Complete Guide For Designing Adaptive Clothing For Rheumatoid Arthritis Patients

In 2019, 18 million people worldwide were living with rheumatoid arthritis (1). About 70% of people living with rheumatoid arthritis are women, and 55% are older than 55 years (1).  Rheumatoid arthritis (RA) is an autoimmune condition impacts the joints, leading to swelling, pain, and restricted movement that creates more challenges for the RA patients. The consequences of this condition can significantly impact individuals’ daily lives, hindering their ability to independently perform tasks such as dressing, cooking, and grooming.

Need of Adaptive clothing for RA

Adaptive clothing is specifically tailored for seniors, people with disabilities, individuals undergoing hospital procedures, rehabilitation, or those with temporary or permanent disabilities. 

Adaptive clothing for Rheumatoid Arthritis (RA) patients offers several benefits, it 

- Facilitates easier dressing

- Reduces pain and inflammation

- Provides convenience with easy closures 

- Offers joint and muscle support

- Promotes independence and self-image

- Ensures comfort for individuals with RA

These adaptations include: Flat seams to minimize friction, discreet adjustments for a natural appearance, easy access with snaps, Velcro, and stretchy fabric, roomy seat designs for  diaper accommodation for adults and children, extended rise at the back for wheelchair users, elastic waistbands for enhanced comfort and easier dressing, and compliance with safety and flammability regulations.

Importance of adaptive clothing for RA patients

Dressing involves joint movements, which can be challenging for patients with certain conditions, leading to dependence on others. Garments have been designed with adaptive solutions to help patients dress independently.

A survey analyzed by the researcher revealed that women in this age group prefer traditional attire like Saree, blouse, petticoat, or Salwaar/Churidar and kurta, despite the effort required to wear them. There hasn’t been a study addressing the dressing challenges faced by Indian women.

This study (Designing adaptive clothing for the rheumatoid arthritis patients) delves into potential adaptive solutions that could assist patients in dressing more comfortably (2).

Understanding RA and Clothing Challenges 

Symptoms and effects of RA  - 

Among all the forms of arthritis, the Rheumatoid Arthritis is considered to be one of the most destructive one.

The disease has a female predominance (female-to-male ratio of 2.5:1), and shows increased incidence with age.

In rheumatoid joints, the synovium is initially affected, leading to eventual joint integrity loss. Inflammation and destruction can impact tendons, ligaments, cartilage, and the joint capsule. Hand deformity is a common characteristic of RA, resulting from the disease affecting various structures like tendons, capsules, bones, and ligaments.

Clothing-related challenges faced by RA patients -

Physical disabilities in rheumatoid arthritis impact the choice of clothing that can be worn. The impact varies based on the nature of the disability, the level of physical restriction, and which part(s) of the body are affected by the disability.

One significant effect of disability is to restrict or impede mobility. Mobility is also a significant issue for clothing product development. A certain amount of ease in clothing is necessary for donning and doffing, manipulating fasteners, adjusting clothing once it is on the body, and comfortable movement, so that the individual does not have to work against their clothing. Clothing must work with the body’s movements during the course of a day, expanding and contracting in a similar way to the body.

Research Design 

Clothing design has evolved into a field that emphasizes both function and fashion. In the functional clothing design process, visual appeal is insignificant if the garment is uncomfortable or fails to serve its purpose. Aesthetic design solely focuses on appearance, while the structural design process determines how the garment is put together to fulfill its function. It involves defining the structural lines, shapes, and components, as well as how they interact, fit, open, and close. When designing clothing for occupational purposes, all three aspects – function, structure, and aesthetic – must be considered. The following framework was employed to create adaptive solutions in garments for Rheumatoid arthritis patients to simplify their casual dressing needs:

Design Framework :

1. Define the problem and objectives.

2. Exploring the Design Situation: Visual observation of patients with RA during activities like dressing and working to understand their challenges. Conducting personal interviews with Rheumatology and Occupational Therapy experts, as well as patients, to gain insights. Studying existing literature to delve deeper into the impact of the disease on daily life.

3. Describing the Specifications: Gathering data on critical factors related to the design problem and assessing movements and activities involved in wearing the garment. Collecting preferences through a structured questionnaire.

4. Establishing Design Criteria: Prioritizing specifications derived from the questionnaire analysis for inclusion in the design solution.

5. Developing Prototypes: Creating prototypes based on the established design criteria, focusing on trims, cuts, and pattern developments for patients.

6. Evaluation: Assessing if the garment meets the criteria by having patients wear the garments and providing feedback.

Design Considerations for Adaptive Clothing 

-Key design elements for adaptive clothing  

Watkins (1984) recommends that when designing clothing to enhance mobility, the designer should first gather all relevant information about the individuals and the activity. By observing body movements, these observations can then be translated into garment specifications. The aim of this research was to pinpoint the clothing and dressing requirements of individuals with RA.  

