Welcome everybody. Welcome to our session on assistive devices for small joint preservation. Our speaker today is Trish Pelc, who works in the Rehabilitation Department here at HSS. She is an Occupational Therapist and a Certified Hand Therapist and has brought a number of items to show you as well as addressing and discussing items that you have brought in to take a look at.
Trish Pelc: Small Joint Protection is a great topic to discuss. It is something we can discuss for healthy joints and for joints that are affected by arthritis as it crosses the whole span. In today’s session, I thought I’d go over some of the main principles and specifics about assistive devices. I will show you what I brought in and then we will discuss what everyone else has found useful in their own journey.
So I put together this presentation called Show-and-Tell, Assistive devices for Small Joint Protection. Basically, why do we need assistive devices. Sometimes unlocking doors is a problem and we are starting to calculate the risks our actions place on the health of our joints. I put this picture in because even doing something with one finger can stress some of those ligaments in that finger.
We unintentionally make our hands feel worse all while searching for answers to our biggest query, "is there a better way"? And I know through my experience talking with people, they often find that even signing their name sometimes is difficult.
So what is assisted technology? Assisted technology is any item, piece of equipment, products, system whether acquired commercially, off the shelf, modified or customized that is used to increase, maintain or improve functional capabilities of individuals with disabilities. This is a definition written by the Technology Related Assistance for Individuals with Disabilities Act in 1988. The term has been used interchangeably with terms such as assistive devices, adapted equipment and assistive technology. A lot of times this will be highlighted in the New York Times or Wall Street Journal. It is becoming a really hot topic right now. And so you will see these names used interchangeably, but it is all the same thing.
So what is the goal of the assistive devices? Basically, it used to protect the involved joints from any stress. It is actually to protect the uninvolved joints from stress and this here is one of the most stressful activities you can do, turn the key in a lock and open the door because there is a loss of stressors, which we will discuss later.
So there are two things to consider for using assistive devices. One is external pressure and the other is internal pressures and these two things are how the assistive device or the motion is going to affect your body or your joints. Right now we are going to discuss the small joints in our hands because it is how we function in terms of what is in front of us.
External pressures are forces that are placed on our joints through the use of odd shaped objects or slippery surfaces. If you are trying to turn a jar that is kind of sticky or open a bottle something Also, tightly fit objects or lids or caps that haven’t been opened, even medicine bottles, small handles or odd objects in your kitchen, small knives, work bench tools, small screwdrivers or hammers or cold objects will affect your small joints.
Basically, most joints tend to become distressed while they are in a flexed or bent position. For example, you might notice if you’ve been driving in your car for a little while, you will try to open your hand and it will be feeling stiff because you’ve been in a half an hour of a flexed or bent or fist position. So these are things that lead the joint to become distressed. Also gripping objects tightly can cause harmful internal tensions on the joints caused by the finger muscles. Also if you grip joints tightly for a long period of time it fatigues the muscle and when the muscle is fatigued it isn’t as able to support that joint or those actions. Also poor placement of the hand on an object stresses the ligament. So if you reach for something on a counter and you are putting your hand in a small space and only have your finger tips on it, it is going to stress your joints more than if you got a good hold of it with two hands. The same goes for poor position on an object.
There are some things that you want to avoid when you are using any type of assistive device or other devices, is to avoid ulnar deviating pressures. This means that pushing your finger sideways and away from the thumb, or any motion that pushes your hand away from the thumb. Some of the more common actions that cause this to happen is holding a knife, lifting plates. This is not a plate but you can see if I raise this, the weight of the plate is going to push my fingers away from my thumb. Lifting up sauce pans do the same thing, opening a jar and even closing a jar, turning a door knob, pushing a drawer. If you are going to push in a drawer this way, you are actually creating stress. Also ringing out cloths or clothes. So these are activities that are going to cause stress to your joints and activities that we could definitely use assistive devices for.
Another thing is avoiding activities involving tight grasps. Some suggestions are to choose kitchen or work shop tools with larger rounded or contoured handles. You can also use a spike board, on a bench if you are cutting on a cutting board, you don’t have to hold onto that cucumber or that tomato when you are cutting it. Also gripping objects between the palm of both hands instead of holding onto a mug with the fingers.
