Looking After Your Joints When You Have Arthritis

An Information Booklet

INTRODUCTION

Who is this booklet for?

This booklet is for people who have arthritis who want to reduce pain and strain in their joints by altering the way they do things. It will be useful for people with inflammatory types of arthritis, such as rheumatoid arthritis and psoriatic arthritis, and for people with osteoarthritis, especially of the hands.

Most people will, in time, find their own ways to reduce the aches and pains in their joints, but this booklet will provide a short cut by helping you to identify the tasks which often cause pain. We will explain the principles of 'joint protection' and give some examples of how to put them into practice. But a short booklet like this cannot cover every situation, so we hope that the booklet will also act as a 'workbook' which will help you to think about how you can apply joint protection techniques to other jobs that you do. There is space at the back of the booklet for you to make notes. If in doubt you might like to discuss your ideas with an occupational therapist. There is also a section on how to reduce tiredness, which may be helpful for people with any type of arthritis who are suffering from fatigue.

The Arthritis Research Campaign (arc) produces booklets on many different types of arthritis, and on various aspects of living with arthritis, and these are referred to, where appropriate, in this booklet.

What sort of problems can arthritis cause?

Many people with arthritis describe how their joints hurt and their muscles ache, and how they often feel extremely tired, especially at the end of the day. Many people with arthritis feel frustrated at the extra time it takes to do everyday jobs. For example, even a simple task such as opening a jar can be difficult. Some people worry about the future and fear they will become a burden to others. But by taking good care of your joints you can help to keep problems to a minimum, and you should find that you can still manage most of the things that you want to do without feeling dependent on others.

What is a joint and how does it work?

A joint is where two (or more) bones meet. Most of our joints are designed to allow the bones to move only in certain directions. A joint is made up of a number of different parts, which all work together so that we can bend, stretch, twist and turn easily but within certain limits. Figure 1 shows the different parts which are present in most of our joints.

The ends of the bones are covered in a layer of gristle called cartilage. This helps to cushion the joint and spread the load evenly when you put pressure on the joint. The slippery surface of the cartilage allows the bones to slide smoothly over each other when they move. At either side of the joint muscles are attached to the bones by tendons. As muscles contract they pull on the bones so that the joint bends or rotates. Surrounding the joint is a tough, fibrous sleeve called the capsule, which stops the bones from moving too much. The inner layer of the capsule, the synovium, produces a fluid which helps to nourish the cartilage and lubricate the joint. Within or just outside the capsule are ligaments. These are thick, strong bands which hold the bones on either side of the joint together. In some joints (e.g. the shoulder) there are fluid-filled pouches called bursas (or bursae) which help the muscles and tendons to slide smoothly over the joint without rubbing against the bones.

Why do joints ache and hurt?

There are many reasons why joints ache and hurt:

1. Swelling (inflammation) inside the joints irritates the nerve endings and this causes pain.
2. If you have arthritis the cartilage which covers the ends of the bones may become worn or damaged. Because cartilage has no nerve endings people are often unaware that it is damaged. But if the cartilage is badly worn the bone just beneath may also begin to wear and change shape. Because bone does contain nerve endings this can be very painful.
3. Putting more pressure on your joints may make the pain worse. Not surprisingly, carrying heavy items can increase the pain in your hands, arms and shoulders, but you may also feel the effects in other joints. For example, just walking or moving about puts a great deal of pressure on your knee joints and feet, and the more you carry, the greater the 'load' on your knees and feet. And if you are overweight this will also increase the pressure on your joints.
4. Extra activity will tend to make you ache more. If you have pushed yourself to complete a job in the house or garden, or at work, you may well have experienced increased pain the next day. This probably occurs because our muscles have a level of stamina built into them and when we exceed this level our muscles begin to ache. Arthritis can reduce the stamina of your muscles, so you tire more quickly. Also, when joints are affected by arthritis the ligaments may become slack (see 'Why do joints become deformed?' below). This means that the muscles have to work harder to keep the bones in place, so the muscles begin to ache even more quickly. (See also arc booklet 'Pain and Arthritis'.)
5. The structures around the joint may cause pain. For example, bursas, which normally allow the muscles and tendons to run smoothly over our joints, may become inflamed and painful. This often happens in the shoulder and hip joints. The ligaments which hold joints together may be put under more pressure, especially if the joint is damaged, and these too may become inflamed and tender. This frequently occurs around the knee joint.
6. Sometimes you may feel pain in one part of the body, but the problem which is causing the pain is in another part. This is known as 'referred pain'. An example of this is sciatica, where a nerve is injured in the back but the pain is often felt in the lower leg. Another example is when the joint where the spine meets the pelvis (the sacroiliac joint) becomes irritated and the pain can be felt in the groin.

