Physiotherapy for Juvenile Idiopathic Arthritis

Sue Maillard MSc Specialist Physiotherapist Paediatric Rheumatology Great Ormond Street Hospital, London

J.I.A.
a

R.A.
a

disease effecting a growing developing skeleton.

disease effecting a developed skeleton.

The treatment needs to be different.

 In

children there is the capacity for regeneration, re-modelling and repair.

This

needs to be used to a maximum.

Assessment

Goal setting

Interventions

Subjective Assessment

 Symptoms

/ Pain / Stiffness

When, where, what

The
The

impact JIA has on the child's life.

impact JIA has on family life. impact life has on the JIA!

Home, school, hobbies Home, hobbies

The

Accommodation / support available (home, religion and school)

 Medication

Benefits
Other

treatments / support agencies of the disease

Understanding

Objective Assessment

Joint Range of Movement

Range
Active

Look
Soft-tissue Effusion Muscle

swelling

Passive

Pain Feel
Stiffness
End-feel

atrophy

Hypermobility Stability Leg

Palpation

length

Muscle Strength
Static

Dynamic
Manual

Muscle Strength
/ Oxford scale

MRC

Myometry

Stamina / Endurance
Specific

Muscle specific
No.

of reps. Muscle fatiguing

General

6 minute walk test Subjective walking distance

Balance / Proprioception
Standing

on 1 leg

Eyes open Eyes closed

Posture / Gait
Head

Shoulders
Arms Trunk Hips Knees Feet

Assessment

Goals

Interventions

Goals of Treatment {1}

No

pain Full joint range of movement. No contractures Full muscle strength Stable joints Excellent Stamina
specific general

Goals of Treatment {2}

Good

balance Age appropriate neuro-muscular co-ordination

Maximal

independent function

Educated

family and child

Assessment

Goals

Interventions

Pain Relief
Ice

/ Heat Packs / Wax Hydrotherapy Stretches Exercises TENS Splinting Massage Relaxation techniques

STRETCHES

Reduce

Pain Reduce Stiffness Increase Joint movement Increase muscle length

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

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

Joints can only be actively protected by MUSCLES.

Exercises
Reduce

pain and stiffness Maintain joint range of movement Increase muscle strength Increase stamina Increase function Increase independence
As

important as the medication

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

Muscle Repair and Growth

Requirements Exercise
Repetitions Resistance Concentric Eccentric Isometric Isokenetic Closed and Open chain

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

American Academy of Pediatrics Recommendations

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 of deconditioning.

Pediatrics Vol.107 No.6 June 2001

Muscle Strengthening and Stamina

High

repetitions Children do best with high repetitions and low weights Low weights Resistance work Concentric and eccentric work Open and Closed chain Postural / static work Aerobic work

Philosophy
The child and family should learn to self-manage the home exercise programme.

Cytokines, Muscles and Exercise

FLU

This feeling is caused by:

Paediatric Rheumatology
Children

have weaker muscles

Pain Swelling Stiffness Loss of movement Loss of activity and mobility Unbalanced muscles Disease activity

Cytokines

Cytokines
Pro-Inflammatory IL-1 IL-6 IL-8 IL-15 TNF Anti-inflammatory IL-4 IL-10 IL-13

IL-10
Level

too low =

inflammatory changes muscle changes

Level

too high = inhibition of:

TNF IL-1 IL-6

Inflammatory disease

Cytokines

Reactive Oxygen Species (ROS)

Proteolytic enzyme
production Depresses myofilament function

Insulin resistance

Loss of muscle protein

Muscle weakness Adverse patient outcomes

Winkelmann C; TNF AACN Clinical Issues, 2004

When considering Muscle Function..

