Joint Protection: A Critical Review
Philip Palmer and Jane Simons
Introduction
Therapists have included 'joint protection' in their therapy with
patients with arthritis since the publication of Cordery's arti-
cle in 1965. 1 The principles she described aim to maintain
joint integrity and muscle strength, reduce pain and inflamma-
tion in affected joints, and reduce fatlgue.i Many occupational
therapy departments have taken these principles to form the
basis for educational programmes.
Therapists at the Guest Hospital have used the principles
listed below in an attempt to relate Cordery's original alms- to
activities of daily living: . gadgets did not result in the decreased muscle activity that
1. Avoid gripping too tightly
2. Balance your rest and activity
3. Exercise little and often
4. Watch your weight
5. Find easier work methods and organise your day
6. Avoid deforming positions
7. Be aware of posture and joint position at all times
8. Spread the strain over many joints or one large joint
9. Wear your orthoses - hands and wrists
10. Listen to your body.
This article provides an analysis of the evidence support-
ing each of these principles. A summary of the evidence
found follows each analysis.
1. Avoid gripping too tightly
This advice is based on the assumption that greater exertion
of grip force leads to: increased pain in the wrist and hand;
increased deforming force at the soft tissues around the
joints; and increased joint destruction.
Gripping too tightly leads to increased pain: The pain expe-
rienced during grip may not be due solely to local inflamma-
tion. Hart and Husklssons considered pain in rheumatoid
arthritis (RA) to be a complex of:
(a) Discomfort arising from peripheral inflamed joints
(b) Systemic illness
(c) Depression and anxiety
(d) Overtones from drugs
(e) Symptoms arising from complications such as peripheral
or compression neuropathtes.s
How close is the correlation between grip force and pain
experienced? Patients have reported that the provision of gad-
gets can reduce the pain experienced when carrying out a
given activity.3.4 It is not clear if this is because less force is
Philip Palmer, DipCOT, SROT, was formerly Senior Occupational Therapist at Guest Hospital, Dudley, and is now based at the Centre for Human
Communication, Oak Tree Lane Centre, Oak Tree Lane, Birmingham B29 6JA.
Jane Simons, DipCOT, SROT, was formerly Acting Head Occupational Therapist, Sub-Regional Rheumatology Unit, Guest Hospital, Dudley, and is
now working in Ontario, Canada. Address for correspondence: 103 Marlborough Avenue, Kitchener, Ontario NZM 1H7, Canada.
British Journal of Occupational Therapy, December 1991, 54(12)
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required when using a gadget or because the gadget facili-
tates the use of a 'less deforming' position. Agnew5 carried
out an electromyographic pilot study recording the activity of
extensor carpi ulnaris (ECU) in five normal subjects while per-
forming tasks by a conventional method and when using a
gadget. She chose ECU because it is active in all wrist move-
ments and easy to locate for experimental study. She hypothe-
sised that the use of gadgets for turning a key, turning a lock
and using scissors would lead to a reduction in the amount of
force required to complete these tasks. The use of two of tne
was expected. No comparison was made of patient discom-
fort or pain during activities. The results were inconclusive
but, even if gadgets do enable a reduction in the ECU force
recruited for a given task, the implications for overall hand
use are unclear.
Gripping too tightly leads to increased deformity: Corderyi
advised against strong grip, claiming that this would increase
the strain on the collateral ligaments of the metacarpopha-
langeal (MCP)joints. She cited the work of Smith et al6 in sup-
port of this hypothesis. The idea that functional patterns of
use exacerbate rheumatoid deformities has gained credence
over the years but the authors know of no controlled studies
that support this.
Gripping too tightly leads to increased joint destruction:
Castillo et al 7 demonstrated a close relationship between the
degree of physical activity and the development of large cystic
erosions. Jayson et al8 were able to relate these cysts to
increased intra-articular pressure. Corderyt claimed that pro-
longed grip was contraindicated and that this also had an
effect on wear of the articular surface.
Summary: On the basis of the above studies, there is
some evidence to suggest that gripping too tightly leads to
increased pain and that it may increase joint destruction.
