Rheumatoid arthritis and occupational therapy interventions



by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit




Both physical and occupational therapy are useful adjunctive treatments for rheumatoid arthritis.



JOINT PROTECTION

When a joint is inflamed it can be damaged more easily by daily activities. If a joint is repeatedly overstressed, deformities may eventually develop. Because RA is so painful, you will tend to hold a joint in the most comfortable position, usually bent or flexed. The muscles and tendons stiffen, causing the joint to bend and become tightened so that the joint cannot be straightened out and assume its normal position. The normal range of motion becomes limited.

For this reason it is important for you to learn how to protect your joints and to avoid overstress. While joint protection will not reverse damage which has already occurred, it can help delay or even prevent the development of deformities.

Joint protection means paying attention to how you use your body. Some postures and motions that are safe for most people may be harmful for you. At first, you need to be aware of certain principles in planning your activities. But, eventually, the process will become automatic.

1. MAINTAIN FULL RANGE OF MOTIONTo use each joint most efficiently you must be able to move it freely through its normal range. Your usual daily activities are not enough to assure this for every joint so each day you must carry out the complete range of motion exercises already described.

2. MAINTAIN MUSCLE STRENGTH
Inflammation and pain in the joints cause muscles to become weak because of less use. Weakness may cause the muscles that bend and straighten a joint to get out of balance with each other leading to deformity as well as loss of normal function. Specially prescribed therapeutic exercises can prevent this situation from happening.

3.RESPECT PAIN
Pain is an inevitable part of RA and you must usually continue to function in spite of it. However, you need to learn when pain is a signal to stop what you are doing. A good general rule is that any activity which makes joint pain worse and lasts more than a few hours is harmful. Such activities should be avoided or changed so that they are less stressful.

An activity which causes pain at one point in time may be handled later when the arthritis is less active. It is important to learn to recognize how active your arthritis is each day in order to keep your activities within the right limits.

4. AVOID FORCES AND STRESSES THAT CAN DAMAGE JOINTS
The force on a joint depends on the amount of weight it has to move and on the length of time the movement takes. If muscles have to exert too much force over an inflamed joint, the various tissues around the joint become stretched and no longer support it or keep the muscles lined up properly. Then, each time the muscles contract, the joint is bent into a deformed position.

Prolonged tight gripping and pinching may lead to hand deformities. Carrying a suitcase or grocery bag, holding a heavy purse, gripping a steering wheel for long periods, hammering, and using a screwdriver or scissors may put too much force on the small joints of the hand.

Instead of carrying heavy loads, use a cart to transport them. Pushing a cart will be easier than pulling it. When you must do stressful activities, use the biggest and strongest joints and muscles you can. For example, use your whole hand rather than one finger; use both arms instead of one.

Always be ready to stop an activity immediately if it becomes too stressful. Joint damage can occur if you continue a movement in spite of sudden or severe pain. Plan for rest stops when you have to do something stressful and only attempt as much as you are sure that you can finish.

5. AVOID DEFORMING POSTURES
Posture refers to how your joints line up in relation to each other. If your posture is good, then your joints will be aligned correctly. Poor body alignment leads to over-fatigue and pain and can cause strains and deformities. The human body is like a tall ladder. It is easy to hold up an upright ladder but it takes a lot of effort to support it when it begins to lean even a little bit.

You also should try not to hold or stay in one position for a long period. Some people think that needlework might be good exercise for arthritis in the hands, but this is not true. When you do needlework you hold your body in a stiff, bent posture. After an hour of knitting, the neck, back, shoulders, wrists, fingers, and knees become stiff and sore from maintaining the same position. The joints need to be moved frequently and you should change your position about every 10-20 minutes. People who use the same position on the job each day, such as typists or machinists, notice damage occurs more rapidly in joints which are always used in a certain way.

LYING

Use a firm mattress and only one pillow under your head. Your neck should be allowed to remain in line with the rest of your spine. If you cannot stand lying flat, raise the entire head end of your bed by placing 4 to 6 inch high, slightly scooped-out blocks under the legs at the head of the bed. You will then be comfortable, but your body will stay in a good position while you rest. NEVER place pillows under your knees, even when they are hot and painful. Try to keep the knees, elbows, and wrists straight as much of the time as possible. You may be given splints to wear at night to prevent deformity in these joints.

Also, avoid always sleeping in the same position. You won’t be so stiff if you change position once in a while. Try to spend at least 30 minutes every night lying perfectly flat on your stomach to keep your hips and knees straight. Let your feet hang over the edge of the mattress so that your knees, hips and spine will straighten out fully.