Also another thing you want to do is avoid the sustained positions. Maintaining grasps or one position tires the muscles quicker. So again, you really need to have healthy and strong muscles in order to support the joints. One thing we try to do is condition and strengthen that part of everyone’s daily routine. But for the fingers it is a really hard task. The muscles that operate the fingers are in your forearm. They are not in your hand. You’ve got tiny little muscles in your hand that do some of the stability work but the big muscles in the forearm are the muscles that work it. So you want to avoid maintaining a strong grasp for too long so you don’t fatigue the muscles. For example, a lot of people read the Sunday Times and that takes everyone a couple of hours to do. If you are constantly holding that paper with your fingers in that position, you’ll notice that it will start to tire the small muscles in your hand for a long period of time. A better way to do it is to place the paper down on a table and read it that way or just read a section at a time and fold it or have it on your lap.
Also you want to stop sustained activities before your muscles feel tired and then resume the task later. So if you have a stack of ironing to do or if you just have a sewing project or if you want to garden because it is perfect weather and you’ve got two hours before its going to rain, you don’t want to do tasks for two hours straight because you are going tire and possibly fatigue the joints out for the next couple of days. Take a chunk of time and do a little bit and then take a 20 minute to half an hour break and you’ll really notice that you are going to preserve the small joints and muscles.
Now we are going to talk about some of the devices that you may see when you are walking through a store. Some things you want to consider are increasing a lever arm. A lever arm, the picture on the right, it is a door knob, a lever-arm door knob is actually sort of a rod whereas a door knob is usually a knob. So basically you want to increase the lever-arm and the objective is that if you increase the lever-arm of an object it will decrease the torque which is the force required to turn the object around its axis. Now that is kind of a complicated explanation but you can see if you are going to open the door on the right hand side of your screen, you can just tap down on the lever-arm handle and the door will just open. And if you are going to open the door knob on the left side of your screen you would actually have to turn the door knob and you would actually have to grasp the door knob, maintaining that grasp and turn. So there is a lot more effort in turning that door knob on the left side of the screen. Therefore a longer lever-arm allows for more stability at your core and less bending and stretching.
So lever-arms are not just for door knobs. Some of you may have seen long handled reachers or longer tool handles, anything that extends a handle is considered a lever. I am going to show you some examples of levers. Everything I will show you today I brought with me. Here we have a pair of ice tongs. With tongs, you can use a bigger muscle instead of using the little tiny muscles and you can use the bigger muscles and you are able to pick things up a little easier. And this is an example of a long-handled reacher.
I also want to say before I go any further is that every single item that I brought in today I picked up at Bed, Bath and Beyond. I am not advertising for Bed, Bath and Beyond, I have no financial consideration with them but it is just a regular store that is in almost every community. You can also find these items in Macys and other stores but I wanted to go to a store that we all know about. For example the long handled reacher on the bottom was 9.99. The ice tongs were 2.99. You don’t have to order from a catalogue.
On the right hand side of the screen you will see what is called a grip wrench. It has the top part, the loopy part there which is sort of a lever, it actually comes with a set of 2 also for $9.99. It is a loop of rubber and it comes in two different sizes and this is the larger size with a very easy to handle knob item. I press it in and I tighten this around whatever I want. We actually used this yesterday around one of these bottles tightened this and tightened the clip so it creates a lever. You can open sauce jars and you can open anything it is really efficient and its adjustable so you can do different sizes.
So these are things that once you see the principle you will walk into that store and spot things like this and say "oh I never even thought that was going to help me" you just thought it was another gidget or gadget. But these kinds of items actually could be useful and are easily obtainable.
Another thing that you obviously want to do is increase the circumference of an object which also promotes the use of the larger joints for the same motion. So here is an example, a lot of people say holding onto a knife and cutting vegetables for salad is difficult. This is the quick chop that you put the vegetable into the bottom then you press the top with your palm and it chops up your vegetables. It does a really nice job and it is easy to clean. There are other products that let you get more high tech. This product is a cutting board but you can see the hand is placed on the top, and you can use your whole hand to slice tomato. It has different attachments and you can just rinse it out and you’re done. It is an easy set up and again you’re not getting those stressors because you are using your entire palm and your entire arm so you are saving your joints.
And this is also another example that I found at the hardware store. It is a foot switch that you attach to the lamp and you can tap it or you can step on it with your foot. The only thing with this is to be careful not to trip over the cord.
Some people only need to use assistive devices in the morning because they have some morning stiffness. But remember that devices aid the biomechanics of unaffected joints, so if it is just your thumb that is affected and you are coming up with different ways to do things you might be changing the normal function of your fingers. Just be a little more careful about that as well as inappropriate use because, you might increase the force on a joint. So if you think you are doing a better way, just watch your hand while you are doing it because if you think your hand or fingers are bending the wrong way then you probably are increasing the force on a different joint or the same joint.
A device that may work for one person may not work for someone else. That is a big thing I caution you about. I am showing you a lot of things today that you may think will work for you and once you purchase it realize it doesn’t work for good for you. You have to figure out what is best for you because everyone needs to manage their own use of assistive devices.