2. Balance your rest and activity
The assumption behind this advice is that too much or too lit-
tle of either is detrimental, but that both are important for the
RA patient.
It is felt that taking rest breaks during activity increases
overall endurance and allows the person to keep energy in
reserve for enjoyable activities later. Furst et 81 9 were able to
show that RA patients can increase their total physical activity
through taking rest periods, with the aid of a workbook-
based programme designed to teach 'energy conservation
453
behaviours'. Smith and Polley,10 in a review, also suggested Summary: There is some evidence to suggest that too
that there should be a balance between exercise and sys- much exercise can damage the joints and that short periods
temic and articular rest. Tromblyu suggested that patients of isometric exercise can increase muscle strength in the RA
should be encouraged to rest prior to fatigue to avoid a long patient. There is no proof that exercise can prevent the occur-
recuperative period. rence of deformity.
There are case studies which suggest that enforced inac-
tivity following hemiplegia, polio and peripheral nerve lesions
might have inhibited joint destruction in patients who subse- 4. Watch your weight
quently developed rheumatoid arthritis. 12·14 Mills et al,15 how- This advice is based on the assumption that excess weight
ever, were unable to demonstrate a substantial difference places unnecessary strain on load-bearing joints, increasing
between one group of inpatients at rest and another group pain during, for example, transfers and walking, and increas-
allowed activity. Alexander et al 16 suggested that the benefits ing the likelihood of joint damage.
of bedrest were less than expected and recommended careful In the quiescent phase of the disease, RA patients have
selection of patients. This view was supported by Lee et al,17 reported that joint pain is more severe during loading of that
Various authors have given specific advice on rest and joint than at rest. Therefore, an increased load (through obesi-
prone lying. Melvin18 advised patients to rest 10-12 hours out ty) should perhaps be expected to increase the pain experi-
of 24, including a 1-2 hour nap in the afternoon, to allow the enced.
body's restorative processes to help combat disease. She There is no proof that increased loading of joints has a
encouraged prone lying to reduce the risk of contractures.ie .Iong-term detrimental effect on joints diseased by RA. There
It is generally agreed that keeping active facilitates joint is also some doubt about the relationship between
mobility and muscle strength, and too much activity may osteoarthritis (OA) and obesity, although Van Saase et al 23
result in fatigue, increased pain and stress to the joints. were able to demonstrate a positive correlation between knee
Oordery- and Melvin18 advised patients to reduce their activity OA and obesity. However, they were unable to conclude that
if pain persisted for more than one hour afterwards. this reflected a true causal relationship.
Summary: There is some evidence to suggest that balanc- Summary: No firm evidence has been found to support the
ing rest with activity can increase overall endurance and inhib- advice that patients should 'weight-watch'. However, weight
it joint destruction. There is some very specific advice in the control seems sensible with regard to general health and
literature on the amount of rest required. However, there has mobility and is, therefore, encouraged by the authors.
been no study done to support the view that there is a specif-
ic period of rest that is the most beneficial to all RA patients.
The needs of each patient are likely to vary. 5. Find easier work methods and
organise your day
Therapists may be involved in supplying gadgets and giving
3. Exercise little and often advice on alternative methods of carrying out ADL tasks. Is
It is generally agreed that short periods of non-resisted exer- there any evidence that patients benefit from this interven-
cise at the correct time can be beneficial to the RA patient. tion?
This assumes that too much exercise at one time, or during It is thought that the occupational therapist can facilitate
the acute phase, can be detrimental. Trornblyn suggested the the patient's independence in ADL directly through analysing
use of exercise to maintain muscle power in order to help exactly what the problem is and why it is occurring.
maintain joint integrity and alignment, and to maintain or Introduction of the right gadget at the appropriate time may
improve the joint range of movement. Too much exercise may improve independence. Some attempts have been made at
lead to fatigue, joint strain and soft tissue damage, and correlating appropriate gadgets, for example, food preparation
inflammation. Too little exercise may lead to joint stiffness, aids, with patterns of disability and with the degree of pain
risk of contractures, and muscle wasting. experienced in their use. 3,4 Thus, certain gadgets have been
It may not be possible to give instructions on the amount shown to be useful.
of exercise necessary for the RA patient. This will vary Some attempts have also been made at assisting the
between patients because it is usually guided by the amount patient in ADL organisation. Furst et al9 used a new pro-
necessary to bring on fatigue. corcerv- and Melvin18 recom- gramme based on a workbook which emphasised developing
mended that pain or discomfort should not last for more than behavioural awareness and problem-solving skills, enabling
one hour following exercise. patients to make decisions when difficulties arose later.