The main movement issues involved fingers, hands, knees, shoulders, and wrists. Challenges such as discomfort, design mismatch, fitting issues, fastener handling, as well as bodily fatigue, pain, and weakness when dealing with complex and rigid clothing were identified as significant concerns.

The participant Identified the most challenging features in ready-to-wear clothing and proposed improvements, such as fabric preferences, adjusting ease in different garment areas, enhancing openings (like at the neckline and armscye), and refining fastener and pocket design and placement.

 Easier dressing

 The dress is made so that it easily slides, shirt, or top on from the front and simply secures at the back of the shoulders with either Velcro or snap press closing. The generous side openings provide plenty of room to pull the pants on or off quickly, and provide easy and quick access for toileting, hygiene or adjustment for comfort if required. Comfort Standard clothing can become uncomfortable in the groin or underarms, or leave the lower back exposed when pants ride down in the seated position.

There are many comfort benefits built into the garments: 

· Additional room in the groin to eliminate tightness and restriction

· Backs of pants are higher to prevent riding down

· Prevention of lower back exposure

· Comfort around the belly and waist to prevent restriction and tightness

· Additional room in the underarms to prevent tightness and pinching

· Soft and fixed back neck labels that won’t flap, move, irritate, or scratch

· Closures that are positioned so as not to cause pressure, discomfort or irritation

 Reduced pain

 Changing clothes at least twice a day is essential. When patients experience stiffness, rigidity, constriction, or pain during movement, getting dressed can be quite challenging. Adaptive clothing can greatly improve this situation by removing the necessity to bend arms, legs, necks, or shoulders. This type of clothing not only reduces distress and discomfort for the wearer but also assists caregivers in preventing injuries by making the dressing process smoother, quicker, and hassle-free.

Dignity

 The goal of this type of clothing is to offer garments that blend in with regular attire while also offering functional and fashionable options. Various factors are considered to achieve this objective.

 · Adaptations are as discreet as is practicable

· Back overlaps provide complete coverage

· No gaping or exposure at the back of the garment

· No seams or joins running down the middle of the back advertising

 ‘adaptive garment being worn’ 

· Garments can be partially removed for physical examinations without the need to fully undress

Appearance

Adaptive clothing is designed to resemble traditional clothing to uphold the dignity and self-respect of the wearer. This is achieved by paying meticulous attention to the following: 

· Keeping zippers, buttons etc in place to maintain the appearance of conventional clothing  

· Concealing the back overlaps as much as is practicable to avoid

 Showcasing the ‘adaption’

· Using top quality fabrics with stylish prints and designs.

After analyzing the completed questionnaire and engaging in discussions with the patients, the researcher collected data to create the prototype. Identifying common features that could be incorporated into garments for RA patients of all sizes, the table below outlines the essential elements needed for clothing designed for RA patients.

Common features of a RA garment -

· An ease of 1” in the upper torso. 

· Armhole ½” lowered. 

· Sleeve mouth %” extra ease.

· Closures within reach(front

· Size of closures medium

· Easy accessible closures.

· Velcro fasteners preferred.

· Type of sleeve: set in.

· Crotch lowered by 1” in bifurcated garments.

· Length of the lower garment above ankle or till ankle

· Less flared garments.

· Keeping flare of the garment just enough for one stride.

· In search of some other trim in place of cording.

Incorporating assistive technologies 

Incorporating Features in Prototype Development to Balance Fashion and Functionality - 

• The prototype was designed with a semi-fit and loose shape, as users preferred loose-fitting garments to accommodate their physical limitations and provide freedom of movement.

• Users expressed a need for modesty, specifically wanting coverage around the neck and chest, aligning with previous modesty research findings.

• Front openings with closures were favored over back closures due to arm and shoulder movement ease.

• Garment openings and closures were strategically placed, with closures chosen to ensure modesty in the chest area as per previous research.

• Respondents varied in their preferences for closures, with most finding buttons acceptable if they were easy to manipulate.

• Velcro closures, offering easy access and functionality, were the preferred closure option over snaps and hooks.

• A majority’of users favored a round neckline that sits low on the neck for comfort and style.

• Sleeve options were considered, with a set-in sleeve being the most accepted choice, despite raglan and kimono styles offering more comfort.

• Deep sleeve openings were appreciated for ease of movement in the arm and shoulder.

• Elastication was preferred over cording in salwar, while Velcro tabs replaced cording in petticoats for a better fit.

• Saree features were designed to simplify pleating and pinning the palla on the shoulder.

Proposed Solutions for Traditional Indian  Clothing 

Set I: Saree Blouse and petticoat

Saree:

During the saree wearing process, patients managed the tucking but faced challenges with front pleating and pinning the palla on their shoulders. To simplify these steps, the following solutions were suggested.

Two proposals were made to assist patients in wearing sarees comfortably:

Proposal 1: 

A strip with buttons is attached to the saree for easy pleating. Measurements for saree division are provided based on hip measurements.