IL-15
Reduces

level of soluble TNF Reduces muscle breakdown and atrophy Important in the management of muscle atrophy in Cancer patients

Figueras M et al; FEBS Lett. 2004

IL-1 & Toxic to Muscles and induces fever

IL-1 Inhibits insulin-growth factor Causing derangement of myocyte metabolism Inhibits protein synthesis Promotes muscle proteolysis

IL-1

Production of prostaglandins Peripheral inflammation Sensitivity to pain Promotes apoptosis

Winkelmann C; AACN Clinical Issues, 2004

INHIBITS

PROMOTES

Yi-Ping Li and Michael B Reid; Current Opinion in Rheumatology 2001 Respiratory Research 2001

Inhibits contractile function of skeletal muscles.

In the 1st few hours of increased levels: Increases NO production = Reduction in contractile force. Blunts the response of muscle cells to calcium activation

Causes Muscle Atrophy

Promotes

protein loss via the central pathway that influences the inflammation genes (NF B)

Directly opposes Insulin affects on muscles Blocks glycogen uptake in muscles

Chronic Increase in TNF

Inhibits protein synthesis in skeletal muscle Causes Skeletal cell myopathy and endothelial dysfunction.

TNF is important in Muscle development and regeneration

Increase

in TNF occurs in 1st hours of cell differentiation and is required for normal cell differentiation. TNF causes impaired expression of adult-type fast myosin heavy chain

Blocking

TNF and Mature Myotubules

TNF reduces fast-type myosin heavy chain

TNF has a bi-phasic response

TNF Increase in MM cells

Apoptosis of mature cells Mature MM cells

TNF

Winkelmann C; AACN Clinical Issues, 2004

Multiple effects
Increases

IL-1 Increases production of B cells Increases production of prostaglandins Affects TNF production and regulation

IL-6
Pro-inflammatory

cytokine Produced by working muscles

Eccentric > Concentric Endurance > resistance Dependent on effort and time Normal response

Metabolism

control

HOMEOSTASIS
IL-6

Muscle function
IL-6

GLYCOGEN

IL- 6
Controlled by:
Type of exercise Degree of exercise Duration of exercise Glycogen availability

Controls:
Glucose homeostasis Lipolysis

CYTOKINES and EXERCISE

Excessive

eccentric, endurance and strenuous exercise causes an increase in cytokine production:

Local muscle inflammation Local muscle damage Glycogen supplies

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

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

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

In healthy individuals a progressive resisted exercise regime has an anti-inflammatory effect.

? Can we extrapolate to children with inflammatory disease?

CONCLUSION
Children with rheumatological conditions have many reasons to lose muscle strength and function. CYTOKINES that control the disease also affect the muscle function.

PHYSIOTHERAPY
Should provide the tools to enable a full and actively independent life. But it will require participation in a regular specific treatment programme as well as participation in sporting activities.

But

Ethos of treatment programme

Start exercise programme from beginning of diagnosis Teach the children the exercises first Specific exercises for specific joints Explain the benefits of the exercises

Associate

the exercises with other activities i.e. sports training Stamina training as well as muscle strength Involve the parents

Lifetime Therapy Programme 1:

Inform

& always be honest about goals Select activities they enjoy that can be performed with minimal discomfort / inconvenience Combine different activities Include a recreational game that minimises skill & competition & maximises participant success Use progress charts to recognise individual achievements / set goals & contracts Periodic assessments (positive reinforcement)

Lifetime Therapy Programme 2

Set

aside a regular time for exercise Use the proper clothing & equipment for exercise Find a friend(s) to exercise with Set goals & share them with others Exercise in different places & facilities Progress at a rate unlikely to promote injury, but that provides a challenge Variation Choice

Lifetime Therapy Programme 3

Specific

exercise programme to ensure muscles are strong enough and fit enough to protect joints. Home exercise programme will alter depending upon disease activity
Rehab / maintenance
Paced

activities

Important Considerations
Often

an underestimation of normal muscle strength in children. Often starting with children who have less muscle strength than normal. Loss of strength is very quick
Lack Pain Loss

of activity

of range of movement

Strength

only regained with exercise

New Philosophy