There has been some discussion on the most beneficial Patients were asked to 'analyse activities according to
form of exercise for the RA patient. Studies have shown that potential energy use' and were given 'training in how to recog-
as few as three isometric contractions per day can significant- nise those activities that may cause pain and/or fatigue and
ly increase muscle strength in RA subjects. 20.21 Isometric how to modify them'. Furst et al9 termed this 'energy conser-
exercise is recommended because it is less painful, in addi- vation' and claimed that, through the use of this programme,
tion to passive or gentle assisted exercise, during the acute patients increased their amount of physically active time and
phase. 2o It has been' suggested that resisted exercises achieved a better balance of rest and physical activity.
should be avoided because they may be deforming due to the Summary: Patients have reported that some gadgets and
alteration of the relationships of tendons to axes of move- advice make their tasks easier. There is evidence that more
rnent.n Castillo et al7 provided some evidence to suggest that intense therapeutic intervention, through 'energy conserva-
'physical activity can lead to joint damage. tion',may be of benefit to the patient.
Patients may benefit from different forms of exercise at
each phase of the disease process. Tromblyu suggested that
as the disease activity subsides, patients should be encour- 6. Avoid deforming positions
aged to increase their active exercises for short periods, with- Patients are taught to avoid placing their joints into positions
in pain limits and balanced with rest. Melvin22 discussed the which are thought to exacerbate the development of deformi-
basic principles of exercise without attempting to describe an ties. corderyi publicised the idea that external and internal
exercise regime which could be generally applied. stresses and their direction influenced the development of

454 British Journal of Occupational Therapy, December 1991, 54(12)

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deformities in joints. Her advice to minimise these potentially
deforming forces in the hands was as follows.t
(a) Maintain range of movement of shoulder, elbow, forearm
and wrist because hand function depends on these joints
(b) Maintain coordination and balance of intrinsic and extrinsic
muscles
(c) Avoid strain on the collateral ligaments by enlarging the
handles of objects
(d) Avoid ulnar pressure at the MCP joints; avoid lateral pres-
sure at interphalangeal joints; and avoid abduction of the
thumb phalanges.
The efficacy of these measures in the prevention of
rheumatoid deformities will depend on the causative factors
involved. Ulnar drift is one of the most common deformities of
the rheumatoid hand and is therefore singled out for analysis
in this section.
Smith et al6,24 implicated the role of the long flexors in
ulnar drift deformity and volar subluxation of the MCP joint
and advocated that flexion at this joint during activity should
be minimised by splinting to reduce deforming forces. They
also advocated working splints to inhibit ulnar deviation.
However, Shapir0 25 was able to show that loss of carpal sta-
bility could lead to radio-metacarpal shift and assumed this to
be a causative factor in the development of ulnar drift, the
implication being that the fingers need to move ulnarward in a
compensatory way to maintain hand function. Support for this
view is provided by a study from Pahle and Raunio.26
Taleisnik27 and Wise28 implicated radial/ulnar variations in
intrinsic muscle attachments as causative of ulnar drift.
Hakstian and Tubiana29 implicated the MCP joint structure
and radial/ulnar variations in collateral ligaments.
All the studies outlined above have used many suojects,
with observation and measurement from in-vitro studies,
cadaverous hands or x-ray examination. By contrast, evidence'
for the role of functional patterns of use has been largely
anecdotal. Lush,3o Fearnley31 and Flatt32 postulated a role for
the effects of gravity, disturbed function and pressure of
usage but provided no evidence for this. Vainio and Oka33
studied the MCP joints of 292 patients and found double the
commonality of ulnar drift in females. They postulated two rea-
sons:
(a) There is more delicate bone structure in females
(b) Females are often obliged to go on with household work
during the active stage whereas men have more opportuni-
ty for rest. 33
Ellison et al34 postulated that children were least affected
since they had no domestic or economic obligations.