Proposal 2: 

Involves channelled seams and a decorative cord to help gather the palla on the shoulder with the option to tie for a design feature.

Blouse: 

The blouse design was adjusted based on questionnaire feedback: armholes lowered, round neckline of medium width and depth, semifit sleeve mouth, and waist-length. Innovative techniques were implemented to improve hook fastening comfort.

Proposal 1:

• A design enhancement was implemented on the blouse placket to aid in locating and securing the fastener.

• Velcro replaced traditional hooks, making fastening and unfastening easier for users.

• Patients were instructed to start fastening from the waist and move towards the neck for optimal placement.

Proposal 2:

• Loops were added to the placket for patients with finger joint impairments, allowing them to insert their fingers to access the fasteners.

• Larger hooks were used instead of small ones to facilitate easy hooking and unhooking.

• Patients were advised to fasten the closure starting from the waist and moving upwards, ensuring correct positioning of the Velcro.

Proposal 3:

• Despite raglan sleeves being comfortable for patients, they were not widely adopted in Indian clothing.

• A circular Velcro tab was introduced in place of traditional closures for ease of use.

• Loops on the placket were incorporated to assist in opening and closing the garment

Peticot: 

The petticoat’s flare was designed to match one stride, with a length above the ankle. It featured two Velcro tabs on the waistband, secured at the back and adjustable from back to front as needed. Loops on the tabs allowed the patient to easily open and close them by inserting a finger. This closure method eliminated the challenge of tying and untying the petticoat’s cord for the patients.

Set II: Salwar and Kurtas

Kurta -

Proposal 1:

Angarkha style kurta with a full front opening to ease the patients’ discomfort of wearing slip-on kurtas.

Front closures for easy access, secured by Velcro straps at the empire level and waist.

Proposal 2:

Peasant style kurta with raglan sleeves that open wide, allowing patients to put it on without raising their arms and experiencing pain.

Adjustable with a drawstring at the neck for a customized fit.

Raglan sleeves provide extra room and fullness for enhanced comfort.

Proposal 3:

Features a front yoke that can be fully opened and neatly secured with Velcro.

The yoke design conceals the closure behind, creating the appearance of a slip-on garment for comfort and ease of wear.

Salwaar:

The hem of the salwaar was kept to be of medium width and length till the ankle. The crotch was lowered by a few centimetres to provide ease at the seat. To ease them of the difficulty of tying and untying the cord, a fully elasticized waist band was used, which allowed them to draw the salwaars just like their Payjamas.

Feedback

Following the development of prototypes, patients were requested to evaluate the degree to which the prototypes met their expectations. This assessment was conducted using a 5-point Likert scale ranging from “Completely Disagree” to “Completely Agree” across several parameters.

The feedback received indicates a high level of satisfaction among patients regarding the additional features incorporated into their garments. While some patients were unable to personally try the garments due to sizing constraints, they assessed the features either by examining them directly or by observing the prototypes on others.

The patients expressed appreciation for the research efforts that yielded solutions easily integrable into their clothing. This newfound ability to enhance their dressing experience has instilled confidence and enabled them to lead a life of dignity.

Conclusion and Future Directions

Physical limitations often affect a woman’s ability to dress herself, especially when wearing traditional garments like sarees, blouses, petticoats, Salwar/Churidaar, and Kurtas. Many patients struggle with putting on these clothes and often require assistance from others. Despite the availability of adaptive solutions developed abroad, they prefer sticking to their traditional attire. One patient expressed, “Women with physical disabilities want apparel that does not set them apart from other women.” This study led to the incorporation of adaptive features into their traditional clothing, which was highly appreciated by both the patients and the doctors.

• Patients found the raglan sleeve blouse to be comfortable, even though it was not familiar to them initially. The design was well-received as it provided roominess at the shoulder and armhole, making the patients more at ease compared to the set-in blouses.

• The option of front pleating in sarees was popular among patients, but they suggested further modifications in the palla area for future research.

• The additional cost of adaptive solutions in the main garment remains within the users’ affordability, only amounting to 10%-20% more than the garment’s original cost.

This project aims to enable Indian manufacturers to create mass-produced garments for rheumatoid arthritis patients, including those from lower-income groups. It will benefit occupational therapists by offering improved clothing options. Research can determine the best fabrics for these garments and lay the groundwork for studying the psychological needs of patients in addition to their physical needs.

References

(1) GBD 2019: Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. https://vizhub.healthdata.org/gbd-results/.

(2) Dissertation/Post Graduate research report NIFT 2011: Designing adaptive clothing for the rheumatoid arthritis patients https://www.vastrashilpakosh.in/search/recordPreview/nift_del-168-acr?searchTerm=&t=Designing%20adaptive%20clothing%20for%20the%20rheumatoid%20arthritis%20patients