Pain-Free Living

Caring for Your Amazing Hands

by Nancy Callinan, MA, OTR, CHT

Our hands are truly amazing. They let us communicate with a gentle touch or a firm handshake. They let us pick a delicate flower without crushing it or grip a sturdy tool tightly. Because we rely so much on our hands for our daily activities, we need them to function well. We need them to be strong and flexible, with joints that move smoothly. But the pain of arthritis can limit the way we use our hands. So can the loss of flexibility and strength that arthritis often brings. Fortunately, there are ways to protect the hands and maintain their mobility and strength. Let’s look at some of them.

Protecting your joints

One of the most important things you can do for your hands is to avoid stress on them and protect the joints that hurt. It’s difficult to avoid painful activities entirely. But by making a few minor changes in how you do certain things, you can reduce the stress on aching joints.

In osteoarthritis (OA), the tip and middle joints of the fingers and the wrists are commonly affected as cartilage wears away and bone spurs develop. But the joint most likely to give you trouble is the joint at the base of the thumb, where the thumb joins the wrist. Normally, this joint has tremendous flexibility, allowing you to hold a large milk carton or do up a small button. During the course of a normal day, you put that joint under a great deal of stress every time you use a pinching motion at the tip of the thumb — to turn a key, for example, or open a jar. Whatever force you use at the tip of the thumb is multiplied 12 times at the base of the thumb. Obviously, the more you can avoid stress on the joint, the better.

In rheumatoid arthritis (RA), there can be damage to the tendons and ligaments that support the joints and keep them properly aligned. The wrist joint and the knuckles are commonly affected and can become painful, unstable, and deformed. The fingers may lean toward the little finger (ulnar drift deformity). There may also be changes in the middle joints of the fingers. They may take on a permanently bent position (boutonniere deformity) or become permanently hyperextended (swan-neck deformity). Avoiding excessive stress on the joints can reduce pain and help you prevent or limit deformities.

Here are some simple strategies you can use to protect the joints of your hands while doing everyday activities.

Listen to your body. Think of pain as nature’s warning that you need to modify an activity. If your fingers hurt when you squeeze a tube, use your palms to do the squeezing. If your thumbs hurt, avoid pinching.

Use two hands whenever possible. You will have more strength and stability when you use both of your hands to lift or support an object. For example, rather than lifting heavy plates by grasping them with your thumbs, try carrying the plates across your palms.

Do it differently. Shaking hands can be painful for people with arthritis. You can avoid some of the firm gripping by extending both of your hands and grasping the other person at about the wrist. This will allow you to give a welcome greeting without suffering from the enthusiastic tight-gripper. Here’s another idea: Rather than holding a book with your thumbs, hold it between your open palms, one on top and one on the bottom. Or use a book rest that can hold the book open on the table.

Easy does it. Using precut veggies, easy-open containers, and quick-fix recipes will not only save you time, it will also make cooking much easier on your hands.

Take a break. When doing tasks that put stress on your hands, such as holding tools or doing repetitive gripping, make sure to give your hands an occasional break and stop to rest or stretch. Some people even find it helpful to set a timer so they don’t forget to take a break.

Mix it up. Alternate heavy and light tasks throughout your day. For example, if you need to do a lot of computer work, mix in other tasks that will allow you to rest your hands and use other muscles.

Adapt and modify. Lots of commonly used items have been or can be adapted or modified to make them easy on your hands. The following are some of my favorite items:

• The PenAgain is a modified pen that allows your hand to assume a more relaxed writing posture so that you don’t have to pinch as much with your thumb. For those using a standard pen, there are rubber pen grips you can put on the pen to make it easier to grip.
• Garden gloves with a rubberized palm can provide just the traction you need to turn a tight faucet or gas cap or open a tight lid. They can provide extra grip for jobs requiring resistance, while maintaining a good grip in both wet and dry conditions.
• The PurrFect Opener allows you to use one tool to easily open pill bottles, water bottles, and many other containers.
• The 5-Way Opener is a very handy device for opening almost any kind of top, including bottle caps, twist-top caps on soda or water bottles, jar lids (it allows you to “pop” the lid to relieve the pressure), pop-tops on soda cans, and pull-tabs (as on cat-food or tuna cans). The 5-Way Opener is available at many stores.
• Mandoline slicers make it easy to shred, slice, julienne, and waffle-cut vegetables. You only need to hold a handle that slides the vegetable over the slicing blades.
• Large knives with an offset upright handle (that is, a handle that is perpendicular to the blade) can be held securely in the hand, reducing pressure and stress on the thumb and fingers during cutting.

