Physiotherapy for JIA

7/30/2019 Physiotherapy for JIA

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Physiotherapy forJuvenile Idiopathic

ArthritisSue Maillard MSc

Specialist Physiotherapist

Paediatric RheumatologyGreat Ormond Street Hospital, London


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J.I.A. R.A.

a disease effecting agrowing developingskeleton.

a disease effecting adeveloped skeleton.

The treatment needs to be different.


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In children there is the capacity forregeneration, re-modelling and repair.

This needs to be used to a maximum.


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Goal setting

Interventions

Assessment


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Subjective Assessment


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Symptoms / Pain / Stiffness When, where, what

The impact JIA has on the child's life. Home, school, hobbies

The impact JIA has on family life. Home, hobbies

The impact life has on the JIA!Accommodation / support available (home,

religion and school)


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Medication

Benefits

Other treatments / support

agencies

Understanding of the disease


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Objective Assessment


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Joint Range of Movement

RangeActive

Passive

Pain Feel

Stiffness

End-feel

Palpation

LookSoft-tissue swelling

Effusion

Muscle atrophy

Hypermobility

Stability

Leg length


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Muscle Strength

Static

Dynamic

Manual Muscle StrengthMRC / Oxford scale

Myometry


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Stamina / Endurance

Specific

Muscle specific

No. of reps.

Muscle fatiguing

General

6 minute walk test

Subjective walking distance


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Balance / Proprioception

Standing on 1 leg

Eyes open

Eyes closed


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Posture / Gait

Head

Shoulders

ArmsTrunk

Hips

KneesFeet


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Goals

Interventions

Assessment


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Goals of Treatment {1}

No pain

Full joint range of movement.

No contractures

Full muscle strength

Stable joints

Excellent Stamina

specific

general


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Goals of Treatment {2}

Good balance

Age appropriate neuro-muscular co-ordination

Maximal independent function

Educated family and child


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Goals

Interventions

Assessment


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Pain Relief

Ice / Heat Packs / Wax

Hydrotherapy

Stretches

Exercises

TENS

Splinting

Massage

Relaxation techniques


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STRETCHES

Reduce Pain

Reduce Stiffness

Increase Joint movement

Increase muscle length


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Important Rules of Stretching

ONE Joint at a time

Apply a slight traction force

Firmly , but GENTLY

Slightly into the Pain

Usually into Extension -Except: Fingers, Elbows &

Feet.Even when Joints are

inflamed


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HYDROTHERAPY

Reduce Pain & Muscle Spasm

Increase Joint Range of Movement

Reduce Joint Stiffness

Increase Muscle Strength

Increase Aerobic Capacity

Increase Fun Element to Programme

BOUYANCY


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Joints can only be actively

protected by MUSCLES.


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Exercises

Reduce pain and stiffness

Maintain joint range of movement

Increase muscle strength

Increase stamina

Increase function

Increase independence

As important as the medication


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Goals of exercise programme

Specific muscle exercised

At least 20 - 30 repetitions

Progress with weights up to 5lb

(!10lb / 5kg)

Rehab. 5x weekly

Maintain 2-3x weekly

Other activities are a bonus Swimming / yoga / pilates etc


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Muscle Repair and Growth

Requirements Exercise

Repetitions Resistance Concentric Eccentric Isometric Isokenetic Closed and Open chain

Satellite cells can replace and increase numbers of musclefibres. Satellite cells are stimulated by exercise.


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American Academy of PediatricsRecommendations

Low resistance until 15 reps.

Strength and fitness increase with reps and

resistance.Need to train 20 30 minutes each session

Min. 2 3 times a week

No increase in benefit of exercising >4/7

Strength gains lost after 6 weeks ofdeconditioning.

Pediatrics Vol.107 No.6 June 2001


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Muscle Strengthening andStamina

High repetitions

Low weights

Resistance workConcentric and eccentric work

Open and Closed chain

Postural / static workAerobic work

Children do best with highrepetitions and low weights


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Philosophy

The child and family should learn to

self-manage the home exercise programme.


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Cytokines, Muscles and

Exercise


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FLU


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This feeling is caused by:


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Paediatric Rheumatology

Children have weaker muscles

Pain

Swelling

Stiffness

Loss of movement

Loss of activity and mobility

Unbalanced muscles

Disease activity

Cytokines


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Cytokines

Pro-Inflammatory

IL-1

IL-6

IL-8

IL-15

TNF

Anti-inflammatory

IL-4

IL-10

IL-13


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IL-10

Level too low = inflammatory changesmuscle changes

Level too high = inhibition of:

TNF

IL-1

IL-6


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Inflammatory disease Cytokines Reactive Oxygen Species (ROS)

Proteolytic enzymeproduction

Depresses myofilament

function

Insulin resistance Loss of muscle protein

Muscle weakness

Adverse patient outcomes

Winkelmann C; TNF AACN Clinical Issues,2004


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h d l


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When considering MuscleFunction..