Your doctor or therapist will try to work out the cause of the pain and help you decide on what treatment is best for you. Medication helps to ease the pain and in some cases it can help to protect the joints by controlling the disease. But there are lots of things that you can do to reduce the pain and strain on your joints and to improve your muscle stamina.

Why do joints become deformed?

There are three main things which keep your joints stable. These are:

• the close fit of the bones
• the capsule and ligaments, which are like strong elastic and keep the bones together
• the muscles and tendons which make the joint move.

If you have arthritis, several parts of the joint can become damaged (see Figure 2). The bones and cartilage may be damaged and the muscles may weaken causing the joint to become unstable. This means that joints may slip out of shape and deformities develop. In rheumatoid arthritis, with repeated joint swelling, the ligaments are stretched and can become slack. These changes may start quite early in the disease. (See arc booklet 'Rheumatoid Arthritis'.)

The way you use your joints can contribute to the development of deformities. Hands are particularly vulnerable as we place a lot of strain on them during the course of the day. Typical deformities in the hands in rheumatoid and osteoarthritis are shown in Figures 3 and 4. These deformities can cause significant problems with activities which require a good grip. Have a look at your own hands to see if any of these have started to happen.

In rheumatoid arthritis, the main types of hand deformity are:

• the wrist or knuckles slipping downwards so that they partially dislocate (known as 'subluxation')
• the fingers bending over towards the little finger (known as 'ulnar drift')
• finger or thumb joints buckling (known as 'swan neck' or 'boutonniere' finger or 'z-shaped thumb' deformities).

About half of all people who have rheumatoid arthritis will develop some hand deformities after about 5 years.

In osteoarthritis, knobbly fingers (Heberden's nodes and Bouchard's nodes) are common types of deformity. There may also be reduced movement and pain at the base of the thumb. Often this is associated with buckling of the main thumb joint.

WHAT CAN I DO TO HELP MYSELF?

Your arthritis can affect your ability to do your work, or home and leisure activities, as you used to. Joint problems can cause pain, weaken your hand grip, and reduce your muscle stamina so that you tire more quickly. Whichever type of arthritis you have it makes sense to start looking after your joints as soon as you know that you have arthritis. By making changes early on you can help to avoid problems becoming worse in the future. The things that you can do to help yourself are listed below and are explained in more detail in the sections which follow:

• Look after your joints – reducing strain should help to ease aches and pains.
• Pace yourself, plan ahead, and decide on your priorities to avoid becoming so tired.
• Try to get a good night's sleep.
• Keep to your ideal weight to reduce pressure on the hips, knees and feet.
• Try to keep as fit as possible, and to build up muscle stamina through regular exercise.
• Do hand exercises most days to improve your grip.

Protecting your joints

The first thing to do is to become more aware of how you are using the joints which ache. Try, for example, watching your actions while you make a hot drink. What is happening to your fingers while you are turning on the tap? Are they being pushed towards the little finger? What is happening to your thumbs as you take off a tight coffee jar lid? Is there pressure or aching at the base of your thumb? What is happening to your wrist as you lift a heavy kettle? Can you feel any aching or pulling at your wrist?

Can you think of another way of doing these activities which will reduce those aches and strains? You might have tried picking up the kettle with two hands. You may find that you do this anyway when your hands are painful. But it is important to do this all the time, not just when your hands are hurting. This is an example of 'joint protection'. Health care professionals often use this phrase – it doesn't mean you should stop using your joints, just that you should use them differently.

The main techniques for joint protection are:

• Take notice of any pain you feel – it can serve as a warning.
• Use larger, stronger joints.
• Spread the load over several joints.
• Reduce the effort you have to put in – labour-saving gadgets can be a great help.
• Avoid gripping things tightly.
• Avoid positions which push your joints towards deformity.
• Use your joints in more stable positions.

These techniques are explained in detail in the sections which follow, with some examples of how you can put them into practice.

What should I do when I am in pain?

The way you use your joints can increase the aches, pain and strain that you feel. And, over time, the way you use your joints may also increase any deformity. This is why you should take notice of pain. Listen to your body – if you are still having more pain an hour after an activity, try taking more short breaks next time. Many people will give up an activity if it hurts (e.g. knitting); however it is better to do a little of such activities at a time, with plenty of rests, rather than give up altogether something which you enjoy.