Exercise

There are many exercises that can reduce pain and improve mobility in the hands. They include range-of-motion and stretching exercises and strengthening exercises.

Range-of-motion and stretching exercise. It’s important to move the fingers through their full range of motion to maintain their flexibility and dexterity. Exercises that do this are called active range-of-motion (AROM) exercises, and you should do them daily. For joints that are particularly stiff or tight, stretches are valuable to improve mobility. The difference between range-of-motion exercises and stretches is that range-of-motion exercises seek to maintain range of motion, while stretches push the motion a bit to improve range of motion. It’s best to do range-of-motion and stretching exercises in the morning to help you loosen up. You’ll find them easier if you warm up your hands first (see “Using heat and cold” below). Take care not to overstretch joints that are already loose or unstable, though. For these joints, focus instead on strengthening the muscles around them.

Strengthening exercise. Muscles provide support for joints, and it is especially important that muscles surrounding joints affected by arthritis give good support. That’s where strengthening exercises come in. A type of strengthening exercise called isometric exercise is especially good if you have arthritis because it allows you to contract the muscles without moving the joint, which can be painful.

Strengthening exercises usually require resistance to make the muscles work harder and grow stronger. In isometric exercises you create the resistance when you hold a tensed muscle, as when you push down against a table or other immovable object. The contraction is held for 5–10 seconds and repeated several times.

For examples of hand exercises you can do at home, see “Sample Exercises.”

Using heat and cold

Heat and cold can provide some relief for hands affected by arthritis. Whether heat or cold works best for you depends on several factors. If your joints are stiff in the morning, you may benefit from applying heat to them. Doing so causes the soft tissues around the joint to become more extensible (stretchy). Heat may also reduce pain, increase blood flow to an area, and relax tight muscles. There are many ways to apply heat to your hands. These include using whirlpool baths, warm-water soaks, hot packs, paraffin wax baths, and gel packs or mitts. Even wrapping your hand around the warm coffee cup in the morning may give you some short-term relief from stiffness.

Here’s an idea you can use at home: Fill a sock with slow-cooking rice (jasmine rice works well). Either sew up the end of the sock, tie it, or use a rubber band to secure it. Heat the sock in a microwave for 30–60 seconds. Lay your hand on top of the sock or wrap the sock around your hand for immediate soothing warmth. You can also buy microwaveable warming mittens, which are perfect for a quick warm-up.

Using heat is not recommended if you have impaired sensation, compromised circulation, or acute inflammation (as may occur during an RA flare-up). If you have acute inflammation, cold may be the better treatment. Cold effectively reduces pain, inflammation, and swelling. In cases of acute swelling in the hand, often it is beneficial to elevate the hand and to apply some pressure to it to control the swelling. Cold gel packs or bags of frozen vegetables work well for this. Another idea is to put an ACE wrap or other elastic bandage in the freezer and apply it when it’s cold to the wrist or hand. However, you should not use cold treatments if you have cold intolerance (Raynaud phenomenon) or have a circulation problem affecting your hands.

Wearing splints

Hand or wrist splints provide support to painful joints and can ease the stress of daily activities. For people with RA, they can decrease pain, reduce inflammation, and hold the joint in a more functional position. Some splints, called resting splints because they rest the joints, are most often worn at night. Others are for use while you’re using your hands.

Wrist splints are commonly used to relieve pain and inflammation in the wrist. These splints usually hold the wrist in a functional position while leaving the fingers and thumb free. The splints can come premade or be custom-made to fit your wrist. However, by limiting wrist motion, splints can interfere with functional ability. One study assessed five different styles of premade splints. Each of them made it more difficult to move or use the hand to some extent. Another study found that only a little more than half of people with RA who were given wrist splints used them. People need to work with their therapists to determine the best times to wear the splint so that they gain the most benefit with the fewest limitations.

Thumb splints can be extremely useful when pain at the base of the thumb from OA limits daily activities. Thumb splints support the thumb and limit its motion. You can have a custom-made thermoplastic splint or a soft splint fitted by an occupational therapist or specially trained hand therapist to provide just the support you need to continue doing daily activities. Some people find that, after they’ve worn a thumb splint for several weeks, the pain subsides enough for them to wear it less often. Then they may wear the splint only during stressful activities.