One of the splints that we sometimes give to people is sort of a temporary one and it is made of plastic. It is intended for those who have a little bit of hyperextension or some joint laxity at their middle joint which is called proximal interphalangeal joint. You put it on and it keeps the joint from hyperextending. You can feel that you get a little bit of a better grasp on things without that joint feeling as if it’s going to give way.
So some things to consider, when you get an assistive device, does the device reduce pain, stiffness or joint stress? If it doesn’t then maybe its not the right device for you. Does the device reduce energy or time expenditure. If you are spending a lot of time setting things up, like if it takes you five minutes just to put this around a jar just to open it well then maybe this is not the right device for you. Maybe there is a different product out there. Is the device convenient, easy to use and transportable, or does it need to be bolted into something or do you have to walk halfway across your house in order to use it? Is the device only needed in the morning or on bad days? Does it substitute for an activity that can be done safely without it? Sometimes if you look at the way you are doing an activity you can find a different way to do that same activity very safely and you don’t have to purchase any assistive devices. Does the device promote loss of motion to mobile joints? Always make sure that you keep your healthy joints healthy.
Does anyone in the audience have things that they found problematic and ways that they have solved that might be interesting for the rest of the group. Maybe we can talk about some of those.
Q. I have a question. Those caps that come on Clorox bleach bottles-- now when you have to push down and push it. I cant get my assistive device to open them. Is there anything for that.
A. We also find those in medicine bottles. I do have one little solution. I’m not sure what store you can find it in but I do know its in the rehab catalogue. It looks like a T-bar lever and the bottom here is sort of a small metal pricky things. You can actually put in on top of a jar. So by increasing this, I have increased the amount of room I’m using. I am increasing the amount of circumference. You put in on and you press down and turn. Now usually these things have a little bit more grip. You can actually put your force down as you are pushing and turn. Some of them you have to squeeze. So this is one that is good for pushing and turn but what we suggest also is that you can push with the one hand and turn with the other because the object will always be bigger and you can push with the one hand and turn with the other. Now the objects you have to squeeze, that is a little trickier. I’m not sure, we would have to try a few things to actually figure out the ones you have to squeeze, maybe something like this would help or even just making it a little stickier surface. So using a product like Dycem in different sizes. This is sticky and you just put it on. There are different sizes It makes the item sticky so you can squeeze and pull.
Q. One of the problems I have with any of those, I can put the thing over the top and turn it with the other hand, but I have to grab the jar and hold it-- I have not found any device to hold the jar.
A. So the question is what happens when you are able to open it with your finger here but the other hand cant support, what do you do? Some of the things that you can try to do is use sticky or use that as a sticky. If you are putting pressure there, you can put it in side something else like a kitchen drawer.
Q. I have tried opening the silverware drawer and putting a bottle there and closing the drawer and leaving it there to hold it.
A. So you are using a vice type technique.
Okay so creating a vice, that is an excellent idea. Using a drawer and opening the drawer and leaning against it while opening it. That is a good idea.
Q. Earlier, You showed us a large, thick rubber band,
A. Keep things simple because if you are using two assistive devices at a time it is probably more complicated —keep it simple. This might be exactly it, she can just hold it and turn it.
Q. When I’m in a restaurant and of course I cant bring my own knife and I’m cutting steak it really hurts when I have to cut food in a restaurant.
A. A suggestion is to ask the waiter to bring out a steak knife which inherently will be sharper, so again keeping things shaper. You can buy little foam pieces if you want to enlarge your grip, you can put them in your purse and you snap it over the top of your knife when you cut it. and then just tuck it back in your purse when you leave.
Q. Its foam?
A. Yes it’s a piece of rubber foam. They sell them at the hardware store. We have foams which are called cylinder foam, you can get them in surgical supply stores and you just cut a smaller piece. They are great for traveling, for your toothbrush, and your knives when you go out.
Q. What do you do for buttons?
The question is what do you do for buttons. Now the problem with buttons is that they are so tiny —Does anyone have a solution for buttons
A. I do. This is for buttons, and this end is for a zipper.
A. Oh, can we turn the lights on so everyone can see that. So what he has brought with him is a button holer and on the back end is for zippers. Can you demonstrate with the buttons.
