Objectives: this study was conducted to review the evidence available regarding the effects and benefits of Joint Protection (JP) education program for patients with Rheumatoid Arthritis (RA).

Results: reviewed evidence reported that the subjects benefited out of the JP program and presented less pain and disability and thus an enhanced health status. Therefore, this approach may efficiently compliment drug therapy. We also found significant improvements for those who attended JP program in the use and knowledge of JP principles, adherence, reduced early morning stiffness, and improved Activities of Daily Living (ADL) functional ability.

Conclusion: our review supported JP principles and summarized that subjects with RA benefited with JP, resulting in pain reduction, better joint adherence, and reduction in stiffness and better ADL functional ability.

Keywords: joint protection, rheumatoid arthritis, functional ability, energy conservation, rehabilitation, occupational therapy

“Rheumatoid Arthritis (RA) is a chronic disabling disease characterized by chronic inflammation of joints that, in most patients, results in progressive joint destruction with deformities and various degrees of limitation in activities of daily living.”.¹ RA has many adverse effects on health and social well being due to its exacerbation’s and remissions. These courses are influenced by different drugs and other factors.² Treatments of RA include: drug therapy, intensive exercise,³ and educational- behavioral programs. A variety of well established education programs like the Joint Protection (JP) program can be helpful as a part of the treatment.¹

“Joint protection is widely provided as a part of the management of people with rheumatoid arthritis”.⁴ JP education program includes exercises along with proper joint positioning techniques, energy conservation, use of orthoses and assistive device and other ergonomic measures. JP helps to reduce joint inflammation, pain, and preserve joint integrity.⁵ Joint protection education mainly includes educating the patient about the disease, effects of RA on joints, factors influencing development of deformities, a brief about joint protection principles and its demonstration.⁶

Attending a JP program and following its principles will improve patient’s joint adherence and maintain functional ability.⁷ A study reported that “Patient education should become part of other team – related efforts and thus an integrated part of total management of RA”.⁸ Besides, another study by Hammond, Lincoln and Sutcliffe⁶ concluded that JP is an effective program to be widely adopted in clinical practice. However, to make joint protection educational programs more beneficial to the patients, a positive behavioral change should occur along with increasing their knowledge about the disease itself.⁹

The purpose of this study was to review the evidence provided by various authors regarding the effects and benefits of Joint Protection education program for patients with Rheumatoid Arthritis. The PICO question (population, intervention, comparison, and outcome) formed for the purpose of our study is as follows:

(P) For patients with Rheumatoid arthritis

(I) Do programs focused on Joint Protection (JP)

(C) Compared to arthritis education program studies that include JP, a pharmaceutical control group, or no control group

(O) Enhance use of JP principles, knowledge of JP principles, functional ability and decrease pain.

Review of literature and search strategy

A research has been made in the following databases: Ovid (MEDLINE, PsychINFO, and Global Health), and CINAHL. Keywords and Search items used to search articles for our study were rheumatoid arthritis, Joint protection education, arthritis education program, joint protection principles. By combining the search results we found many articles on rheumatoid arthritis and joint protection. Based on the format of PICO question, three most relevant articles were selected for our study. Studies cited in the reference of the three articles along with other articles were also used to collect important information.

The three selected articles were related to effects of joint protection program on people with rheumatoid arthritis, which is in co-ordination with our PICO question. A summary of the 3 selected articles based on the most recent article published first is as follows.

The first study by Masiero et al.,¹ level II Randomized controlled trial study, investigated the effects of joint protection education program on people with RA. Out of 91 eligible subjects diagnosed with RA, 85 remained for the study and were randomly assigned to Control Group (CG) and Experimental Group (EG). CG consisted of 39 subjects who received only anti TNF drugs (infliximab) and no occupational therapy or other additional treatment. EG consisted of 46 subjects who received drug treatment as well as educational behavioral JP program. The EG group had three hour sessions of the JP program which was developed by an interdisciplinary team of rheumatologist, occupational therapist and physiotherapist. The sessions included pathophysiology of RA, mechanisms and control of pain and stress and home exercise program. Evaluation was conducted at baseline and after 8months. The authors reported significant difference in pain reduction (p=0.001) which was measured using the 100mm Visual Analogue Scale (VAS) in the EG compared to the CG. The authors also reported significant improvement in the EG in the Arthritis impact measurement Scale 2(AIMS2) in the physical (p=0.000), symptoms (0.049), and social interaction (0.045) subscales but not in the work and psychological dimension subscale. They also reported that the EG did better than the CG in the Health Assessment Questionnaire (HAQ), (p=0.000). 75% of the EG population were satisfied by the education program. However the authors did not find any significant difference in the Ritchie Articular Index (RAI) between both the groups. The authors concluded that the subjects benefited out of the JP program and “presented less pain and disability and thus an enhanced health status. This approach may efficiently compliment drug therapy”. (p. 2043).¹