One small study compared soft premade splints made of neoprene (a type of synthetic rubber) with custom thermoplastic thumb splints in 25 people with early-stage arthritis of the thumb joint. After wearing each type of splint, the study participants reported significant pain relief with both splints; however, most of them found that the soft neoprene splint relieved pain more and was more comfortable.

For finger joints deformed because of RA or other inflammatory arthritis, there are splints you can wear to hold the joints in a more functional position. For example, silver ring splints, which are designed to look like rings, help with problems such as ulnar drift, boutonniere deformity, and swan-neck deformity. These splints are custom-designed and are measured and fitted by a therapist.

Taking medicines

Medicines for arthritis in the hands are for the most part the same as the medicines used for arthritis anywhere in the body. They include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn). These drugs are commonly used to treat people with all types of arthritis.

For people with inflammatory arthritis, disease-modifying antirheumatic drugs (DMARDs) can help reduce symptoms. DMARDs include methotrexate (Rheumatrex, Trexall), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), and azathioprine (Imuran). A subset of DMARDs called biologics are now also frequently used to treat inflammatory arthritis. They include etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira).

More specific to the hands are corticosteroid injections. Corticosteroids are drugs that reduce inflammation. (Prednisone is a common example.) They can be taken orally to treat inflammation throughout the body in people with inflammatory arthritis. As injections, they are used to treat both OA and inflammatory arthritis in specific joints. One injection directly into a painful wrist or thumb joint can provide pain relief for weeks or even months. However, since there are potential side effects of corticosteroids, the number of repeat injections you can have is limited.

Having surgery

If the conservative treatments described above fail to relieve pain, or if function is severely limited, surgery may be an option. There are many surgical procedures for the treatment of arthritis in the hands, and the best choice is made following careful consideration of the risks and benefits of each. An experienced orthopedic surgeon who specializes in hand surgery can help you understand your options. Surgery is rarely done for cosmetic reasons only, but appearance of the hand is a consideration.

For arthritis in the hands, there are three main surgical options: arthroscopy, joint fusion, and joint replacement. An arthroscopy provides simple removal of damaged tissue through small incisions. For example, a person with OA may have bone spurs removed from a finger joint. A person with RA may have inflamed portions of a tendon or inflamed joint lining removed. In joint fusion, the ends of the two bones in a painful joint are fused. This procedure relieves pain in the joint but also eliminates all movement of the joint. Joint fusion is most common in the tip and middle joints of the fingers. It may also be used in the wrist.

Joint replacement can provide pain relief and improved functional mobility. Most of the major joints of the hand and wrist can be replaced. Joints commonly replaced include the joint at the base of the thumb and the large knuckles of the hand.

In a common procedure to replace the joint at the base of the thumb, surgeons remove a wrist bone called the trapezium. Then they use an artificial spacer to fill up the space the trapezium used to occupy. Or they take a nonessential tendon from another part of the hand, roll up part of it, and use that to fill the space. They may also use tendon tissue to reconstruct the ligaments that support the joint. Research shows that removing the trapezium and using tendon tissue to fill up the space and to reconstruct ligaments is highly effective for treating OA at the base of the thumb. Thumb stability, pain relief, and improvements in strength are the expected outcomes.

The large knuckles of the hand, often affected by RA, can be replaced with silicone implants. These joint replacements have been performed successfully for more than 40 years. Studies have reported improvement in mobility and strength following knuckle replacements. The replacements allow people to open their hands wider, and they correct for ulnar drift. The middle joint of the finger can also be replaced, as can the tip joint, although the tip joint is more commonly fused.

After joint replacement surgery, your hand may at first be protected in a cast or splint. Afterward, you will begin physical rehabilitation under the supervision of a hand therapist. During this recovery period, you may be limited in how you can use your hand and will need to modify your daily activities. People are usually able to resume most of their daily activities after three months.

Your hands need proper care. Protecting your joints by making changes in how you do your daily activities, preserving motion and strength by doing exercises, using heat or cold and splints to reduce pain — all of these strategies will go a long way toward maintaining the harmony of movement, dexterity, and strength that will keep you doing what you love to do. The proper medicines also have a role to play, and if you need more help to keep your hands functioning well, surgery may be the answer.

Last Reviewed September 15, 2010

Nancy Callinan is Manager of Hand Therapy at TRIA Orthopaedic Center in Minneapolis, Minnesota.

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