Hasselkus et al35 attempted to test the concept that joint
stress during daily activity resulted in deformity, by looking at
differences in deformities between dominant and non-domi-
nant hands. They hypothesised that the dominant hand was
subjected to greater stress during daily activities and that this
would be reflected in their findings. Instead, they found no sig-
nificant difference in the incidence of rheumatoid deformities
between the hands.35 Mody et al36 confirmed the result.
Summary: Many factors have been implicated in the devel-
opment of ulnar drift. It is therefore unclear whether or not
there is a single main determining factor. It remains unproven
that functional patterns of use lead to deformity at the MCP
joints.
7. Be aware of posture and joint
position at all times
Tromblyll suggested that patients should be encouraged to
'use each joint in its most stable, anatomical and functional
plane' and use 'correct patterns of motion' in order to min-
imise pain and protect joints against deforming forces.
British Journal of Occupational Therapy, December 1991, 54(12)
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Therapists encourage patients to be aware of posture during
rest, sitting and standing. General advice on maintaining a
good posture during activities is well documented. ll,18,19 No
research specifically on posture to support the benefits of
this advice was found.
8. Spread the strain over many joints
or one large joint
Corderyi emphasised the 'use of the strongest joints avail-
able for the job'. Large joints are protected by stronger mus-
cles than the smaller joints. The assumption is that a reduc-
tion in strain will:
(a) Reduce pain experienced during the activity
(b) Reducejoint damage over the longer term.
The level of patient pain/discomfort will determine the suc-
cess of this instruction in the short term. If the patient does
not experience significant pain, he/she may be unaware of
the need to reduce the loading. However, from studies done
on the use of gadgets there is some evidence to support the
idea that spreading the strain does reduce pain experienced
during activity.3,4
In the absence of pain, patient compliance to this principle
may still be worth attaining if evidence can be found that joint
stress leads to joint damage in the long term. There are sev-
eral studies relating handedness to joint erosions. Mody et
a136 studied 256 patients and found significantly greater radio-
logical changes in the dominant hand, especially in the middle
and index fingers. They postutated that the severe involve-
ment of these fingers might be related to their greater use in
daily activities. Owsianik et al37 demonstrated significantly
greater joint destruction in the dominant hand; this difference
was seen in all joints, especially the wrists, but with the
exception of the MCPjoint of the thumb.
Summary: There is some evidence that spreading. the
strain leads to a reduction in pain experienced during certain
activities. There is also some evidence to suggest that
increased joint stress in the hand can lead to increased dam-
age in selected joints.37 However, this assumes that the domi-
nant hand is more stressed than the non-dominant hand; if
this is the case, why is the thumb comparatively spared given
its major role during hand function?
9. Wear your orthoses - hands and
wrists
The wearing of orthoses is thought to assist the RA patient in
the followingways: protection, support, rest and prevention of
deformity.
Protection: It is thought that MCP joint synovitis may lead
to laxity of the capsule and ligaments, encouraging the forma-
tion of deformities. Therefore, if therapists protect the joint
structures through splinting during exacerbations, they may be
helping to prolong joint integrity, for example, by rest
orthoses. Spinner and Keplan38 suggested the early use of
wrist supports to protect ECU and therefore the stability of
the wrist.
Support: Patients have reported a reduction in hand func-
tion as a result of wrist pain. When the wrist is supported in
an orthosis, pain is reduced and hand function improves.
Rest: It is thought that joint motion aggravates inflamma-
tion and increases pain. Therefore, to immobilise the joint in a
splint should reduce stress to the capsule and ligaments,
allow the muscles to relax, eliminate pain with motion and
reduce inflammation. Partridge and Duthie39 and Gault and
Spyker40 have produced evidence to support this.