The objectives of the second study by Hammond et al.,⁴ a level II Randomized controlled trial study, was to “evaluate whether joint protection can reduce pain and local inflammation and maintain the integrity of joint structures and functional ability of people with RA 1yr after attending an educational –behavioural joint protection programme” (p.1045). Subjects diagnosed with RA were randomly assigned in two groups: The Standard Education Program (SP) and the Educational- behavioural joint protection program group (JP). The SP included 8hours of education program with 2.5hours of joint protection education, alternative therapies, drug treatment, and exercise, methods to control pain, relaxation techniques and assistive devices. The JP group included 8hours of educational behavioural joint protection, self efficacy strategies, motor learning, methods to increase adherence to joint protection program, booklets and pictorial representations of joint protection techniques and information related to RA. The evaluations were performed at baseline, at 6months and after 12months. The authors reported significant reduction in pain in the JP group as compared to the SP (p=0.02) in VAS. They also reported significant use of joint protection in the JP group in the Joint Protection Behavior assessment (JPBA) measure (p=0.001). In the Assessor’s global disease status, the JP group did significantly better than the SP at 12months, (p=0.03). The JP group did significantly better than the SP in AIMS2, (p=0.03). The SP did not show any significant improvement. However the authors did not report any significance difference in the disease activity, hand status (the grip strength and joint alignment and motion) between both the groups, but the authors mention a significant improvement in all scales at the end of 12months within the JP group. The authors concluded that JP group improved at the end of 12months where as the SP group maintained or slowly worsened. The authors found “significant improvements for those who attended JP programme in the use of JP principles, adherence, reduced pain, reduced early morning stiffness, improved ADL functional ability and assessor patient ratings of the disease status” (p.1049).

The aim of the third study article by Hammond et al.⁵ Level III repeated measures design/ pre post cohort study, was “to evaluate the effects of an education programme in improving adherence with joint protection by people with RA” (p.392). Subjects diagnosed with RA were included in 2 sessions of joint protection education program for 2hours. The sessions included information of the disease, the anatomy of hand joints, significance of RA on hand joints, energy conservation, problem solving, demonstration of techniques in kitchen activities and practicing the joint protection techniques. Evaluations were made 6weeks before, 1week before, at baseline, 6weeks after, and 12weeks after. The authors reported no major significant improvement in pain or functional status in the JPBA (p=0.28), tender hand joint counts (p=0.63), VAS (p=0.29), HAQ questionnaire (p=0.49), and pain scale (p=0.74), and interviews (p=0.82), before and after education. They noted a significant difference in the 20-item multiple choice joint protection item questionnaire after education (p=0.01). The authors concluded that “the joint protection education program improved knowledge, but not use of taught methods” (p.398) (Table 1).

Two articles were level II articles, and one was level III. After reviewing the level of evidence, and the number of subjects, the Hammond et al.,⁴ article was chosen for the study as the strongest evidence. It has the largest number of subjects and better group interactions. The article supported JP principles and summarized that subjects with RA benefited with JP, resulting in pain reduction, better joint adherence, and reduction in stiffness and better ADL functional ability. Thus clinical guidelines, recommendations, a plan and audit tool have been developed in our study to implement JP principles in clinics. The clinical guidelines for recommended intervention, the plan, and the audit tool recommend therapists to use joint protection education and techniques with patients with Rheumatoid arthritis (Appendices A and B).

Appendices A

Clinical Guidelines and Recommendations for Use of Joint Protection Techniques in Patients with Rheumatoid Arthritis

The effects of JP on RA were supported by the evidence article by Hammond et al.⁴ Thus JP intervention techniques can be recommended in clinics based on the health belief model, self management, and the theories of social learning. Target population should include patients diagnosed with RA. All occupational therapists should be certified by attending programs and workshops on joint protection technique. After therapists prove their competency in JP educational program, they can include JP as a part of treatment program with patients diagnosed with RA.