Wearing splints can often help to ease the strain on your joints. There are two types of hand and wrist splint – resting and activity splints. Resting splints consist of a custom-made 'cradle' with straps to hold it in place (see Figure 5), and can help with pain and swelling by supporting your joints in a stable position while you are resting. Elastic wrist and thumb splints provide more flexible support to help reduce pain while you are working (see Figures 6 and 7). (An arc leaflet on splints is in preparation.)

How can I use stronger joints to do a job?

How about trying the following:

• Use your hip or shoulder, rather than your hand, to shut a drawer or door.
• Hug larger objects close to your body as you carry them (see Figure 8).

How can I spread the load of what I lift over several joints?

How about trying this:

• using two hands
• keeping as much of your hand as you can in contact with the object
• not gripping with your thumbs.

Figure 9 shows how you might apply this to lifting a kettle. Why not try this for other activities? Whenever possible, use two hands rather than one to lift pans and other items – but do remember to protect your hands when lifting something hot.

How can I use less effort to do things?

How about trying these tips:

• Use labour-saving gadgets (see Figure 10). Many specialized aids and tools are available – see the arc booklet 'Gardening and Arthritis' for more ideas.
• Reduce the weight of what you lift or, if you cannot reduce the weight:
• 'Shift, not lift' – slide objects along a work surface, or use a trolley or wheelbarrow (see Figure 11).

 

How can I avoid gripping things tightly?

Tight grips produce a lot of strain on knuckles and thumb joints. You will tend to use a tight grip when you do things like writing, knitting, or using a screwdriver. Take frequent breaks to rest your hands briefly. Reduce the length of time you spend doing these activities and try to relax your grip. Use padding to enlarge the grip on things such as your pen, knife, toothbrush or spanner.

How can I avoid positions which push my joints towards deformity?

By becoming aware of how you use your hands you can identify which movements push your joints in the direction of the deformities described earlier. For your hands, the important things to remember are to:

• Avoid lifting heavy things with your wrists bent downwards.
• Avoid pushing your fingers over towards your little finger and putting pressure on your thumb.
• Avoid twisting or over-straightening your fingers.

Figures 12–14 show some examples of tasks which can push your joints into deforming positions, along with better grips which you can try. See if they help to reduce the 'pulling' feeling or pain in your joints. Think about other tasks you do where you might be able to use a different grip.

 

 

 

If your arthritis affects your hands, avoid pushing down on your knuckles, for example when getting up from a chair (see Figure 15).

 

How can I use joints in more stable positions?

Change position from one which puts strain on particular joints to one which spreads the weight evenly over several joints. Try the following:

• When working at a table or bench, sit or stand as close as you can, and reduce stretching and bending.
• If you are standing, keep your weight so it is supported evenly through both legs, standing squarely on.
• When carrying things use a grip which keeps the wrists straight and the fingers in line with the wrist, as in Figure 16. Notice how the thumb rests across the fingers without pressure. (The other hand supports the watering can with the palm flat.) (See also arc booklet 'Gardening and Arthritis'.)

 

Making changes Following the suggestions made above would be a lot to change all at once, and changing the habits of a lifetime can be difficult to do. It is a good idea to change things bit by bit. You might like to set yourself a goal each week to change two or three things. Start with something which is causing you most pain and try following these steps: Using the advice above, work out another way of doing it which causes less pulling or pain on joints. Practise the new movements until you get them right and feel comfortable doing them. Keep practising until the new movements become automatic, and you can do them without slipping back into old habits if you get distracted. If possible, get a friend or family member to remind you to do it properly.

Do joint protection techniques really work?

Research has shown that using these joint protection methods does help to reduce pain and makes everyday activities easier. People have reported less stiffness in the morning and fewer flare-ups when they use these techniques regularly.

Avoiding tiredness (fatigue)

Many people feel tired, especially at the end of the day. This can also make your joints and muscles ache more. In rheumatoid arthritis, the disease itself is partly responsible for this tiredness. Living with pain caused by any kind of arthritis can make more demands on your energy. (See arc leaflet 'Fatigue and Arthritis'.)

Many people find that making changes to their lifestyle helps to make their energy last longer. This is not always easy to do: it can be difficult to do a job less thoroughly than usual, even if the job does make you tired. But in the long run you will find it is better to save your energy for the more enjoyable things, rather than being tired out by routine tasks.

Here are some things you can do to spread your energy further. You may like to try some of them and see what works for you.

• Pace yourself.
• Plan ahead and set priorities.
• Find the best position for the job you are about to do.
• Get better organized.
• Get a good night's sleep.

How can I pace myself better?

Try taking a break for a few minutes every half hour. Change activities regularly and swap between light and heavier jobs. For example, after vacuuming a room, do some dusting, then sit down and take a break. When mowing the lawn, take a break before you get tired, change to a lighter job and go back to mowing later when you feel rested.