Prevention or correction of deformity: Splintage has been
used to correct or minimise joint contractu res through gentle
455
passive stretching, though no study to show that this is effec- required in all aspects of joint protection. (A summary of the
tive was found. findings is provided in Table 1.) The authors suggest the fol-
Splintage has been used in the management of ulnar drift. lowing items as worthy of further study:
Pahle and Rauni0 26 found evidence to suggest that splinting (a) The relationship between functional patterns of use and
the wrist in ulnar deviation can reduce or eliminate radial devi- rheumatoid deformities
ation as a contributing factor to ulnar drifting of the fingers, (b) Can exercise influence the progression of deformities?
the 'Zig-zag deformity'. (c) Does joint stress lead to joint damage in the long term?
Splintage has been used in the management of MCP joint (d) How effective are orthoses in the prevention of deformi-
subluxation. An ulnar cuff orthosis may be used in an attempt ties?
to minimise the damaging influence of the long finger flexors
Table 1. Summary of findings
on the MCP joints during grasp.> It is suggested that the use
of this orthosis may also discourage the development of fin- No firm
Evidence to Evidence to evidence
ger swan-necking in some patients, by stretching the intrinsics Principle support disclaim found
and encouraging proximal interphalangeal (PIP) joint flexion
with the MCP joints blocked in extension, although there is no 1. Avoid gripping too tightly .I
2. Balance rest and activity .I
evidence to support the efficacy of this. 3. Exercise little and often .I
Summary: There is no study to confirm the benefits of 4. Watch your weight .I
wrist supports as reported by patients. No evidence has been 5. Find easier work methods
found to support the view that orthoses are effective in pro- and organise your day .I
6. Avoid deforming positions .I
tection of joints. Studies have indicated that resting joints in 7. Be aware of posture and
orthoses may be effective in reducing inflammation, and joint position at all
patients have reported that they are useful in reducing pain times .I
experienced. 8. Spread the strain over
Pahle and Rauni0 26 have shown how splinting the wrist can many joints or one large
joint .I
influence the progression of ulnar drift in some patients, but 9. Wear your orthoses .I
there is no study on the application of splintage for preventing 10. Listen to your body .I .I .I
other types of deformity.
There is no detailed research on the long-term benefits of
The review has examined the basic principles of joint pro-
splintage, although Karten et al41 suggested that splinting is
tection. However, there are wider issues worthy of discussion,
unlikely to prevent hand deformities if synovitis persists.
and the following questions need to be raised:
- Is it possible to teach joint protection?
10. Listen to your body - Is it necessary to teach it?
Patients are encouraged to be aware of the sensation of pain - Are there more effective ways of influencing disease pro-
as a guide to overuse of the joint (that is, pain avoidance) and gression?
as an indication of joint inflammation necessitating rest. The Patient education groups are widely used in the treatment
degree of pain experienced and the levels of inflammation of arthritis, but there is conflicting evidence about their effec-
present may not be closely correlated because pain is a sub- tiveness.
jectiveexperience influenced by many other factors - psy- There are studies of these groups which indicate that
chological, cultural and emotional.42 Therefore, it has been patient knowledge about the disease does improve44-46.50.51
suggested that therapists should treat pain with reference to and also claiming effectiveness in gaining compllance-e and
a behavioural model rather than in a purely physiological self-reported behaviour change. Furst et al9 claimed to have
way. 2,43 effected significant behavioural change through teaching ener-
Encouraging awareness of joint sensation may influence gy conservation techniques with only six sessions lasting 1 1/ 2
the pain threshold. Parker et al,44 in a study of a joint protec- hours each plus home tasks. Lorig et al,46 in a self-help edu-
tion patient education group, found an increase in pain experi- cational programme taught by laypersons, claimed that sub-
enced by this group when compared with a control group. jects exceeded controls in recommended behaviours at 4
Another study of a similar patient education group found no months after the programme, and that these changes
effect on patient pain.45 Lorig et al46 claimed that patient pain remained significant at 20 months.
