Juvenile Idiopathic Arthritis (JIA)

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2 Juvenile Idiopathic Arthritis (JIA) Formerly known as juvenile rheumatic arthritis Most common rheumatic disease in childhood International League Against Rheumatism (ILAR) and World Health Organization reclassified chronic childhood arthritis as JIA Occurs under the age of 16 years, lasts for at least 6 weeks, other conditions excluded

3 Goals of Rehabilitation

4 Goals of treatment: Controlling symptoms Reducing risk of complications eg., contractures, excessive joint damage, immobility, deconditioning Achieving normal growth and development Maintaining function and normal activity levels Improving level of independence Goals vary during flare ups and maintenance Rehabilitation of the Child with arthritis

5 Goals of Rehabilitation Goals change with stages of development

6 Rehabilitation of the Child with arthritis Flare-ups Rest joint(s) Prevent aggravation of the disease process Reduce stress to joints Splinting Resting Functional Dynamic Ice Medications

7 Rehabilitation of the Child with arthritis Maintenance Improve strength Improve endurance Improve range of motion Resting bracing/splints

8 Rehabilitation Team

9 Rehabilitation Team

10 Rehabilitation Team Requires a coordinated, multidisciplinary team approach Rheumatology Physical Medicine & Rehabilitation Pediatrician Orthopedic surgery Nursing Social Services / Case Management Orthotist / Prosthetist / Orthotech Physical Therapy Occupational Therapy Dietitian Psychology School Teacher Therapeutic Rec

11 Rehabilitation Team Physical Therapy Bed mobility Transfer training Gait training Lower extremity Strength Range-of-motion Endurance Family training Mobility equipment needs Recommendations for bracing Joint protection Energy conservation

12 Rehabilitation Team Occupational Therapy Activities of Daily Living Adaptive equipment Upper extremity Strength Range-of-motion Dexterity Family Training Visual-perceptual skills Cognition Upper extremity splinting Joint protection Energy conservation

13 Role of a Rehabilitation Medicine Physician Early/serial assessment Advise and assist in acute preventive and maintenance strategies Provide education and counseling to family members Facilitate/order appropriate therapy regimen Provide rationale for appropriate interventions and facilitate funding

14 Rehabilitation of the Child with arthritis History Underlying medical problems Particularly neurologic and muscular Functional history prior / current Social history support, resources, school Psychologic needs of the patient Examination Emphasis on musculoskeletal and neurologic systems Skin integrity Nutritional status Medical status

15 Splinting/Casting Splinting benefits Provide alignment Promote local joint rest Support weakened structures Assist function Splinting Wrist-hand orthoses Resting knee immobilizers Ring splints Foot orthoses/inserts Serial casting

16 Range of Motion Gentle range of motion with emphasis on passive extension more than flexion Both during flare ups and maintenance phases Resting in a prone (face down) position to stretch hips and knees Considerations to maximize gains: Pain medication Progress muscle relaxation Breathing exercises Biofeedback Massage Superficial heat

17 Benefits Heat Decrease stiffness Increase tissue elasticity Reduce pain Reduce muscle spasm Types Heating pads/hot packs Paraffin Moist heat Hot shower/bath Ultrasound ** (not appropriate if growth plates open) Avoid during flare-ups Increases inflammatory response

18 Cold Useful during flare-ups Benefits Decrease inflammation Decrease swelling Reduce pain Should not be used over areas with poor sensation/numbness Should not be used in those with Raynaud s Phenomenon

19 Strengthening Numerous studies demonstrate the benefits of regular exercise program Improved function Improved aerobic capacity Improved bone density Improved mood Play and recreational activities Aerobic activity swimming, dancing, non-contact martial arts, tai chi Isometric strengthening OK during acute flare up but vigorous exercise should be held until acute phase over Hydrotherapy/aquatic therapy

20 Adaptive Equipment Used for joint protection, rest and to maximize independence with activities of daily living (ADLs) Examples: Adaptive utensils Adaptive pens/pencils/grips Computer access Body mechanics/ergonomics Table/desk modifications Dressing sticks Long-handled brushes Modified clothing fasteners (large buttons, velcro, elastic, zipper pulls)

21 Walking/Mobility Activity and walking should be encouraged as much as possible Assistive devices Canes Crutches Walkers (anterior/posterior) Wheelchairs Braces/orthoses Ankle-foot orthoses (AFOs) Foot orthoses/inserts Custom Off the shelf

22 Growth and Nutrition Optimize nutrition Balanced diet Multivitamins Adequate Vitamin D Sunshine Omega 3 Low-impact weightbearing activities Weight control

23 Emotional Health Regular physical activity Maximize independence and social integration Pain control Counseling / psychotherapy Therapeutic recreation programs Peer support Summer camps Benefits include increased control, selfesteem, physical fitness, independence from parents, self-management of health care, opportunity to meet others with a similar condition

24 Pre- and post-operative Joint Rehabilitation Program Will help facilitate recovery and postoperative goals Improve strength and range of motion Improve endurance Identify adaptive equipment Outpatient/Inpatient Rehabilitation

25 Effects of deconditioning and immobilization

26 Effects of deconditioning and immobilization Musculoskeletal System Muscle atrophy and weakness Lose 10-15% of strength per week of bedrest, 50% in 3-5 weeks Electron microscopy Fiber degeneration Increased proportion of fat and fibrous tissue Decreased fiber size

27 Effects of deconditioning and immobilization Musculoskeletal System First muscles to weaken are those of the lower extremities and trunk which resist gravity Quadriceps Gluteus Maximus Spinal extensors Difficulty with transfers and climbing stairs

28 Effects of deconditioning and immobilization Musculoskeletal System Endurance decreases at similar rate as muscle strength Reduced metabolic activity Decreased oxidative capacity Reduced tolerance to lactic acid and oxygen debt

29 Effects of deconditioning and immobilization Musculoskeletal System Strength gains best achieved through regimented a progressive resistive exercise program Electrical stimulation may be used for strengthening of isolated muscles Quadriceps sets / isometrics Ankle pumps Maintain strength Reduce venous stasis

30 Effects of deconditioning and immobilization Musculoskeletal System Osteopenia Increased osteoclastic activity (bone resorption) Inhibition of osteoblastic activity Loss of calcium and hydroxyproline from the cancellous bone of long bone epiphyses and metaphyses. Rate of bone loss greater in younger individuals and in weightbearing bones Immobilization hypercalcemia Vitamin D deficiency

31 Effects of deconditioning and Musculoskeletal System Contractures immobilization Definition : Loss of passive range-of-motion due to decreased elasticity in subcutaneous tissue, ligament, muscle, joint capsule, or synovium Intrinsic factors Shortening of collagen fibers in unstretched muscles Extrinsic factors Muscle imbalance Spastic Paralytic Biomechanical

32 Effects of deconditioning and immobilization Musculoskeletal System Contractures 2-joint muscles effected first Hamstrings Rectus femoris Tensor fasciae latae Erector spinae Gastrocnemius Position of maximal comfort in bed predisposes to contractures

33 Effects of deconditioning and immobilization Musculoskeletal System Contractures PREVENTION Cessation of bedrest Early joint mobilization Proper positioning Trochanter roll to maintain neutral position (prevent external rotation / abduction) Attention to upper extremity adductors and internal rotators Hand splints or palmar rolls

34 Effects of deconditioning and immobilization Musculoskeletal System Contractures treatment Active and passive ROM with sustained terminal stretch Superficial or deep heat prior to stretching Hot packs Ultrasound (if growth plates closed) Serial casting Orthoses Static Dynamic CPM

35 THANK YOU!