How can I plan ahead and set priorities?

You may find you have more energy if you spread heavier jobs out over the week, planning to do a bit each day. Some people use up a lot of energy doing 'the chores' and are too tired to do the enjoyable things. If you find this happens to you a lot, think about the things you have to do and the things you enjoy doing. You might keep a diary of such things. Set a balance between these when planning your week, making sure you will have time to do things you enjoy. You may find you need to cut some jobs out or ask someone else to help with them. If you plan to do more than you are actually able to do, it's time to start asking some hard questions.

• Are there any activities you can do less often or drop entirely?
• Is there someone, for example a relative or friend, who can do the job for you or help you with it?
• Can you say 'no' when someone's expectations of you are unrealistic?
• Can you say 'no' to yourself when your own expectations are too high?
• Can you make any of the suggested changes to your lifestyle to conserve more energy (pace, plan, prioritize, position yourself better)?

You may like to try keeping a record of your activities during the day. Every half an hour or so make a note of what you have done, how tired you felt, and whether you had any pain. If you were tired at the end of the day ask yourself some of the questions you have just read above. Can you think of any changes you can make so that you will be less tired next time? Try out some of your ideas during the coming week. At the end of the week ask yourself, 'Has it made a difference?'.

How can I find a less tiring position to work in?

Standing for long periods and working in a cramped position for a long time can make you ache and feel more tired. Try changing positions more often. Stretch out your arms and legs from time to time to help prevent them becoming stiff. Make sure that work surfaces are at the correct height and that you do not have to stoop or stretch as you work at them. A lot of tasks that you might normally do in a standing position can be done just as well 'perching' on a stool. If you are sitting it is important to consider whether the seat you are on is comfortable, supportive and the right height and depth for you.

How can I get better organized?

Look at how you are doing things and see if you can organize a job better:

• Make sure you have all the things you need to hand before you start.
• Can any part of the job be cut out or done more efficiently?
• Can you sit rather than stand to work?
• Can you slow down a bit?

Store things where you can reach them more easily. Organize your cupboards with the seldom-used things at the back. Get rid of things that you don't use.

How can I get a good night's sleep?

Think about why you are not sleeping well.

Is it pain and stiffness during the night?
Take some painkillers before bed. Have a warm bath or shower to help you relax. Check your mattress is supportive and comfortable (you might consider buying a new one, but you need not go for the most expensive – try before you buy). If you have neck pain you may find using fewer pillows helps, or ask your doctor for a soft surgical collar to wear while you sleep. Rearrange pillows into a V-shape to support painful shoulders, or try a specially shaped neck pillow. These are available from department stores. Although there is no evidence that they help with the cause of the pain some people find they help to keep the neck in a comfortable position. If your hands are painful, resting splints may help.

Are you having difficulty winding down?
Avoid eating a big meal and avoid drinking tea, coffee or alcohol for a couple of hours before bedtime. Try a hot, milky drink instead. Get into a bedtime routine. Try to go to bed at the same time every night. Do a few gentle stretching exercises, have a warm bath or shower and listen to some relaxing music. Take time for yourself! Make your bedroom a relaxing place – low lighting, relaxing colours, no clutter, no computer or TV.

Keeping fit and healthy

Why should I exercise?

Exercising helps to keep your muscles strong and your joints moving. There are some exercises in the arc leaflet 'Keep Moving' which show how to do these without putting strain on your joints. Joint protection and exercise work together. Joint protection reduces strain on the joint capsule and ligaments. As mentioned above, these can become slack in arthritis (see 'Why do joints become deformed?'), and straining them can make this worse. Exercise helps make the muscles around the joint stronger so that they can support the joint if the capsule and ligaments are weak.

What can I do to improve my grip?

Many people with hand arthritis find their grip weakens and their hands become stiffer. This can be very frustrating. Regular hand exercises will improve your grip. Do them most days of the week, for short periods a couple of times a day. There are some good exercises for the hands in the arc leaflet 'Keep Moving'. Start slowly and build up the amount of exercise you do over several weeks. Ask to be referred to a Rheumatology or Hand Therapist for extra hand exercises to suit you.

How can I keep to my ideal weight?

Keeping to your ideal weight can be hard when you have arthritis. But being overweight puts an extra burden on the weight-bearing joints (back, hips, knees, ankles and feet) when they are already damaged or under strain. Because of the way joints work, the pressure in your knee joints is 5–6 times your body weight when you walk. The arc booklet 'Diet and Arthritis' gives advice on how to help manage your weight.