in their education group had decreased compared with con- There are studies which indicate that educational groups
trols. Others have claimed similar results on reducing pain have been less effective in reaching their objectives. Cohen et
using group work with various behavioural training pro- al45 compared the relative effectiveness of a patient educa-
grammes.47,48 tion course led by laypersons and a similar course· using
Huskisson and Hart49 found a significantly higher pain health professionals and found that neither was any more
threshold in patients suffering from ankylosing spondylitis effective than non-intervention in improving health behaviour
(AS) compared with RA patients. They postulated as a possi- beyond that of exercise. Hammond52 analysed behaviour fol-
ble explanation •.., the different attitude transmitted by the lowing joint protection education and discovered an obvious
physician to the patient with this disease. They [AS patients] discrepancy between observed and self-perceived joint care
are encouraged to lead normal lives, remain mobile, and take behaviour. She suggested that education leads to attitudinal
up rather than give up. The patient with RA is encouraged to change but behavioural change may require longer and more
rest and protect his joints. '49 targeted input. 52 Before it is possible to evaluate if education
Summary: It is not proven that 'listening to your body' is is effective, there is a need to establish that behavioural
beneficial to the RA patient. There are some studies which change has actually taken place.
suggest that the therapist's intervention may even be detri- Is it necessary to teach 'joint protection'? Callahan and
mental. Pincus53 may have provided a rationale for patient education
(in the widest sense) for the individual with RA. They studied
385 patients and found the poorest results in patients of a
Discussion lower formal education level, and progressively better results
This literature review has shown that further research is in those with a high school education, high school graduates,

456 British Journal of Occupational Therapy, December 1991, 54(12)

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and those with some college education, but no differences in
those who had attended college or graduated or were post-
graduates.53 If this finding is reproducible in the UK, it has
implications for the teaching of joint protection techniques; it
suggests a need for more teaching input for low academic
achievers, if only because these are the patients who are like-
ly to be the most severely affected by the disease.
The present approach to joint protection at the Guest
Hospital is rather mechanistic: patients are told that if they
follow the above principles (1-10) it will help to minimise the
effects of the disease on their bodies. However, this mecha-
nistic and rather physiologically based approach may not be
the best way to prevent disability. There is mounting evidence
that the major determinants of disability progression are not
physical but psychological. 54-60
McFarlane and Brooks54,55 have shown that psychological
factors predict more of the variance of disability than disease
activity. These factors are associated with the tendency to
deny the emotional dilemmas caused by having a chronic ill-
ness, difficulty in accepting doctors' reassurances and clinical
depression. McFarlane and Brooks55 showed few significant
relationships between duration of illness, disease severity
and the psychological measures, but a strong correlation
between disability and attitude to illness. Hawley and Wolfe56
showed that the development of depression in RA was associ-
ated with socioeconomic and not clinical factors, and disease
activity appeared to have a limited effect on psychological sta-
tus. Frank et al57 showed a significant relationship between
the presence or history of depression and higher levels of
pain. They too found no significant relationship between cur-
rent depression and common indicators of RA activity.
The recent studies referred to above pose a question
which occupational therapists working in rheumatology cannot
afford to ignore. If the ultimate goal is to reduce disability,
should therapists now be adopting a more psychodynamic
approach?
Conclusion
Patients with RA will always have problems with completing
their ADL tasks, so the need for occupational therapists to
assess these problems and provide appropriate advice and
gadgets will remain a priority. Many therapists working in
rheumatology spend some time teaching joint protection in an
attempt to influence disease progression. Mounting evidence
for the importance of psychological factors for disease pro-
gression suggests that therapists may need a new hypothesis
to provide a rationale for a different approach to disease-
modifying therapy. This new approach may involve an attempt
to influence more directly the psychological factors shown to
be most disabling to the RA patient.
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457
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Equipment Review: Adapted Tricycle
Children with cerebral palsy benefit in many ways from the
ability to be mobile'! It gives them the freedom to explore
their environment as well as the opportunity to initiate interac-
tion with their peers on an equal basis. Independent mobility
can be achieved by self-propulsion (crawling, walking, cycling,
self-propelling wheelchair) or by powered mobility (power
chair). The former method has the advantage of mobility com-
bined with active exercise for the child. Many children with
severe cerebral palsy are unable to walk without assistance
and even with assistance have difficulty achieving a good
walking pattern. A tricycle allowing self-propulsion and a good
movement pattern can provide an alternative solution.