Q. I’ve only been using this recently.
A. Where did you get it?
Q. My niece gave it to me. I just realized how cheap all of these gifts are that she is giving me! Let me demonstrate for you…
A. So what has he done here, he has increased the lever so he’s not using his tiny finger but he can put his entire hand around that handle so that he is using a lever. Okay I’ll pass another one around. This is the same thing and it has a cylindrical foam that I was talking about that you can also buy. I brought a catalogue with me and I have a few that I can give out that are old but with the phone number you can just call and have them send you an updated one, its an assistive devices catalogue and they are on the web so you can take down their website address and I have the phone numbers too. The best thing is that if you go to surgical supply stores you can find them there too because they are stocking them more and more as they are finding that this is really a revenue generating device so you don’t need to wait for a catalogue. Someone just suggested that if you go to the internet and do a search on "aids for daily living", you will find a whole list of things, different catalogues that you can look at.
One of the big companies is called Sammons Preston Rolyan and their phone number is 1-800-323-5547 and we will make sure that we put this all on the website and if you look onto the web site you will see this also. If you call them up they actually have ADL products. The nice thing is that these are coming down in price. For example I don’t know if any of you have used paraffin for heat treatments. Well those paraffin units are now 50 dollars. You can get them on sale at Macys for 38. These are really important items that you shouldn’t be without.
Q. I ordered something to help me cut my nails and what they sent me was sort of a cutting board and I couldn’t use it, it was really hard to do. You put your nail in , but I couldn’t do it for my toenails. I couldn’t believe it and I was so disappointed and I never used it after that.
A. This is a good example how an assistive device can be useful and not useful. She was having trouble cutting her nails which is a hard thing because you are using a little nail clipper. This is a great thing because she doesn’t need to stabilize it with her small joints like her hands and like she said it is probably easy to do for your finger nails, but what do you do for your toes. I don’t know who can do that. You can fasten it to the floor. But this is a product that maybe 10 of us can use but the rest of us cannot use. You may want to look into something, they have the longer nail clippers at surgical supply stores.
Q. I have a question, I bought the kind of mop that I have with a sponge and a lever, but I cant do that at all. Any suggestions.
A. If you do use a conventional sort of scrubber mop, how do you account for taking those suds off the floor, those sponge things that you use a lever to crank the soap out, they are too hard. Does anyone have any good suggestions for that?
Q. What I use is from the hardware store, it is a pail with a roller on it and you use your feet. The rollers are built into the pail. I use it with the old fashion mop, not the sponge mop.
A. Let me just repeat what she said so the whole group can hear. She purchased a pail that you can actually use your foot and it has rollers built into it and you can use your feet and actually the rollers will go over the end of your mop. Now where did you find a pail like that? The hardware store, great.
So another solution is a mop that you’ve seen probably advertised it looks like dangling pieces of cloth and its very fine and its nice as you are sliding the handle down the mop, you are actually squeezing. Yes it slides down and you can use the larger joint and the handle is actually big. And the handles are made out of a light weight aluminum.
Q. There is a ridiculously expensive mop for about 50 bucks. It is an Italian mop. It has a very smooth operation and you can replace the sponges and it is a natural sponge that lasts for about a year. It is very smooth and it doesn’t rust.
A. A lot of the products that are really good are expensive. If you are going to spend 50 dollars up front and if it is going to last for about 2 years it might be something you want to consider instead of going through ten mops at 5 dollars a piece.
Q. I have the reacher and the thing that I don’t like about this is that it has a black thing that you have to pull all the way back with one hand and grab whatever you are grabbing onto, and then you have to push the lock forward so that it will keep a grip on whatever you are grabbing and its hard to do. If you are grabbing something up high from a cabinet, its hard to grab it, push the thing and then bring it down.
A. Does everyone see what is happening here? The principle of it is that you are using your bigger joints. So the problem is that you are using all of your bigger joints which is great but now you have to use the smaller joint to lock this in place and it takes two hands and it is a little too complicated. Some people may be able to do it with one hand. I am able to do it with one hand. Maybe some of the people with larger hands, maybe some of the gentleman here, they can reach their hand all the way around it but for the people with smaller hands it is more difficult to do. So this is a great product but it may not be as useful for everyone. There are different types of reaches you can buy too.
Q. What I did was just rearrange everything. I cant reach up. Everything I know that I am going to be reaching for everyday, I put them in cabinets underneath or nearby.
A. Give this lady a hand, the most simple thing and logical is to look at your environment and to take the items you use regularly and put them on the bottom shelves, put them on your counter top or put them underneath you counters.
Q. I also just put things in a different container. If has a top that I cant get into I change the container.
A. Yes. If you have medications ask the pharmacist to put it in an easy top. They have them there and there is no reason why they cant do that for you. Secondly if those easy tops are still a little to tricky-- put it into a little container when you get home so that you can get in and out of the container easily. That is a great suggestion.