Evidence in support of the above clinical guidelines is as follows:

Intervention technique

Joint Protection (JP) education program that can apply a variety of educational, behavioral, and motor learning methods for the convenience of the different learning styles of group members and in order to increase the adherence to the program.

Evidence article:

Hammond A, Freeman K.⁴ One-year outcomes of a randomized controlled trial of an educational-behavioural joint protection programme for people with rheumatoid arthritis. Rheumatology. 2001;40:1044‒1051.

Level of significance

Level II Randomized Control Trial (RCT)

Target population

Subjects diagnosed with mild to moderate Rheumatoid Arthritis. These patients should be able to follow verbal instructions, pictorial instruction on JP techniques.

Inclusion criteria

Subjects between 18 and 65years old diagnosed with mild to moderate RA, experiencing hand pain during any activity, and a history of metacarpophalangeal (MCP) or wrist joint pain and inflammation.

Exclusion criteria

Other diagnoses affecting hand function.

Intervention

A certified occupational therapist will receive training in use of JP techniques, and implement these techniques to patients with RA.

Tasks should include:

Schedule

Subjects will be seen for a total of 8hours, 4 sessions of 2hours during the outpatient rehabilitation.

Outcome measures

Patients will be evaluated for hand pain using the VAS. Adherence with joint protection will be measured using the JPBA. The grip strength will be measured using the Jamar dynamometer. Range of motion of hand was evaluated using the Joint Alignment Motion scale (JAM).

Recommendations

The recommendations were selected from our strongest evidence. Additionally, other recommendations were taken from the two other articles.

Recommendations from the strongest evidence (Hammond & Freeman, 2001)⁴

Appendices B

Implementation of joint protection education program (Plan/Audit Tool)
In order to implement the proposed intervention properly, the following plan should be applied. A summary of recommendations, plan, and audit is provided in Table 1.

1. An occupational therapist will attend workshops on JP education principles and practice the principles before applying it to the patients. In order to establish competency, the occupational therapist will answer a questionnaire on JP and obtain a certificate to practice JP.
2. Physicians referring a patient with RA will be given a brief knowledge (hand-outs) about the intervention plan based on the evidence article. The physicians will be asked their opinion regarding the intervention
3. The department of OT should conduct presentations provided by the qualified therapist on JP for all new therapists, and should be affiliated with current JP principles. The therapists should answer questions related to JP and must score a minimum of 90%. They will have to re-attend the presentation if they get a score less than 90%.
4. The OT director should have a record of all the certificates of attendance of all therapists
5. The therapists must demonstrate each principle before educating the client. This can be done by asking the therapist to answer a quiz or a questionnaire on JP principles or demonstrate at least the basic principles, to the certified therapist. The OT manager must maintain a record of the therapist performance along with the certificate previously provided. The incompetent therapist must re attend the presentation along with the certified therapist, and should not practice JP until competence is proved.
6. The evaluating therapist will follow a check list to find out if patients met the following criteria: Inclusion: Subjects between 18 and 65years old diagnosed with mild to moderate RA, experiencing hand pain during any activity, and a history of metacarpophalangeal (MCP) or wrist joint pain and inflammation Exclusion: other conditions affecting the hand.
7. The department should also have an educational booklet with pictorial instructions on JP principles and their use should be mandated on all patients with RA. The clients will be provided an educational videotape along with a booklet on JP principles.
8. The therapist must document use of JP after each session with the client.
9. On completion of intervention, the therapist will administer the VAS and JPBA and also measure the grip strength to note the effects of intervention at the baseline, and at the end of 6months and 12months respectively. Improvement in pain scores and JPBA scores at the end of 12months will establish effectiveness of JP on RA patients.
10. The clients will be asked to maintain a diary on daily basis to write down practiced techniques and activities
11. The clients will be rescheduled for follow-up purposes after 6-12months
12. The clients will be interviewed and provided with a questionnaire to measure their behavioral change and level of satisfaction.

Our review supported JP principles and summarized that subjects with RA benefited with JP, resulting in pain reduction, better joint adherence, and reduction in stiffness and better ADL functional ability. Thus clinical guidelines, recommendations, a plan and audit tool have been created in our study to implement JP principles in clinics. The clinical guidelines for recommended intervention, the plan, and the audit tool recommend therapists to use JP education and techniques with patients with RA.

No funding was required.

None.

The author declares no conflict of interest.

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