Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article


Doctor of Philosophy


Health and Rehabilitation Sciences

Collaborative Specialization

Musculoskeletal Health Research


MacDermid, Joy C.


The fact that Joint Protection Programs (JPP) can reduce pain and improve function is based on small, but definitive Randomized Controlled Trials (RCTs), conducted in the 1980s. However, changes over time in the nature of hand use, the rapid expansion of technology, and improvements in our understanding of health literacy mean that these programs are now outdated. Further, problems with adherence to JPP are well documented. The purpose of this thesis was 1) to conduct a scoping review to map all the available evidence around joint protection programs in published and unpublished studies 2) to evaluate the effectiveness of joint protection programs when compared to usual care/no joint protection/advice on pain reduction and improvement of hand function for individuals with hand arthritis 3) to conduct an overview of systematic reviews to establish the current state of evidence evaluating the effectiveness of joint protection for people with hand RA and OA 4) to investigate the barriers, facilitators, expectations and patient preferences regarding joint protection programs in people with hand arthritis 5) to evaluate the Content Validity Index (CVI) of Patient-Rated Wrist Evaluation (PRWE), Australian/Canadian Osteoarthritis hand Index (AUSCAN) and Thumb Disability Exam (TDX) in patients with hand arthritis and 6) to design a single center, investigator-blinded, randomized, 12-month, parallel-group, superiority study for the evaluation of the efficacy of a hand exercise and a joint protection program on pain Intensity levels in people with hand osteoarthritis. From the existing literature, we found evidence of very-low to low quality that the effects of joint protection programs compared to usual care/control on pain and hand function are too small to be clinically important at short-, intermediate- and long-term follow-ups for people with hand arthritis. We also found that awareness of the potential benefits of JP, and prior experience with JP program were very low. Common potentially modifiable patient-reported barriers to participate in future JP interventions, included: cost, work commitments distance from home to clinic and times that the JP intervention were provided. These barriers might be addressed with free and accessible forms of delivery of JP, which may lead to better uptake and participation in JP. Our findings also demonstrated very high content validity indices for the PRWHE, AUSCAN, and TDX; with strong consensus across reviewers. This augments prior statistical evidence supporting statistical measurement properties, to provide support for the content validity.

Summary for Lay Audience

The most common location for osteoarthritis (OA) is the hand. Hand OA is responsible for pain and limitations in hand function that can limit peoples’ ability to work or remain independent. As hand OA progresses, the joints become deformed. Joint Protection Programs (JPP) were developed in the 1980’s to help people with hand OA do tasks in daily life, alleviate pain, and prevent joint deformity. JPP teach people how to change, or pace tasks, and how to use devices that reduce joint loading. Although studies have shown these programs can be effective, many people do not fully understand or use JPP. The JPP in use today have not been updated to reflect the life tasks and tools of the 21st century. Much has changed - like how we use our phones.

This thesis aimed to investigate the efficacy of JPP and to update the JPP to better address the important daily tasks that people do, by working with patients and engineers to find the best solutions. This study will lead to more useful, accessible and effective JPP that will help people with hand OA avoid pain and prevent joint deformity.