This is a product that she is using, it is a potato or vegetable peeler and the unique thing is that not only is a thicker lever it actually has a sharp blade, these products are always very sharp and it swivels so you only need to take one swipe of your carrot instead of a lot of little swipes. This helps me, because I like to make apple crisp. These are good for quick peeling and reduce the stress on your joints. They are great for potatoes because again they contour and swivel onto the surface of oddly shaped potatoes.
Q. Can I show you the device for tucking in sheets. I have been using this for a number of years and it has shown no adverse effects on the sheets.
A. That’s fantastic, what she is showing us is a regular spatula or pancake turner and she is using it to tuck in her sheets. She has increased her lever arm and she doesn’t have to stick her fingers in here. And its something you could buy at the dollar store. Fantastic.
Q. I use a rubber glove for everything I open. I don’t even put it on, just take it and open something.
A. So what she is saying is that if you don’t want to buy anything fancy, just get those rubber gloves, that you already have hanging at your sink. Her suggestion is to use a cook book holder to hold your book and set that on your lap. That is excellent. Thank you, that is a big thing, holding that book, especially at night because if you are tired, your joints are tired. (audience member speaks) That is a great suggestion again, taking away the weight so you don’t have to hold onto the big newspaper, she tears the news paper in half so she only has to hold onto one sheet instead of a double sheet.
Q. I’m having trouble finding dishwashing gloves that I can fit my hands into. I do a lot of dishes and I cant wear gloves and I cant find them for my hands, otherwise I have to wear big ones and the water gets in there.
A. So the question is, What do you do if you cant really fit into those dish gloves, because you don’t want to have your hands constantly in hot water, it doesn’t do so many nice things for your hands. Does anyone have suggestions for washing dishes?
Q. What I do, because I hate my hands getting wet when wearing the gloves anyway. So I just get a pair of gardener’s gloves, they’re cotton, little cotton gloves and I put those on and then I put the big rubber gloves, I buy the box of 50.
A. Okay so her suggestion was, actually a good suggestion and again, it just shows that things are going to work for some people and not for others. You just buy the cotton gloves, something you can buy at the store and you are going to put a surgical glove on top, a latex glove that you can buy in a box of 50.
So another suggestion is using a thick heavy balm, its more like a balm, it’s a barrier cream, it doesn’t allow the water to get into your skin. There is a group of people that actually use it for their work and I cant remember what group of people it is. It is kind of like a Vaseline type cream, its greasy still but it’s a little thicker. There are actually are oven mitt type rubber gloves. I am from Canada and I don’t know if you can find them here but I know in Canada you can. They are actually rubber, silicone gloves that you can actually use to take your products out of the oven. They are silicone oven mitts and they are great, they don’t allow heat to get to your hands, that is #1 but you can also use them because they are silicone and they are a mitt in this position. So it is not a mitt like this, it’s a mitt like this, so it already puts you in a functional position to hold your plate and you find it in the kitchen areas and its made of silicone. I don’t know if places like Crate & Barrel and Williams & Sonoma or places like that have it. So they are silicone oven mitt, and it is really great.
Q. If you are having trouble with a key and go with a lever arm, you can put the key on something and turn the key with your entire hand.
A. That is a great suggestion, that is probably something that a lot of people have trouble with. What she is saying is that, what do you do if you cant get yourself into a door or your car, and you cant turn the key in the ignition.. She has brought in a great example which has also seen something similar at the hardware store. So it is a key extender sold at the hardware store. In closing, I just want to let you know that here at HSS we have ADLs available as well. here at HSS.
*3-Point Products Innovation by Design. 1610 Pincay Court, Annapolis, MD 21401. 1-888-378-7763.
*Foot Switch: Power Sentry, A Division of Fiskars Inc.
*Good Grips oxo ®. 1-800-545-4411
*Grip Wrench: Idea Village, Fairfield, NJ, 07004.
*Silver Ring Splint Company. P.O. Box 2856, Charlottesville, VA 22902-2856., 1-800-311-7028.
*Sammons Preston Rolyan, An AbilityOne Company, P.O. Box 5071 Bolingbrook, IL 60440 5071. 1-800-323-5547. http://www.sammonspreston.com/
*North Coast Medical, Inc., 18305 Sutter Boulevard, Morgan Hill, CA 95037-2845, USA. 1-800-821-9319.
*Medical Specialties, Inc. 4600 K Lebanon Rd., Charlotte, NC 28227. 1-800-334-4143. http://www.medspec.com/
*Quick Chop: Smart Inventions, Inc., http://www.smartinventions.com/
*Sheet Snugglers: S n S International., P.O. Box 572002, Tarzana, CA. 91357
*Zyliss ® Switzerland. http://usa.zyliss.com/