches that were reported from the included studies.
position, participants maintained standardized glenohumeral and elbow joint positions as well as hand placements to control for the distal kinetic variance that might result from non-standardized posturing.
Respect pain; distribute the load over several joints; use the strongest, largest joint to perform an activity; avoid working in positions of potential deformity; reduce effort by using assistive devices and avoiding lifting and carrying, and avoid prolonged periods of working in the same position.• Energy conservation: Pace by balancing rest and work and alternate heavy and light activities; use work simplification; use correct working positions and postures.Dziedzic 2013 distributing the weight of what you lift over several joints (e.g., spread the load over two hands) avoiding putting strain on the thumb and repetitive thumb movements avoiding prolonged grips in one position using as large a grip as possible reducing the effort needed to do a task (e.g., use labor-saving gadgets; avoid lifting heavy objects, and reduce the weight of what you lift) energy conservation (activity pacing and planning) 2014Training includes movement training to promote daily manual work by reducing pain and joint strain, preventing deformity, and maintaining functional capacity; self-exercise programs for hands; and provision of information on assistive devices, methods to adapt the environment, and the value, use, and handling of orthoses.Niedermann 2012 Demonstrations and supervised practice of hand JP methods, mostly in kitchen activities, and demonstration of appropriate assistive devices.The interventions consisted of five 45-minute sessions, four over a three-week period and one booster session two months later Beasley 2012 Respect pain, balance rest and activity, perform the exercise in a pain-free range, avoid positions of deformity, reduce the effort and force, use larger/stronger joints Swann 2011 The main techniques for joint protection are to (Arthritis Research UK, 2010): Use larger, stronger joints, Spread the load over several joints, Reduce effort by using labor-saving gadgets, Avoid gripping things tightly, Avoid positions that push joints towards Boustedt 2010

Table 6 . East Sussex Healthcare NHS. Joint protection techniques for hands (claiming source Arthritis Research UK, www
.arthritisresearchuk.org.)(GreyLiterature).1.Use joints in a stable position• Sit or stand as close as you can when working at a table or bench as this reduces stretching • and bending.