At Chailey Heritage Rehabilitation and Development
Centre, special adaptations have been made to standard
Pashley Pickle and Polo trikes to allow children with severe
cerebral palsy to cycle independently. The posture induced on
the trike compares closely to postures achieved with other
types of saddle seating. 2 .3 and carries through the therapeutic
benefits of this posture with mobility.
The standard saddle is replaced with a special Evazote
saddle, shaped to allow the ischial tuberosities to rest on a
flat surface with a narrow raised wedge anteriorly (see dia-
458
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51. Spiegel TM. Knutzen KL, Spiegel JS. Evaluation of an inpatient
RA patient education program. Clin Rheumatol 1987; 6(3): 412-
16.
52. Hammond A. Joint protection behaviour of patients with RA fol-
lowing an education programme. Southampton: Department of
Rehabilitation Studies, University of Southampton. 1988.
53. Callahan LF. Pincus T. Formal education level as a significant
marker of clinical status in RA. Arth Rheum 1988; 31: 1346-57.
54. McFarlane AC. Brooks PM. Determinants of disability in rheuma-
toid arthritis. Br J Rheumato/1988; 27: 7-14.
55. McFarlane AC. Brooks PM. An analysis of the relationship
between psychological morbidity and disease actiVity in rheuma-
toid arthritis. J Rheumato/1988; 15(6): 926-31.
56. Hawley OJ. Wolfe F. Anxiety and depression in patients with
rheumatoid arthritis. A prospective study of 400 patients. J
Rheumato/1988; 15(6): 932-41.
57. Frank RG, Beck NC. Parker JC. et al, Depression in rheumatoid
arthritis. J Rheumato/1988; 15(6): 920-25.
58. Hagglund KJ. Haley WE. Reveille JD. Alarcom GS. Predicting indi-
vidual differences in pain and functional impairment among
patients with rheumatoid arthritis. Arth Rheum 1989; 32(7):
851-58.
59. Keefe FJ. Brown GK. Wallston KA. Caldwell OS. Coping with
rheumatoid arthritis pain: catastrophismg as a maladaptive strat-
egy. Pain 1989; 37(1): 51-56.
60. Crosby U. Stress factors, emotional stress and rheumatoid
arthritis disease activity. J Adv Nurs 1988; 13(4): 452-61.
gram). A forward support attached to the saddle provides
adjustable anterior and lateral trunk control. A Velcro strap
across the back provides additional security. The anterior
chest support encourages the trunk weight forwards over the
sitting base and shoulder girdle protraction which allows the
arms to come to a forward prop position. Straight handlebars
facilitate this position and maintenance of hand grasp. Wrist
supports, footplates and footstraps can be added as appropri-
ate.
It is recommended that a cycle safety helmet is worn at all
times when the child is cycling.
Catharine Mulcahy. Research Occupational Therapist.
Teresa Pountney, Research Physiotherapist.
Geoffrey Billington. Medical Technical Officer,
Chailey Heritage. Rehabilitation and Development Centre,
North Chailey, Nr Lewes, East Sussex BNB 4EF.
Acknowledgements
This Item of equipment was developed in the Rehabilitation
Engineering Unit, Chailey Heritage. as part of a project developing a
total postural management approach for children with cerebral palsy.
The authors are grateful to Action Research for funding this project
and to Mark Edmondson-Shawfor the drawing shown.
A similar review was published in Physio-
therapy 1991; 77(10): 660.
References
1. Trefler E. Marcrum J. Trends in powered
mobility for school aged physically handi-
capped children. Proceedings RESNA 10th
Annual Conference. San Jose. California:
RESNA 1987.
2. Stewart PC. McQuilton G. Straddle seating
for the cerebral palsied child. Physio-
therapy 1987: 73(4): 204-206.
3. Pope PM. Booth E. Gosling G. The devel-
opment of alternative seating and mobility
systems. Physiotherapy Pract 1988; 4: 78-
93.
BritiSh Journal of Occupational Therapy. December 1991. 54(12)