SITTING

Choose a chair that lets your hips, knees, and ankles be at right angles. Both feet should reach the floor comfortably and there should be a one to two inch space between the back of your knees and the front edge of the seat. Arm rests should be high enough so that when your shoulders are relaxed and elbows bent, the full length of your forearms rest on them. A chair for working should have a low back reaching from just below to a few inches above the waist. You should be able to adjust the height of seat, arm rests, and back as well as the forward/backward position of the back support. A chair for resting should have a high back, including support for the head and the legs. It should be easy to move into comfortable positions for different activities.

When you read you may want to bring the reading material up to eye level. A book stand on a table top will let you relax the arms and the neck while reading.

Work surfaces should be at a height so your elbows can stay at right angles with your shoulders relaxed when you work. If you work at a desk, a slanted top will raise the material, reducing strain on the neck and upper back.

STANDING

Stand with your feet comfortably apart, your weight evenly distributed between the two feet, and your knees straight but loose. Keep your shoulders relaxed, your stomach pulled in and your buttocks tucked under. Check yourself in the mirror and get accustomed to this attractive and comfortable posture. Maintain it when you walk, moving in a relaxed manner, taking even stops and putting an equal amount of weight on each leg.

If you have to stand at work, think of your posture. Just as in sitting, your work surface should be high enough such that your elbows can remain at right angles and your shoulders relaxed when you work. Take frequent rest periods if you must stand to work. Try to lie down for a while for complete rest and relaxation or sit if lying is not possible. While you are working, shift your weight from one leg to the other by placing one foot and then the other on a stop or stool in front of you.

HANDS

The hands take a great deal of stress, but you can avoid much of it by paying attention to the way you use them. Wringing a washcloth, holding a teacup, opening a jar, pushing a thumbtack, twisting a can opener, turning a key, and carrying luggage all may create poor joint positioning and stress on vulnerable joints. With care and practice you can make these activities less damaging.

Maintain full range of motion so that you can straighten (extend) and bend (flex) your fingers. In time you will learn to use the pal or heel of your hand whenever you can instead of the fingers to grasp objects.

Avoid a tight grasp because it creates too much pressure in and around the small joints. Keep your grip more relaxed by using large handles and by avoiding heavy loads.

When you buy new utensils or other items with handles, select large, comfortable handles or objects which do not require you to grasp. Choose coffee mugs over teacups, and luggage carriers or rollers to eliminate lifting. Select sponges which can be patted dry instead of dishrags or washcloths. Do not hold anything such as a telephone receiver tightly for long periods. Use a telephone shoulder rest. Avoid strong pinching motions. Velcro fasteners for clothing can make dressing and undressing easier, thus reducing joint stress. They can be simply peeled apart instead of being unbuttoned.

Use a bottle opener to pry up the tops of cans or jars with pull-tops.

The thumb is used for just about every hand activity, so a chronically inflamed thumb easily becomes deformed. When you put pressure on the thumbs by tight grasp or pinch, they may become bent backward and lose their usefulness. Rely on tools to pry lids and push thumbtacks. A short length of broomstick, or foam-padded doweling with a hook screwed in the end, can serve as a pulling tool for the car door handle.

Hold it so that all of your fingers gently curve around it, hook it under the handle and pull up. When you cut foods, hold the knife with full grasp and draw it toward you. Heavy loads on the hands stress them. Distribute the weight over as many joints as you can so that your fingers will not have to accept all of the pressure. When you carry a pan, support it with both hands from underneath with fingers straight and palm up.

A common deformity of the hand in rheumatoid arthritis is a bending of the four fingers to one side. When this position becomes fixed you cannot use your hand properly. The use of tools such as a hammer or screwdriver requires forceful motions in the direction of finger deformity. Turning faucets does the same. Lever controls are the best solutions because you can work them with your palms.

Hand splints can be designed to allow hands to work or rest in good positions. Use them regularly if they have been prescribed for you. Avoid constant bending of your fingers when you are not using the splints.

If you follow all these protective methods for the fingers, you will cut down on stress to the wrist as well. You can avoid heavy lifting, twisting, wringing and circular motions which can damage wrists by distributing the motion along your arm or by using tools to perform the work for you. For example, when you stir food hold the spoon at right angles to the fingers and use a circular forearm motion.

You should review all your usual daily activities with your occupational or physical therapist to be sure you are using the least stressful techniques to get them done.





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