How can I care for my feet?

Having painful feet can limit you getting out of the house for work, leisure, shopping and exercise. Good shoes help to protect your feet in the long term. See the arc booklet 'Feet, Footwear and Arthritis' for lots of practical advice on looking after your feet. Ask to be referred to a rheumatology podiatrist if you have rheumatoid arthritis and your feet are painful or starting to change shape.

FURTHER HELP AND INFORMATION

How can family and carers help?

Learning about the things described here can help family and carers to understand some of the problems people with arthritis face. Some people find it very helpful if their family or friends become involved as they practise some of the ideas mentioned in this booklet. If they are supportive, give you feedback on how you are doing, and help you to find solutions to problems you may find you are able to adopt the new movements or activities more quickly.

Who else can provide help and support?

The health professionals attached to rheumatology units help support people in adapting their lifestyle: nurses, occupational therapists and physiotherapists can all help. The occupational therapist will discuss this booklet with you and suggest more ways in which you can reduce aches, pain and strain, and which may help to slow down the development of joint deformities. Because changing the habits of a lifetime can be very difficult to do, many people find it helpful to get together with others who wish to do the same. Many occupational therapy departments offer joint protection programmes where groups of people with arthritis support each other through learning and practising activities together. This may be part of an overall programme for people with arthritis.

If you find the self-help methods suggested here useful, you may like to join a local group. Arthritis Care, a national organization with local branches, runs a programme called 'Challenging Arthritis', which teaches self-management techniques for people with any kind of arthritis (see 'Useful addresses'). There are similar programmes available locally for people with long-term medical conditions, like arthritis. Ask at your doctor's surgery or rheumatology unit about the NHS Expert Patient Programme.

Further reading

The Arthritis Helpbook: A Tested Self-Management Program for Coping with Arthritis and Fibromyalgia. By Kate Lorig and James F Fries. 6th edition. Da Capo Press, 2006. ISBN: 9780738210384

Tips for Good Living with Arthritis. Arthritis Foundation, USA, 2001. ISBN: 9780912423272

This book is published in the US but can be ordered via a good book store or from online booksellers in the UK. You can also order direct from the Arthritis Foundation, PO Box 932915, Atlanta, Georgia 31193-2915, USA. Telephone orders: 001 800 283 7800, or order via the 'Store' then 'Books' section of the web site: www.arthritis.org.

Arthritis: Improve your health, ease pain, and live life to the full. By Howard Bird, Caroline Green, Andrew Hamer, et al. Dorling Kindersley, 2006. ISBN: 9781405310574

Useful addresses

The Arthritis Research Campaign (arc)
PO Box 177
Chesterfield
Derbyshire S41 7TQ
Phone: 0870 850 5000
www.arc.org.uk

As well as funding research, we produce a range of free information booklets and leaflets. Please see the list of titles at the back of this booklet or, on this website, see Publications for People with Arthritis.

Arthritis Care
18 Stephenson Way
London NW1 2HD
Phone: 020 7380 6500
Helpline (freephone): 0808 800 4050
www.arthritiscare.org.uk

Offers self-help support, a helpline service, and a range of leaflets on arthritis. Please send a stamped self-addressed envelope for details.

The College of Occupational Therapists
106–114 Borough High Street
London SE1 1LB
Phone: 020 7357 6480
www.cot.org.uk

The professional body of occupational therapists in the UK. Also has a specialist section for members with a special interest in arthritis.

Disabled Living Centres
Assist UK
Redbank House
4 St Chad' s Street
Manchester M8 8QA
Phone: 0870 770 2866
www.assist-uk.org

Can provide a list of all Disabled Living Centres in the UK – where you can try out tools and equipment designed to help make everyday tasks easier.

Disabled Living Foundation (DLF)
380–384 Harrow Road
London W9 2HU
Phone: 020 7289 6111
Helpline: 0845 130 9177
www.dlf.org.uk

Provides information and advice on daily living equipment for elderly and disabled people.

NHS Expert Patients Programme
For details of courses in your area, visit:
www.expertpatients.nhs.uk

nras (National Rheumatoid Arthritis Society)
Unit B4 Westacott Business Centre
Westacott Way
Littlewick Green
Maidenhead SL6 3RT
Phone: 0845 458 3969
Helpline (freephone): 0800 298 7650
www.rheumatoid.org.uk

A national charity which focuses specifically on rheumatoid arthritis.

RADAR (Royal Association for Disability & Rehabilitation)
12 City Forum
250 City Road
London EC1V 8AF
Phone: 020 7250 3222
www.radar.org.uk

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