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IL-15

Reduces level of soluble TNF

Reduces muscle breakdown and atrophy

Important in the management of muscleatrophy in Cancer patients

Figueras M et al; FEBS Lett. 2004

IL 1 &


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IL-1 &Toxic to Muscles and induces fever

IL-1

Inhibits insulin-growthfactor

Causing derangement ofmyocyte metabolism

Inhibits protein synthesis

Promotes muscle

proteolysis

IL-1

Production ofprostaglandins

Peripheralinflammation

Sensitivity to pain

Promotes apoptosis

Winkelmann C; AACN Clinical Issues, 2004


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INHIBITS

PROMOTES


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Yi-Ping Li and Michael B Reid;

Current Opinion in Rheumatology 2001

Respiratory Research 2001


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Inhibits contractile function ofskeletal muscles.

In the 1st

few hours of increased levels:

Increases NO production =Reduction in contractile force.

Blunts the response of muscle cells to calciumactivation


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Causes Muscle Atrophy

Promotes protein loss via the centralpathway that influences the inflammationgenes (NFB)


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Directly opposes Insulinaffects on muscles

Blocks glycogen uptake in muscles


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Chronic Increase in TNF

Inhibits protein synthesis in skeletal muscle

Causes Skeletal cell myopathy and endothelial

dysfunction.

TNF i i i


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TNF is important inMuscle development and

regeneration

Increase in TNF occurs in 1st hours of cell

differentiation and is required for normalcell differentiation.

Blocking TNF causes impaired expressionof adult-type fast myosin heavy chain


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TNF and Mature Myotubules

TNF reduces fast-type myosin heavy chain


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TNF has a bi-phasic response

TNF Increase in MM cells

Apoptosis of mature cells

Mature MM cells

TNF


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Winkelmann C; AACN Clinical Issues, 2004


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Multiple effects

Increases IL-1

Increases production of B cells

Increases production of prostaglandins

Affects TNF production and regulation


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IL-6

Pro-inflammatory cytokine

Produced by working muscles

Eccentric > Concentric

Endurance > resistance

Dependent on effort and time

Normal response

Metabolism control


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HOMEOSTASIS

Muscle function GLYCOGEN

IL-6

IL-6


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IL- 6

Controlled by: Type of exercise

Degree of exercise

Duration of exercise Glycogen availability

Controls: Glucose homeostasis

Lipolysis


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CYTOKINES and EXERCISE

Excessive eccentric, endurance andstrenuous exercise causes an increase incytokine production:

Local muscle inflammation

Local muscle damage

Glycogen supplies

Moderate progressive resisted exercise


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Moderate progressive resisted exercise

programmes:

Reduce production of:

IL-6

TNF

Improves the bodies homeostasis abilities

Efficient use of glycogen and Lipolysis

AND THEREFORE ARE

Greiwe JS; FASEB J 2001


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Castaneda C; Am J Kidney Dis. 2004. Gielen S; J Am Coll Cardiol. 2003

Perdersen BK; Pflugers Arch. 2003. Starkie R; FASEB J 2003


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In healthy individuals a progressive resistedexercise regime has an anti-inflammatory

effect.

? Can we extrapolate to children withinflammatory disease?


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CONCLUSION

Children with rheumatological conditions have

many reasons to lose muscle strength and

function.

CYTOKINES that control the disease also affect

the muscle function.


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PHYSIOTHERAPY

Should provide the tools to enable a full and activelyindependent life.

But it will require participation in a regular specific

treatment programmeas well as

participation in sporting activities.


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But


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Ethos of treatment programme

Start exercise programmefrom beginning ofdiagnosis

Teach the children the

exercises first Specific exercises for

specific joints

Explain the benefits of the

exercises

Associate the exerciseswith other activitiesi.e. sports training

Stamina training aswell as musclestrength

Involve the parents


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Lifetime Therapy Programme 1:

Inform & always be honest about goals

Select activities they enjoy that can beperformed with minimal discomfort /

inconvenienceCombine different activities

Include a recreational game that minimisesskill & competition & maximises participant

successUse progress charts to recognise individual

achievements / set goals & contracts

Periodic assessments (positive reinforcement)


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Lifetime Therapy Programme 2

Set aside a regular time for exercise

Use the proper clothing & equipment forexercise

Find a friend(s) to exercise withSet goals & share them with others

Exercise in different places & facilities

Progress at a rate unlikely to promote injury,

but that provides a challengeVariation

Choice


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Lifetime Therapy Programme 3

Specific exercise programme to ensuremuscles are strong enough and fit enoughto protect joints.

Home exercise programme will alterdepending upon disease activity

Rehab / maintenance

Paced activities


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Important Considerations

Often an underestimation of normal musclestrength in children.

Often starting with children who have less

muscle strength than normal.Loss of strength is very quick

Lack of activity

Pain

Loss of range of movement

Strength only regained with exercise


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New Philosophy


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Physiotherapy for JIA

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